PRIMARY CARE
AND
PREVENTION
Readying the Workforce Evaluation of VHA’s Comprehensive Women’s Health Primary Care Provider Initiative Natalya C. Maisel, PhD,* Sally Haskell, MD,w Patricia M. Hayes, PhD,w Vidhya Balasubramanian, MS,* Anupama Torgal, MPH,w Lakshmi Ananth, MS,z Fay Saechao, MPH,* Samina Iqbal, MD,y8 Ciaran S. Phibbs, PhD,*zz# and Susan M. Frayne, MD, MPH*y8#
Background: Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women’s health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. Objective: To evaluate early implementation of this national policy. Methods: At each VHA health care system (N = 140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. Results: Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD = 27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD = 7%) for Other PCPs (P < 0.001). For women veterans using primary care (N = 313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P < 0.001).
From the *Women’s Health Evaluation Initiative (WHEI), Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; wWomen’s Health Services, VA Central Office, Washington, DC; zHealth Economics Resource Center; yWomen’s Health Service, Medical Service, VA Palo Alto Health Care System, Palo Alto, CA; 8Division of General Medical Disciplines; zDepartment of Pediatrics; and #Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA. This evaluation was conducted by the Women’s Health Evaluation Initiative at VA Palo Alto Health Care System, which is funded for program evaluation work by VA Women’s Health Services in the Veterans Health Administration’s Office of Patient Care Services. All authors received funding from, or are employees of, the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. The authors declare no conflict of interest. Reprints: Natalya C. Maisel, PhD, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5304-0S39
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
Conclusions: VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention. Key Words: women’s health, veterans, primary health care, policy (Med Care 2015;53: S39–S46)
T
he Veterans Health Administration’s (VHA) commitment to optimizing quality of care for the growing population of women veterans1 includes its goal of offering comprehensive primary care services for women.2 However, in 2008, a federal report2 highlighted gaps in comprehensive primary care for women: approximately half of VHA facilities at that time referred women out of primary care to women’s preventive health clinics or specialists for basic sex-specific needs, such as Pap smears and clinical breast examinations.3 Because of women veterans’ status as a numerical minority, “many VA providers [had] little or no exposure to women patients”2(p16) and, therefore, often lacked experience delivering women’s health (WH) care.4 Responding to this inequity, VHA created policy5 in 2010 to improve comprehensive primary care for women. One of the central goals highlighted in this policy was that all VHA facilities would now have Designated WH comprehensive primary care providers (Designated WH Providers). These providers were to be selected based upon their interest in treating women and their willingness to be preferentially assigned women, and would be expected to maintain ongoing proficiency in WH. Proficiency was operationalized as having a substantial number of women in the provider’s panel; these providers were expected to see at least 10% women in primary care (suggesting a panel enriched with women, as women represented only 5%–6% of veteran patients at that time1,6), or have an alternative proficiency plan in place. VHA’s structure includes 140 health care systems nationally, each composed of one or more hospitals (typically providing inpatient and outpatient care) and multiple smaller www.lww-medicalcare.com |
S39
Medical Care
Maisel et al
community clinics (geographically dispersed points of primary care, potentially also offering other onsite specialty services7). Women’s use of community clinics has been on the rise.8 The new policy was designed to make Designated WH Providers available to women across VHA at all hospitals and community clinics, not only in WH Clinics available at some hospitals. Despite VHA’s sustained commitment to WH care quality improvement,9 it is unclear whether the goals of this policy are fully met VHA-wide. Previous evaluations focused on availability and utilization of WH Clinics1,9–12 and on initial estimates of the size of the Designated WH Provider workforce.13 Although creation of Designated WH Providers is the central focus of VHA policy for comprehensive primary care for women, these providers have not been identified previously at the national level, and it is unknown if the current workforce meets the goals of VHA policy. For VHA to address gaps in its ability to provide comprehensive primary care, it is necessary to know more about the implementation of Designated WH Provider policy. Therefore, the current evaluation of early policy implementation built on previous work, capitalizing on a national workforce capacity assessment that for the first time identified all Designated WH Providers. We asked 3 central questions in this evaluation of the 2012 Designated WH Provider workforce: (1) Were Designated WH Providers located at every site across VHA, including community clinics? (2) Were Designated WH Providers indeed seeing more women veterans and having more encounters with women veterans than Other PCPs? (a) How did the patient panel of Designated WH Providers at hospitals compare to those at community clinics? (3) Were women veterans accessing Designated WH Providers for primary care? (a) Were new women patients as likely as established women patients to see Designated WH Providers?
METHODS Overview of Evaluation VHA’s national Designated WH Provider Assessment of Workforce Capacity (DAWC) asked key informants to identify all local Designated WH Providers at all primary care sites within the 140 health care systems, consisting of 148 hospitals and 743 community clinics in total. DAWC data were then merged with VHA administrative data on providers and patients.
Evaluation Design and Data Sources
Volume 53, Number 4 Suppl 1, April 2015
at all hospitals/community clinics in their local health care systems. Participation was 100%. After training, each Women Veterans Program Manager received a personalized Excel spreadsheet prepopulated with a list of all PCPs at the local health care system. The Program Manager selected the Designated WH Providers from the list, manually adding the name of any missing Designated WH Provider; any added provider was later located in VHA administrative datasets. If the Program Manager was uncertain about a provider’s status, he or she marked the provider as a “possible” Designated WH Provider. Only 4.5% of all Designated WH Providers were identified as “possible” and are treated as Designated WH Providers herein except when noted. Using a unique provider identification number for linkage, we merged data from the assessment with information from VHA administrative data. These data included patient records of encounters (National Patient Care Database) and provider records (Primary Care Management Module).
Analytic Cohorts PCP Cohort Analyses focused on PCPs in VHA; some analyses examined only the Designated WH Provider subset. We compared Designated WH Providers to the Other PCPs in VHA, selecting medical doctors, doctors of osteopathy, nurse practitioners, or physician’s assistants, exclusive of residents/trainees. To confirm that these Other PCPs were active PCPs at least part time for at least part of FY2012, we restricted to providers with Z50 primary care encounters with veterans in FY2012 (exploring other cutoffs with sensitivity analyses); this resulted in 8432 PCPs (“Designated WH Providers” or “Other PCPs”).
Patient Cohort For patient analyses, the cohort was composed of 313,033 women veterans with at least 1 VHA primary care encounter in FY2012, as defined elsewhere.1 Note that for this evaluation, nonveterans,14 comprising 11% of women primary care patients in FY2012, were excluded.
Variables, Provider-Level Provider Location Provider location came from VHA administrative datasets; for Designated WH Providers, the Women Veterans Program Manager had the opportunity to correct location if this required updating. Each provider was assigned a unique location, even if he/she provided some care at another location. Locations were classified as a hospital or a community clinic.7,13
The key informant completing this assessment was the Women Veterans Program Manager5 at each health care system; the Program Manager serves as a point of contact for women in VHA and is knowledgeable about the Designated WH Providers at the local facility. These Women Veterans Program Managers (N = 140) completed the assessment in Fall 2012 to describe the Fiscal Year (FY) 2012 (October 2011–September 2012) Designated WH Provider workforce
Patients/Encounters in Primary Care
S40 | www.lww-medicalcare.com
Copyright
From VHA administrative datasets, for each provider we counted number of unique veterans and number of veteran encounters in primary care in FY2012, by patient sex. r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
VHA Women’s Health Provider Evaluation
Variables, Patient-Level Encounters With Providers
New/Established Status A woman was considered “new” to VHA if she used no outpatient or inpatient services in the 3 years before her first FY2012 outpatient visit (N = 36,425).15 All others were classified as “established” patients (N = 276,608).
40% 30% 20% 10%
0
For descriptive purposes, we present unadjusted percents, means, SDs, and medians. For basic tests of statistical significance, analyses were conducted in Stata version 11.2, including negative binomial regression to account for overdispersion of count data. To account for health care systemlevel variability, we included Stata’s “cluster” command.
RESULTS Designated WH Provider and Other PCP Workforce Among the 8432 VHA PCPs in FY2012, 1945 (23%) were Designated WH Providers for at least part of FY2012 (including 87 “possible” Designated WH Providers). Of the 1945 Designated WH Providers, the majority (62%) were located at community clinics. Percent of PCPs identified as Designated WH Providers varied across the 140 health care systems. For example, Designated WH Providers comprised 14% of PCPs for the 25th percentile of health care systems, 21% for the 50th percentile (ie, the median), and 32% for the 75th percentile. Likewise, Designated WH Providers comprised 16% of all hospital-based PCPs, and 32% of community clinic-based PCPs. To address one of the central aspects of VHA policy,5 we examined whether there were Designated WH Providers at all points of care. Across the 140 health care systems, 100% had at least 1 Designated WH Provider. Within these health care systems, of the 148 hospitals, 97% had at least 1 Designated WH Provider, and of the 743 community clinics, 83% had at least 1 Designated WH Provider. In Figure 1, 3% of hospitals had no Designated WH Providers, 31% had exactly 1 or 2, and the majority (66%) had 3 or more. In contrast, 17% of community clinics had no Designated WH Providers, the majority (64%) had exactly 1 or 2, and only 19% had 3 or more.
Patients of Designated WH Providers When examining the patient composition of Designated WH Providers, we restricted the Designated WH Provider cohort to those with at least 50 primary care encounters (to be consistent with the cohort definition of the Other PCPs), and we excluded the “possible” Designated WH Providers. Figure 2 presents the frequency distribution for the percent unique women veterans out of total veterans seen by Designated WH Providers in FY2012, which varied widely across providers. For example, for over three-quarters (78%) of Designated WH Providers, women veterans comr
Community Clinics
50%
0%
Analysis
Copyright
Hospitals 60%
Percent of Sites
From VHA administrative datasets, we counted number of primary care encounters that each woman veteran had with Designated WH Providers and Other PCPs in FY2012.
70%
2015 Wolters Kluwer Health, Inc. All rights reserved.
1
2
3+
Number of Designated WH Providers at Site
FIGURE 1. Distribution of number of Designated WH Providers per site at hospitals versus community clinics in FY2012. The count of Designated WH Providers here represented the number of Designated WH Providers at each site, whether they were full-time or part-time providers. For 8 Designated WH Providers, the Women Veterans Program Manager noted that this person worked at more than 1 site. According to the Veterans Health Administration administrative dataset, for
AND
PREVENTION
Readying the Workforce Evaluation of VHA’s Comprehensive Women’s Health Primary Care Provider Initiative Natalya C. Maisel, PhD,* Sally Haskell, MD,w Patricia M. Hayes, PhD,w Vidhya Balasubramanian, MS,* Anupama Torgal, MPH,w Lakshmi Ananth, MS,z Fay Saechao, MPH,* Samina Iqbal, MD,y8 Ciaran S. Phibbs, PhD,*zz# and Susan M. Frayne, MD, MPH*y8#
Background: Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women’s health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. Objective: To evaluate early implementation of this national policy. Methods: At each VHA health care system (N = 140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. Results: Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD = 27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD = 7%) for Other PCPs (P < 0.001). For women veterans using primary care (N = 313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P < 0.001).
From the *Women’s Health Evaluation Initiative (WHEI), Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; wWomen’s Health Services, VA Central Office, Washington, DC; zHealth Economics Resource Center; yWomen’s Health Service, Medical Service, VA Palo Alto Health Care System, Palo Alto, CA; 8Division of General Medical Disciplines; zDepartment of Pediatrics; and #Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA. This evaluation was conducted by the Women’s Health Evaluation Initiative at VA Palo Alto Health Care System, which is funded for program evaluation work by VA Women’s Health Services in the Veterans Health Administration’s Office of Patient Care Services. All authors received funding from, or are employees of, the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. The authors declare no conflict of interest. Reprints: Natalya C. Maisel, PhD, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5304-0S39
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
Conclusions: VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention. Key Words: women’s health, veterans, primary health care, policy (Med Care 2015;53: S39–S46)
T
he Veterans Health Administration’s (VHA) commitment to optimizing quality of care for the growing population of women veterans1 includes its goal of offering comprehensive primary care services for women.2 However, in 2008, a federal report2 highlighted gaps in comprehensive primary care for women: approximately half of VHA facilities at that time referred women out of primary care to women’s preventive health clinics or specialists for basic sex-specific needs, such as Pap smears and clinical breast examinations.3 Because of women veterans’ status as a numerical minority, “many VA providers [had] little or no exposure to women patients”2(p16) and, therefore, often lacked experience delivering women’s health (WH) care.4 Responding to this inequity, VHA created policy5 in 2010 to improve comprehensive primary care for women. One of the central goals highlighted in this policy was that all VHA facilities would now have Designated WH comprehensive primary care providers (Designated WH Providers). These providers were to be selected based upon their interest in treating women and their willingness to be preferentially assigned women, and would be expected to maintain ongoing proficiency in WH. Proficiency was operationalized as having a substantial number of women in the provider’s panel; these providers were expected to see at least 10% women in primary care (suggesting a panel enriched with women, as women represented only 5%–6% of veteran patients at that time1,6), or have an alternative proficiency plan in place. VHA’s structure includes 140 health care systems nationally, each composed of one or more hospitals (typically providing inpatient and outpatient care) and multiple smaller www.lww-medicalcare.com |
S39
Medical Care
Maisel et al
community clinics (geographically dispersed points of primary care, potentially also offering other onsite specialty services7). Women’s use of community clinics has been on the rise.8 The new policy was designed to make Designated WH Providers available to women across VHA at all hospitals and community clinics, not only in WH Clinics available at some hospitals. Despite VHA’s sustained commitment to WH care quality improvement,9 it is unclear whether the goals of this policy are fully met VHA-wide. Previous evaluations focused on availability and utilization of WH Clinics1,9–12 and on initial estimates of the size of the Designated WH Provider workforce.13 Although creation of Designated WH Providers is the central focus of VHA policy for comprehensive primary care for women, these providers have not been identified previously at the national level, and it is unknown if the current workforce meets the goals of VHA policy. For VHA to address gaps in its ability to provide comprehensive primary care, it is necessary to know more about the implementation of Designated WH Provider policy. Therefore, the current evaluation of early policy implementation built on previous work, capitalizing on a national workforce capacity assessment that for the first time identified all Designated WH Providers. We asked 3 central questions in this evaluation of the 2012 Designated WH Provider workforce: (1) Were Designated WH Providers located at every site across VHA, including community clinics? (2) Were Designated WH Providers indeed seeing more women veterans and having more encounters with women veterans than Other PCPs? (a) How did the patient panel of Designated WH Providers at hospitals compare to those at community clinics? (3) Were women veterans accessing Designated WH Providers for primary care? (a) Were new women patients as likely as established women patients to see Designated WH Providers?
METHODS Overview of Evaluation VHA’s national Designated WH Provider Assessment of Workforce Capacity (DAWC) asked key informants to identify all local Designated WH Providers at all primary care sites within the 140 health care systems, consisting of 148 hospitals and 743 community clinics in total. DAWC data were then merged with VHA administrative data on providers and patients.
Evaluation Design and Data Sources
Volume 53, Number 4 Suppl 1, April 2015
at all hospitals/community clinics in their local health care systems. Participation was 100%. After training, each Women Veterans Program Manager received a personalized Excel spreadsheet prepopulated with a list of all PCPs at the local health care system. The Program Manager selected the Designated WH Providers from the list, manually adding the name of any missing Designated WH Provider; any added provider was later located in VHA administrative datasets. If the Program Manager was uncertain about a provider’s status, he or she marked the provider as a “possible” Designated WH Provider. Only 4.5% of all Designated WH Providers were identified as “possible” and are treated as Designated WH Providers herein except when noted. Using a unique provider identification number for linkage, we merged data from the assessment with information from VHA administrative data. These data included patient records of encounters (National Patient Care Database) and provider records (Primary Care Management Module).
Analytic Cohorts PCP Cohort Analyses focused on PCPs in VHA; some analyses examined only the Designated WH Provider subset. We compared Designated WH Providers to the Other PCPs in VHA, selecting medical doctors, doctors of osteopathy, nurse practitioners, or physician’s assistants, exclusive of residents/trainees. To confirm that these Other PCPs were active PCPs at least part time for at least part of FY2012, we restricted to providers with Z50 primary care encounters with veterans in FY2012 (exploring other cutoffs with sensitivity analyses); this resulted in 8432 PCPs (“Designated WH Providers” or “Other PCPs”).
Patient Cohort For patient analyses, the cohort was composed of 313,033 women veterans with at least 1 VHA primary care encounter in FY2012, as defined elsewhere.1 Note that for this evaluation, nonveterans,14 comprising 11% of women primary care patients in FY2012, were excluded.
Variables, Provider-Level Provider Location Provider location came from VHA administrative datasets; for Designated WH Providers, the Women Veterans Program Manager had the opportunity to correct location if this required updating. Each provider was assigned a unique location, even if he/she provided some care at another location. Locations were classified as a hospital or a community clinic.7,13
The key informant completing this assessment was the Women Veterans Program Manager5 at each health care system; the Program Manager serves as a point of contact for women in VHA and is knowledgeable about the Designated WH Providers at the local facility. These Women Veterans Program Managers (N = 140) completed the assessment in Fall 2012 to describe the Fiscal Year (FY) 2012 (October 2011–September 2012) Designated WH Provider workforce
Patients/Encounters in Primary Care
S40 | www.lww-medicalcare.com
Copyright
From VHA administrative datasets, for each provider we counted number of unique veterans and number of veteran encounters in primary care in FY2012, by patient sex. r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
VHA Women’s Health Provider Evaluation
Variables, Patient-Level Encounters With Providers
New/Established Status A woman was considered “new” to VHA if she used no outpatient or inpatient services in the 3 years before her first FY2012 outpatient visit (N = 36,425).15 All others were classified as “established” patients (N = 276,608).
40% 30% 20% 10%
0
For descriptive purposes, we present unadjusted percents, means, SDs, and medians. For basic tests of statistical significance, analyses were conducted in Stata version 11.2, including negative binomial regression to account for overdispersion of count data. To account for health care systemlevel variability, we included Stata’s “cluster” command.
RESULTS Designated WH Provider and Other PCP Workforce Among the 8432 VHA PCPs in FY2012, 1945 (23%) were Designated WH Providers for at least part of FY2012 (including 87 “possible” Designated WH Providers). Of the 1945 Designated WH Providers, the majority (62%) were located at community clinics. Percent of PCPs identified as Designated WH Providers varied across the 140 health care systems. For example, Designated WH Providers comprised 14% of PCPs for the 25th percentile of health care systems, 21% for the 50th percentile (ie, the median), and 32% for the 75th percentile. Likewise, Designated WH Providers comprised 16% of all hospital-based PCPs, and 32% of community clinic-based PCPs. To address one of the central aspects of VHA policy,5 we examined whether there were Designated WH Providers at all points of care. Across the 140 health care systems, 100% had at least 1 Designated WH Provider. Within these health care systems, of the 148 hospitals, 97% had at least 1 Designated WH Provider, and of the 743 community clinics, 83% had at least 1 Designated WH Provider. In Figure 1, 3% of hospitals had no Designated WH Providers, 31% had exactly 1 or 2, and the majority (66%) had 3 or more. In contrast, 17% of community clinics had no Designated WH Providers, the majority (64%) had exactly 1 or 2, and only 19% had 3 or more.
Patients of Designated WH Providers When examining the patient composition of Designated WH Providers, we restricted the Designated WH Provider cohort to those with at least 50 primary care encounters (to be consistent with the cohort definition of the Other PCPs), and we excluded the “possible” Designated WH Providers. Figure 2 presents the frequency distribution for the percent unique women veterans out of total veterans seen by Designated WH Providers in FY2012, which varied widely across providers. For example, for over three-quarters (78%) of Designated WH Providers, women veterans comr
Community Clinics
50%
0%
Analysis
Copyright
Hospitals 60%
Percent of Sites
From VHA administrative datasets, we counted number of primary care encounters that each woman veteran had with Designated WH Providers and Other PCPs in FY2012.
70%
2015 Wolters Kluwer Health, Inc. All rights reserved.
1
2
3+
Number of Designated WH Providers at Site
FIGURE 1. Distribution of number of Designated WH Providers per site at hospitals versus community clinics in FY2012. The count of Designated WH Providers here represented the number of Designated WH Providers at each site, whether they were full-time or part-time providers. For 8 Designated WH Providers, the Women Veterans Program Manager noted that this person worked at more than 1 site. According to the Veterans Health Administration administrative dataset, for
