EDITORIAL
The Role of Research in a Time of Rapid Change Lessons From Research on Women Veterans’ Health David Atkins, MD, MPH and Linda Lipson, MA
T
he coming year will bring a set of fundamental changes to the Department of Veterans Affairs (VA) as the VA undergoes substantial reorganization and works to restore the trust that was seriously ruptured by recent scandals involving delays in access to care. Foremost of these changes will be implementation of the Veterans Access, Choice and Accountability Act of 2014, which provides $10 billion for increasing non-VA care options for Veterans waiting >30 days or living >40 miles from a VA facility, as well as an additional $5 billion for expanding VA facilities and services.1 Further changes are outlined in the Blueprint for Excellence, a detailed plan by the new VA leadership to improve Veteran access to quality health care and ensure an exceptional patient experience for all Veterans.2 Meeting these challenges will require we demonstrate that the VA delivers quality and value comparable to the best of the private sector, continues to set the standard of care for military service–related conditions such as traumatic brain injury and posttraumatic stress disorder, and coordinates care that best meets the needs of Veterans, including care outside of VA. These challenges provide an opportunity for the VA Office of Research and Development, and specifically the Health Services Research and Development (HSR&D) program to demonstrate how an embedded research program can support the transformation of VA health care and improve outcomes for Veterans. The recent history of HSR&D research in women Veterans’ health care provides an excellent model of how embedded research can help a health system adapt to changing needs. As women became the most rapidly increasing segment of the Veteran population, health services researchers played a critical role in helping VA adapt to their unique needs. Researchers documented specific needs, preferences, and barriers to access for women Veterans; helped evaluate the impact of new models of women-centered care; and brought attention to unique issues of female Veterans such as military sexual trauma. Beginning 10 years ago, the concerted effort of VA health services researchers working with program partners in the Office of Women’s Health Services, helped outline a comprehensive research agenda and grow the pool of VA researchers working in this increasingly important area.3 In 2010, HSR&D funded the transformative Women’s Health Research Network to further grow VA’s women’s health research capacity, systematically assess and address priority research areas, and develop a VA Practice-based Research Network to significantly expand the scope of research and the number of women Veterans participating in research, as well as develop a nationwide infrastructure for multisite research that optimally includes women Veterans.4 The fruits of these efforts and the diverse research on access, patient experience, and issues specific to women Veterans are highlighted in this special issue. Also featured are several articles on projects funded as part of a 2012 HSR&D funding initiative on CollabFrom the Health Services Research and Development, Office of Research and Development, Department of Veterans Affairs, Washington, DC. Supported by Health Services Research and Development Service, Office of Research and Development, 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: David Atkins, MD, MPH, Health Services Research and Development (10P9H), Office and Research and Development, Department of Veterans Affairs, Washington, DC 20420. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5304-00S5
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
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Volume 53, Number 4 Suppl 1, April 2015
orative Research to Enhance and Advance Transformation and Excellence (CREATE), which emphasized VA program partnerships and coordination across multiple projects.5 The VA Women’s Health CREATE, led by Dr Elizabeth Yano, in partnership with Dr Patricia Hayes, Chief Consultant of VA Women’s Health Services, is not yet complete but already has helped accelerate research on how best to improve access to comprehensive women’s health care in VA.6 The experience of women Veterans highlights the important connections between our current priorities of access and improving patient experience. As Veterans have increasing options of where to seek care, VA’s survival as an integrated delivery system depends on our ability to provide timely high-quality care that meets their needs. As outlined by Secretary McDonald, “Customer satisfaction is the most important metric for any organization, and that means Veteran satisfaction.”7 Although VA patient satisfaction on average is on a par with other health systems, national surveys have highlighted gaps in satisfaction for the 2 most rapidly growing cohorts of Veterans—women Veterans and younger Veterans.8 Female enrollees are less likely than male enrollees to concur on statements regarding respect, satisfaction, appointment time, and availability.8 The articles in this supplement illustrate how careful research can help unpack the reasons behind this sex gap and inform strategies for addressing it. The paper by Washington provides a comprehensive national view of care needs and barriers to care for women Veterans, whereas other articles explore specific sex-specific needs in more depth.9 Multiple articles describe different approaches to expanding capacity to sex-specific care, including expanding use of gynecologists, training up women’s health expertise among primary care providers, and using novel telehealth strategies such as the Specialty Care Access Network-Extension for Community Healthcare Outcomes (or SCAN-ECHO), to provide gynecology consultation and education.10–12 The research highlights both important progress as well as specific challenges in using these approaches to meet the documented need. Dr Susan Zickmund, in the VA HSR&D Center for Health Equity Research and Promotion, is completing a major project “Understanding Women’s Disparities in Satisfaction with VA Healthcare (DISC WOMEN)” to understand Veterans’ reasons for satisfaction with their overall VA care, examining 13 different domains of care (eg, access, communication, respect, women’s health) and exploring how race, ethnicity, and sex affect satisfaction. The unique needs of women Veterans are not restricted to sex-specific issues such as gynecologic and reproductive health. Common conditions among Veterans, including mental health problems and substance use, may manifest themselves differently and have different correlates among women. Research by Kimerling et al13 in this supplement documents high perceived need for mental health services (50%) among a primary care population of women Veterans, but it also confirms good access to mental health care (75% of those reporting need received services). Implementation of the Choice Act poses a substantial challenge to VA leadership, and evaluating its impact will similarly challenge researchers. To the extent that women Veterans are less satisfied with their current VA options, they
may be more likely than male Veterans to seek authorization for non-VA services under the Act. But providing more timely access does not guarantee better outcomes or improved patient experience. Research has shown that Medicare-aged Veterans who use both VA and non-VA care have worse outcomes than those getting all of their care in VA.14 We will need to study and learn how to ensure good communication and coordination across different systems of care as well as develop valid indicators for the quality of the care received outside VA. For example, will women accessing gynecology services outside the VA be more likely to be screened for cervical cancer, will the screening and follow-up procedures be more likely to be consistent with the latest guidelines, and will the results of testing be reliably transmitted to VA? HSR&D research in partnership with policy and operations leaders will help ensure that we are able to answer those questions and ready the VA health care system for the changes ahead.
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CONCLUSIONS Research on women Veterans offers several important lessons for the VA and our researchers as we adjust to rapid change. Foremost is the value of “patient-centeredness” as an organizing principle for care and for research on that care. Both should begin with an understanding of the needs, values, and preferences each patient brings to their clinical encounters and which shape their expectations for care. Although research has documented many areas of distinct needs or barriers for women Veterans compared with their male counterparts, Veteran men and women have much more in common in other areas (eg, in the barriers imposed by living far from care). The second is the need to examine care and clinical policy at the level of the patient, the provider, the clinical microsystem, the larger health care system and the community. Solutions that do not consider these different levels are more likely to fail or to have unintended consequences. Third, mixed-method research that uses careful qualitative research to derive deeper understanding of quantitative findings is crucial for developing effective interventions. Finally, the highly successful researchoperations partnership in women’s health highlights the opportunities and challenges of trying to align the interests and timelines of both the partners. On both sides, effective partners must be engaged, responsive, creative, and dogged. But perhaps the most important key to success is a sense of urgency. Our researchers and partners knew that the problems of women Veterans were urgent, and they responded in kind and their efforts are now bearing fruit. This is a hopeful lesson as we face a new series of critical challenges to the VA. REFERENCES 1. Veterans Access, Choice and Accountability Act of 2014. Available at: http://www.va.gov/opa/choiceact/documents/Choice-Act-Summary.pdf. Accessed January 30, 2015. 2. Blueprint for Excellence. Available at: http://www.va.gov/HEALTH/ docs/VHA_Blueprint_for_Excellence.pdf. Accessed January 30, 2015. 3. Yano EM, Bastian LA, Bean-Mayberry B, et al. Using research to transform care for women Veterans: advancing the research agenda and enhancing research-clinical partnerships. Womens Health Issues. 2011;21(suppl):S73–S83. 4. Frayne SM, Carney DV, Bastian LA, et al. The VA women’s health practice-based research network: amplifying women veterans’ r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care
5. 6. 7. 8. 9.
Volume 53, Number 4 Suppl 1, April 2015
voices in VA research. J Gen Intern Med. 2013;28(suppl 2): S504–S509. HSR&D Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative. Available at: http:// www.hsrd.research.va.gov/centers/create/. Accessed January 26, 2015. Yano EM. A partnered research initiative to accelerate implementation of comprehensive care among women veterans: The Women’s Health CREATE. Med Care. 2015;53(Suppl 1):S10–S14. Remarks by Secretary Robert A. McDonald. American Legion 96th Annual Convention Charlotte, NC, August 26, 2014. Available at: http://www. va.gov/opa/speeches/2014/08_26_2014.asp. Accessed January 30, 2015. Wright SM, Craig T, Campbell S, et al. Patient satisfaction of female and male users of Veterans Health Administration Services. J Gen Intern Med. 2006;21:S26–S32. Washington DL, Farmer MM, Mor SS, et al. Assessment of the health care needs and barriers to VA use experienced by women veterans:
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Role of Research in a Time of Rapid Change
10. 11. 12. 13. 14.
findings from the National Survey of Women Veterans. Med Care. 2015;53(Suppl 1):S23–S31. Maisel NC, Haskell S, Hayes PM, et al. Readying the workforce: evaluation of VHA’s comprehensive women’s health primary care provider initiative. Med Care. 2015;53(Suppl 1):S39–S46. Cordasco KM, Zuchowski J, Hamilton AB, et al. Lessons learned in implementing VA’s comprehensive women’s health SCAN-ECHO program. Med Care. 2015;53(Suppl 1):S88–S92. Gray KE, Katon JG, Callegari LS, et al. Gynecologists in the VA: do they enhance availability of gender-specific services in the emergency department? Med Care. 2015;53(Suppl 1):S76–S80. Kimerling R, Pavao J, Greene L, et al. Access to mental health care among women Veterans: is VA meeting women’s needs? Med Care. 2015;53(Suppl 1):S97–S104. Pizer SD, Gardner JA. Is fragmented financing bad for your health? Inquiry. 2011;48:109–122.
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The Role of Research in a Time of Rapid Change Lessons From Research on Women Veterans’ Health David Atkins, MD, MPH and Linda Lipson, MA
T
he coming year will bring a set of fundamental changes to the Department of Veterans Affairs (VA) as the VA undergoes substantial reorganization and works to restore the trust that was seriously ruptured by recent scandals involving delays in access to care. Foremost of these changes will be implementation of the Veterans Access, Choice and Accountability Act of 2014, which provides $10 billion for increasing non-VA care options for Veterans waiting >30 days or living >40 miles from a VA facility, as well as an additional $5 billion for expanding VA facilities and services.1 Further changes are outlined in the Blueprint for Excellence, a detailed plan by the new VA leadership to improve Veteran access to quality health care and ensure an exceptional patient experience for all Veterans.2 Meeting these challenges will require we demonstrate that the VA delivers quality and value comparable to the best of the private sector, continues to set the standard of care for military service–related conditions such as traumatic brain injury and posttraumatic stress disorder, and coordinates care that best meets the needs of Veterans, including care outside of VA. These challenges provide an opportunity for the VA Office of Research and Development, and specifically the Health Services Research and Development (HSR&D) program to demonstrate how an embedded research program can support the transformation of VA health care and improve outcomes for Veterans. The recent history of HSR&D research in women Veterans’ health care provides an excellent model of how embedded research can help a health system adapt to changing needs. As women became the most rapidly increasing segment of the Veteran population, health services researchers played a critical role in helping VA adapt to their unique needs. Researchers documented specific needs, preferences, and barriers to access for women Veterans; helped evaluate the impact of new models of women-centered care; and brought attention to unique issues of female Veterans such as military sexual trauma. Beginning 10 years ago, the concerted effort of VA health services researchers working with program partners in the Office of Women’s Health Services, helped outline a comprehensive research agenda and grow the pool of VA researchers working in this increasingly important area.3 In 2010, HSR&D funded the transformative Women’s Health Research Network to further grow VA’s women’s health research capacity, systematically assess and address priority research areas, and develop a VA Practice-based Research Network to significantly expand the scope of research and the number of women Veterans participating in research, as well as develop a nationwide infrastructure for multisite research that optimally includes women Veterans.4 The fruits of these efforts and the diverse research on access, patient experience, and issues specific to women Veterans are highlighted in this special issue. Also featured are several articles on projects funded as part of a 2012 HSR&D funding initiative on CollabFrom the Health Services Research and Development, Office of Research and Development, Department of Veterans Affairs, Washington, DC. Supported by Health Services Research and Development Service, Office of Research and Development, 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: David Atkins, MD, MPH, Health Services Research and Development (10P9H), Office and Research and Development, Department of Veterans Affairs, Washington, DC 20420. E-mail: [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5304-00S5
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
www.lww-medicalcare.com |
S5
Editorial
Medical Care
Volume 53, Number 4 Suppl 1, April 2015
orative Research to Enhance and Advance Transformation and Excellence (CREATE), which emphasized VA program partnerships and coordination across multiple projects.5 The VA Women’s Health CREATE, led by Dr Elizabeth Yano, in partnership with Dr Patricia Hayes, Chief Consultant of VA Women’s Health Services, is not yet complete but already has helped accelerate research on how best to improve access to comprehensive women’s health care in VA.6 The experience of women Veterans highlights the important connections between our current priorities of access and improving patient experience. As Veterans have increasing options of where to seek care, VA’s survival as an integrated delivery system depends on our ability to provide timely high-quality care that meets their needs. As outlined by Secretary McDonald, “Customer satisfaction is the most important metric for any organization, and that means Veteran satisfaction.”7 Although VA patient satisfaction on average is on a par with other health systems, national surveys have highlighted gaps in satisfaction for the 2 most rapidly growing cohorts of Veterans—women Veterans and younger Veterans.8 Female enrollees are less likely than male enrollees to concur on statements regarding respect, satisfaction, appointment time, and availability.8 The articles in this supplement illustrate how careful research can help unpack the reasons behind this sex gap and inform strategies for addressing it. The paper by Washington provides a comprehensive national view of care needs and barriers to care for women Veterans, whereas other articles explore specific sex-specific needs in more depth.9 Multiple articles describe different approaches to expanding capacity to sex-specific care, including expanding use of gynecologists, training up women’s health expertise among primary care providers, and using novel telehealth strategies such as the Specialty Care Access Network-Extension for Community Healthcare Outcomes (or SCAN-ECHO), to provide gynecology consultation and education.10–12 The research highlights both important progress as well as specific challenges in using these approaches to meet the documented need. Dr Susan Zickmund, in the VA HSR&D Center for Health Equity Research and Promotion, is completing a major project “Understanding Women’s Disparities in Satisfaction with VA Healthcare (DISC WOMEN)” to understand Veterans’ reasons for satisfaction with their overall VA care, examining 13 different domains of care (eg, access, communication, respect, women’s health) and exploring how race, ethnicity, and sex affect satisfaction. The unique needs of women Veterans are not restricted to sex-specific issues such as gynecologic and reproductive health. Common conditions among Veterans, including mental health problems and substance use, may manifest themselves differently and have different correlates among women. Research by Kimerling et al13 in this supplement documents high perceived need for mental health services (50%) among a primary care population of women Veterans, but it also confirms good access to mental health care (75% of those reporting need received services). Implementation of the Choice Act poses a substantial challenge to VA leadership, and evaluating its impact will similarly challenge researchers. To the extent that women Veterans are less satisfied with their current VA options, they
may be more likely than male Veterans to seek authorization for non-VA services under the Act. But providing more timely access does not guarantee better outcomes or improved patient experience. Research has shown that Medicare-aged Veterans who use both VA and non-VA care have worse outcomes than those getting all of their care in VA.14 We will need to study and learn how to ensure good communication and coordination across different systems of care as well as develop valid indicators for the quality of the care received outside VA. For example, will women accessing gynecology services outside the VA be more likely to be screened for cervical cancer, will the screening and follow-up procedures be more likely to be consistent with the latest guidelines, and will the results of testing be reliably transmitted to VA? HSR&D research in partnership with policy and operations leaders will help ensure that we are able to answer those questions and ready the VA health care system for the changes ahead.
S6 | www.lww-medicalcare.com
Copyright
CONCLUSIONS Research on women Veterans offers several important lessons for the VA and our researchers as we adjust to rapid change. Foremost is the value of “patient-centeredness” as an organizing principle for care and for research on that care. Both should begin with an understanding of the needs, values, and preferences each patient brings to their clinical encounters and which shape their expectations for care. Although research has documented many areas of distinct needs or barriers for women Veterans compared with their male counterparts, Veteran men and women have much more in common in other areas (eg, in the barriers imposed by living far from care). The second is the need to examine care and clinical policy at the level of the patient, the provider, the clinical microsystem, the larger health care system and the community. Solutions that do not consider these different levels are more likely to fail or to have unintended consequences. Third, mixed-method research that uses careful qualitative research to derive deeper understanding of quantitative findings is crucial for developing effective interventions. Finally, the highly successful researchoperations partnership in women’s health highlights the opportunities and challenges of trying to align the interests and timelines of both the partners. On both sides, effective partners must be engaged, responsive, creative, and dogged. But perhaps the most important key to success is a sense of urgency. Our researchers and partners knew that the problems of women Veterans were urgent, and they responded in kind and their efforts are now bearing fruit. This is a hopeful lesson as we face a new series of critical challenges to the VA. REFERENCES 1. Veterans Access, Choice and Accountability Act of 2014. Available at: http://www.va.gov/opa/choiceact/documents/Choice-Act-Summary.pdf. Accessed January 30, 2015. 2. Blueprint for Excellence. Available at: http://www.va.gov/HEALTH/ docs/VHA_Blueprint_for_Excellence.pdf. Accessed January 30, 2015. 3. Yano EM, Bastian LA, Bean-Mayberry B, et al. Using research to transform care for women Veterans: advancing the research agenda and enhancing research-clinical partnerships. Womens Health Issues. 2011;21(suppl):S73–S83. 4. Frayne SM, Carney DV, Bastian LA, et al. The VA women’s health practice-based research network: amplifying women veterans’ r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care
5. 6. 7. 8. 9.
Volume 53, Number 4 Suppl 1, April 2015
voices in VA research. J Gen Intern Med. 2013;28(suppl 2): S504–S509. HSR&D Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative. Available at: http:// www.hsrd.research.va.gov/centers/create/. Accessed January 26, 2015. Yano EM. A partnered research initiative to accelerate implementation of comprehensive care among women veterans: The Women’s Health CREATE. Med Care. 2015;53(Suppl 1):S10–S14. Remarks by Secretary Robert A. McDonald. American Legion 96th Annual Convention Charlotte, NC, August 26, 2014. Available at: http://www. va.gov/opa/speeches/2014/08_26_2014.asp. Accessed January 30, 2015. Wright SM, Craig T, Campbell S, et al. Patient satisfaction of female and male users of Veterans Health Administration Services. J Gen Intern Med. 2006;21:S26–S32. Washington DL, Farmer MM, Mor SS, et al. Assessment of the health care needs and barriers to VA use experienced by women veterans:
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Role of Research in a Time of Rapid Change
10. 11. 12. 13. 14.
findings from the National Survey of Women Veterans. Med Care. 2015;53(Suppl 1):S23–S31. Maisel NC, Haskell S, Hayes PM, et al. Readying the workforce: evaluation of VHA’s comprehensive women’s health primary care provider initiative. Med Care. 2015;53(Suppl 1):S39–S46. Cordasco KM, Zuchowski J, Hamilton AB, et al. Lessons learned in implementing VA’s comprehensive women’s health SCAN-ECHO program. Med Care. 2015;53(Suppl 1):S88–S92. Gray KE, Katon JG, Callegari LS, et al. Gynecologists in the VA: do they enhance availability of gender-specific services in the emergency department? Med Care. 2015;53(Suppl 1):S76–S80. Kimerling R, Pavao J, Greene L, et al. Access to mental health care among women Veterans: is VA meeting women’s needs? Med Care. 2015;53(Suppl 1):S97–S104. Pizer SD, Gardner JA. Is fragmented financing bad for your health? Inquiry. 2011;48:109–122.
www.lww-medicalcare.com |
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