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Pace R, Goldstein KM, Williams AR, Clayton-Stiglbauer K, Meernik C, Shepherd-Banigan M, Chawla N, Moss H, Skalla LA, Colonna S, Kelley MJ, Zullig LL. The Landscape of Care for Women Veterans with Cancer: An Evidence Map. J Gen Intern Med 2024:10.1007/s11606-024-08903-7. [PMID: 38965201 DOI: 10.1007/s11606-024-08903-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. METHODS We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. RESULTS Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. DISCUSSION Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.
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Affiliation(s)
- Rachel Pace
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - April R Williams
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Cooperative Studies Program Epidemiology Center, Durham VA Healthcare System, Durham, NC, USA
- Million Veteran Program, Boston Coordinating Center, Boston, MA, USA
| | | | | | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, NC, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC), Durham VA Healthcare System, Durham, NC, USA
| | - Neetu Chawla
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Haley Moss
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Department of Obstetrics and Gynecology, Duke University Healthcare System, Durham, NC, USA
| | - Lesley A Skalla
- Duke University Medical Center Library and Archives, Duke University School of Medicine, Durham, NC, USA
| | | | - Michael J Kelley
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- National Oncology Program, Department of Veterans Affairs, Washington, DC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Finley EP, Chrystal JG, Gable AR, Fletcher EH, Palma A, Canelo I, Oberman RS, Jackson LSS, Lesser R, Moin T, Bean-Mayberry B, Farmer MM, Hamilton A. The Rapid Implementation Feedback (RIF) report: real-time synthesis of qualitative data for proactive implementation planning and tailoring. Implement Sci Commun 2024; 5:69. [PMID: 38907331 PMCID: PMC11191329 DOI: 10.1186/s43058-024-00605-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/09/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Qualitative methods are a critical tool for enhancing implementation planning and tailoring, yet rapid turn-around of qualitative insights can be challenging in large implementation trials. The Department of Veterans Affairs-funded EMPOWER 2.0 Quality Enhancement Research Initiative (QUERI) is conducting a hybrid type 3 effectiveness-implementation trial comparing the impact of Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) as strategies for implementing three evidence-based practices (EBPs) for women Veterans. We describe the development of the Rapid Implementation Feedback (RIF) report, a pragmatic, team-based approach for the rapid synthesis of qualitative data to aid implementation planning and tailoring, as well as findings from a process evaluation of adopting the RIF report within the EMPOWER 2.0 QUERI. METHODS Trained qualitative staff conducted 125 semi-structured pre-implementation interviews with frontline staff, providers, and leadership across 16 VA sites between October 2021 and October 2022. High-priority topic domains informed by the updated Consolidated Framework for Implementation Research were selected in dialogue between EMPOWER 2.0 implementation and evaluation teams, and relevant key points were summarized for each interview to produce a structured RIF report, with emergent findings about each site highlighted in weekly written and verbal communications. Process evaluation was conducted to assess EMPOWER 2.0 team experiences with the RIF report across pre-implementation data collection and synthesis and implementation planning and tailoring. RESULTS Weekly RIF updates supported continuous EMPOWER 2.0 team communication around key findings, particularly questions and concerns raised by participating sites related to the three EBPs. Introducing the RIF report into team processes enhanced: team communication; quality and rigor of qualitative data; sensemaking around emergent challenges; understanding of site readiness; and tailoring of REP and EBQI implementation strategies. RIF report findings have facilitated rapid tailoring of implementation planning and rollout, supporting increased responsiveness to sites' needs and concerns. CONCLUSIONS The RIF report provides a structured strategy for distillation of time-sensitive findings, continuous team communication amid a complex multi-site implementation effort, and effective tailoring of implementation rollout in real-time. Use of the RIF report may also support trust-building by enhancing responsiveness to sites during pre- and early implementation. TRIAL REGISTRATION Enhancing Mental and Physical Health of Women Veterans (NCT05050266); https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1 Date of registration: 09/09/2021.
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Affiliation(s)
- Erin P Finley
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Joe R. & Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Joya G Chrystal
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alicia R Gable
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Erica H Fletcher
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Agatha Palma
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ismelda Canelo
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rebecca S Oberman
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - La Shawnta S Jackson
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rachel Lesser
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Tannaz Moin
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Bevanne Bean-Mayberry
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Melissa M Farmer
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alison Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Pebole MM, Whitworth JW, Iverson KM, Currao A, Fortier CB. Traumatic Brain Injury and Posttraumatic Stress Disorder Are Associated with Physical Health Burden among Post-9/11 Women Veterans. J Womens Health (Larchmt) 2024. [PMID: 38873776 DOI: 10.1089/jwh.2024.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
Background: Little research focuses on physical health outcomes of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) among post-9/11 women veterans (WVs). This study examined lifetime TBI, current PTSD, and their associations with biomarkers of cardiometabolic health, sleep, pain, and functional disability among post-9/11 WVs. Methods: WVs (n = 90) from the Translational Research Center for TBI and Stress Disorders longitudinal cohort study were included in this study. Gold standard clinician administered interviews assessed lifetime TBI (Boston Assessment of TBI-Lifetime) and current PTSD symptoms (Clinician-Administered PTSD Scale-IV). Objective measures of health included waist-hip ratio (WHR) and fasted blood biomarker (high density lipoprotein [HDL], low density lipoprotein [LDL], blood glucose, triglycerides) levels. Self-reported surveys assessed sleep, pain, and functional disability. Results: Just under two-thirds (58.9%) of WVs experienced a lifetime TBI, and just over half (53.3%) of this sample had a current PTSD diagnosis at the time of testing. Lifetime TBI was significantly associated with higher WHR, triglycerides levels, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.01 to 1.12). Current PTSD was significantly associated with higher WHR, lower HDL, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.009 to 1.19). PTSD was significantly associated with lower total functioning and each of its subdomains (βs = -0.58 to 0.63; ps = <0.001 to 0.02). Lifetime TBI was significantly associated with total functioning, mobility, and life/work (βs = -0.20 to 0.30; ps = <0.01 to 0.02). Conclusions: These findings highlight the importance of screening for lifetime TBI and cardiovascular disease for WVs and support transdiagnostic treatment approaches targeting physical health outcomes.
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Affiliation(s)
- Michelle M Pebole
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - James W Whitworth
- National Center for PTSD Behavioral Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Massachusetts, USA
| | - Katherine M Iverson
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Massachusetts, USA
- National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Alyssa Currao
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Catherine B Fortier
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Yano EM, Than C, Brunner J, Canelo IA, Meredith LS, Rubenstein LV, Hamilton AB. Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs. J Gen Intern Med 2024; 39:1349-1359. [PMID: 38424344 PMCID: PMC11169220 DOI: 10.1007/s11606-024-08647-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).
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Affiliation(s)
- Elizabeth M Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095, USA.
- Department of Medicine, UCLA Geffen School of Medicine, 855 Tiverton Drive, Los Angeles, CA, 90024, USA.
| | - Claire Than
- National Precision Oncology Program, Veterans Health Administration, Washington, DC, USA
| | - Julian Brunner
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
| | - Ismelda A Canelo
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
| | - Lisa S Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Lisa V Rubenstein
- Department of Medicine, UCLA Geffen School of Medicine, 855 Tiverton Drive, Los Angeles, CA, 90024, USA
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Alison B Hamilton
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA, 91343, USA
- Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
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5
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Farkas AH, Kibicho J, Ndakuya-Fitzgerald F, Mu Q. Development of the Ready to Care Survey for VA Women's Health Primary Care Provider. J Gen Intern Med 2024; 39:1010-1014. [PMID: 37946022 DOI: 10.1007/s11606-023-08467-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/06/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Women Veterans are at increased risk for poor pregnancy outcomes and are increasingly using Veteran Affairs (VA) for maternity benefits. VA Women's Health Primary Care Providers (WH-PCPs) are well positioned to improve maternal outcomes for women Veterans, yet little is understood about their experience and comfort with perinatal care. The objective of this study was to develop and validate a survey that could be utilized to assess WH-PCPs' experience, comfort, and attitudes towards perinatal care. METHODS After a review of the literature, we adapted a previously published survey to address four content areas including clinical experience, comfort level, and attitudes towards perinatal care and knowledge of VA specific maternity services. This survey was piloted with five WH-PCPs before undergoing two rounds of content validation with content experts. Content validity indexes (CVI) were calculated based on the content experts' ratings. Qualitative feedback from the content experts were summarized and reviewed by the research team. The CVI and qualitative responses were utilized to guide the decision to revise, refine, or delete survey questions. RESULTS After the first round of content validation, we deleted three questions, revised three questions, and add three questions to the content areas of clinical experience and comfort. In the domain of attitudes towards perinatal care, we deleted one question and revised two questions and three questions were added to the knowledge of VA specific maternity services domain. After the second round of content validation, only one question was deleted from the attitudes domain. DISCUSSION We developed and validated the Ready to Care Survey for VA WH-PCP using two rounds of content validation. The final survey had face and content validity. This survey tool can be used to assess VA WH-PCP's knowledge and readiness in caring for Veterans of child-bearing age for operational and research needs.
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Affiliation(s)
- Amy H Farkas
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
- Department of Medicine, Milwaukee VA Medical Center, Milwaukee, WI, USA.
| | - Jennifer Kibicho
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | | | - Qiyan Mu
- Division of Nursing Education and Research, Milwaukee VA Medical Center, Milwaukee, WI, USA
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Presseau C, Carney JR, Kline NK, Grimshaw AA, DeMoss L, Gunderson C, Portnoy GA. Child Maltreatment, Adult Trauma, and Mental Health Symptoms Among Women Veterans: A Scoping Review of Published Quantitative Research. TRAUMA, VIOLENCE & ABUSE 2024:15248380241234345. [PMID: 38468375 DOI: 10.1177/15248380241234345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
The objective of this scoping review was to describe and synthesize the measures, methods, and key findings of published quantitative research examining the influence of child maltreatment (i.e., abuse and/or neglect) and adult trauma exposure on mental health symptoms among women Veterans. A systematic search from database inception to June 2023 generated 18,861 unique articles retrieved and independently screened for eligibility. A total of 21 articles met pre-established inclusion criteria: (a) quantitative data and results within a sample or subsample of U.S. women veterans, (b) published in a peer-reviewed journal, and (c) examining variables of interest simultaneously (i.e., child maltreatment, adult trauma exposure, mental health symptom) in quantitative analyses. Reviewed literature showed a lack of uniformity in measurement and methodologies to evaluate women veterans' lifetime trauma exposure in relation to mental health. Studies most frequently used self-report survey data to evaluate exposure to child maltreatment and/or adult trauma with convenience samples of women veterans (52.4%, n = 11) and examined depressive and/or posttraumatic stress symptomatology. Findings demonstrate the need for additional research attending to the interplay between child maltreatment and adult trauma exposures in relation to women veterans' mental health using comprehensive assessment, longitudinal methods, and understudied as well as more representative samples.
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Affiliation(s)
- Candice Presseau
- VA Connecticut Healthcare System, West Haven, USA
- Yale School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Craig Gunderson
- VA Connecticut Healthcare System, West Haven, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, USA
- Yale School of Medicine, New Haven, CT, USA
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Holder N, Ranney RM, Bernhard PA, Holliday R, Vogt D, Hoffmire CA, Blosnich JR, Schneiderman AI, Maguen S. Which veterans with PTSD are most likely to report being told of their diagnosis? J Psychiatr Res 2024; 170:158-166. [PMID: 38147692 DOI: 10.1016/j.jpsychires.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023]
Abstract
Veterans who do not know about their posttraumatic stress disorder (PTSD) diagnosis experience a fundamental barrier to accessing effective treatment. Little is known about the characteristics that influence veterans' PTSD diagnosis knowledge (i.e., report of being told they have a PTSD diagnosis by a healthcare provider). Veterans who met probable and provisional criteria for PTSD on the self-report PTSD checklist for DSM-5 were identified from the Comparative Health Assessment Interview Research Study (n = 2335). Weighted logistic regression was performed to identify demographic variables, clinical characteristics, and social determinants of health (e.g., economic instability, homelessness, healthcare coverage) associated with PTSD diagnosis knowledge among post-9/11 veterans. Approximately 62% of veterans with probable and provisional PTSD had PTSD diagnosis knowledge. Predictors with the strongest associations included another mental health diagnosis (OR = 6.10, CI95:4.58,8.12) and having Veterans Affairs (VA) healthcare coverage (OR = 2.63, CI95:1.97,3.51). Veterans with combat or sexual trauma were more likely to have PTSD diagnosis knowledge than those with different trauma types. Results suggest veterans with VA healthcare coverage and military-related trauma are more likely to be informed by a healthcare professional about a PTSD diagnosis. Further research is needed to improve PTSD diagnosis knowledge for those with non-military-related trauma and those without VA healthcare coverage.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States.
| | - Rachel M Ranney
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States
| | - Paul A Bernhard
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, United States
| | - Ryan Holliday
- Department of Veterans Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, United States; University of Colorado Anschutz Medical Campus, Department of Psychiatry, United States
| | - Dawne Vogt
- Women's Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, United States; Boston University School of Medicine, United States
| | - Claire A Hoffmire
- Department of Veterans Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, United States; University of Colorado Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, United States
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, United States; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, United States
| | - Aaron I Schneiderman
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, United States
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco School of Medicine, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States
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Gao G, Vaughan CP, Markland AD, Reinicke K, Annavaram N, Burningham Z. Leveraging A Clinical Dashboard and Process Mappings to Improve Treatment Access and Outcomes for Women Veterans with Urinary Incontinence. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2024; 2023:359-368. [PMID: 38222400 PMCID: PMC10785906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
In support of the Improving Primary Care Understanding of Resources and Screening for Urinary Incontinence to Enhance Treatment initiative with the Veterans Health Administration, we developed a clinical dashboard to support primary care providers in identifying underdiagnosed, undertreated women Veterans with urinary incontinence. This paper describes our dashboard development and evaluation. We employed a user-centered design in determining dashboard requirements, interface design, and functionality. We invited early users at three pilot sites to formal usability reviews. We quantified the dashboard usability using the System Usability Scale and administered surveys and interviews for insights on performance. We employed process maps to uncover processes of end-users' dashboard engagements within local environments. User evaluations demonstrated the dashboard as a helpful instrument in identifying women Veterans with good to excellent usability performance. User feedback offers a user-driven pathway to develop our dashboard that supports clinicians to better care for women Veterans with urinary incontinence.
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Affiliation(s)
- Grace Gao
- Atlanta VA Healthcare System, Atlanta, GA
| | - Camille P Vaughan
- Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta, GA
- Emory University, Atlanta, GA
| | - Alayne D Markland
- Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Birmingham, AL
- University of Alabama at Birmingham, AL
| | | | | | - Zachary Burningham
- Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation, Salt Lake City, UT
- Veterans Affairs Medical Center, Salt Lake City, UT
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9
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Shepherd-Banigan M, Cannedy S, Rodriguez A, Burns M, Woolson S, Hamilton A, Quiroz I, Matthews H, Garber-Cardwell D, Byrd KG, Brown A, Goldstein KM. Veteran Caretaker Perspectives of the Need for Childcare Assistance During Health Care Appointments. Womens Health Issues 2024; 34:98-106. [PMID: 37838585 PMCID: PMC11145655 DOI: 10.1016/j.whi.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE In 2020, Congress passed legislation to establish the national Veterans Child Care Assistance Program (VCAP) targeting eligible veterans receiving care through the Veterans Health Administration (VA). This needs assessment describes the childcare needs of veteran caretakers of young children and explores the implications of inadequate childcare on health care engagement. METHODS Survey data were collected from 2,000 VA users with dependent children; data were analyzed using standard descriptive statistics. Qualitative data were collected from 19 veterans through focus groups and analyzed using rapid thematic analysis. FINDINGS More than 75% of veterans surveyed indicated that they required childcare assistance during health care appointments and 73% reported barriers to finding childcare. Prominent barriers included the high cost of childcare and not having a trusted source of childcare. Nearly 58% of survey respondents reported missed or canceled VA health care appointments due to childcare challenges. Furthermore, 35% of surveyed veterans reported that their children had accompanied them to an appointment in the past year. Among these veterans, 59% brought their children into the exam room. Focus group participants discussed how having children present during their health care appointments hampered communication with health care providers. CONCLUSIONS Veterans report that lack of childcare keeps them from attending and remaining focused on the provider during their health care visits, which could compromise quality of care. As one of the only health systems in the United States that will offer childcare assistance, VCAP presents an opportunity to improve health care access and quality by reducing missed appointments and suboptimal care.
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Affiliation(s)
- Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina; Duke-Margolis Center for Health Policy, Durham, North Carolina.
| | - Shay Cannedy
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Adriana Rodriguez
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Alison Hamilton
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Ismael Quiroz
- VA Childcare Assistance Program, Office of Women's Health, VA Central Office, Department of Veterans Affairs, Washington, District of Columbia
| | - Hanh Matthews
- VA Childcare Assistance Program, Office of Women's Health, VA Central Office, Department of Veterans Affairs, Washington, District of Columbia
| | - Diane Garber-Cardwell
- VA Childcare Assistance Program, Office of Women's Health, VA Central Office, Department of Veterans Affairs, Washington, District of Columbia
| | - Kaileigh G Byrd
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Adrian Brown
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina; Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
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10
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Rao M, Greene L, Nelson K, Maciejewski ML, Zulman DM. Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans. J Gen Intern Med 2023; 38:3339-3347. [PMID: 37369890 PMCID: PMC10682359 DOI: 10.1007/s11606-023-08269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services. OBJECTIVE To study associations between social risks and primary care utilization among patients with medical complexity. DESIGN Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion. PARTICIPANTS Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death. MAIN MEASURES Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter. KEY RESULTS Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of ≥ 1 social work encounter. CONCLUSIONS We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.
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Affiliation(s)
- Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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11
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Goldstein KM, Patel DB, Van Loon KA, Shapiro A, Rushton S, Lewinski AA, Lanford TJ, Cantrell S, Zullig LL, Wilson SM, Shepherd-Banigan M, Alton Dailey S, Sims C, Robinson C, Chawla N, Bosworth HB, Hamilton A, Naylor J, Gierisch JM. Optimizing the Equitable Deployment of Virtual Care for Women: Protocol for a Qualitative Evidence Synthesis Examining Patient and Provider Perspectives Supplemented with Primary Qualitative Data. Health Equity 2023; 7:570-580. [PMID: 37731781 PMCID: PMC10507937 DOI: 10.1089/heq.2023.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Women experience numerous barriers to patient-centered health care (e.g., lack of continuity). Such barriers are amplified for women from marginalized communities. Virtual care may improve equitable access. We are conducting a partner-engaged, qualitative evidence synthesis (QES) of patients' and providers' experiences with virtual health care delivery for women. Methods We use a best-fit framework approach informed by the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework and Public Health Critical Race Praxis. We will supplement published literature with qualitative interviews with women from underrepresented communities and their health care providers. We will engage patients and other contributors through multiple participatory methods. Results Our search identified 5525 articles published from 2010 to 2022. Sixty were eligible, of which 42 focused on women and 24 on provider experiences. Data abstraction and analysis are ongoing. Discussion This work offers four key innovations to advance health equity: (1) conceptual foundation rooted in an antiracist action-oriented praxis; (2) worked example of centering QES on marginalized communities; (3) supplementing QES with primary qualitative information with populations historically marginalized in the health care system; and (4) participatory approaches that foster longitudinal partnered engagement. Health Equity Implications Our approach to exploring virtual health care for women demonstrates an antiracist praxis to inform knowledge generation. In doing so, we aim to generate findings that can guide health care systems in the equitable deployment of comprehensive virtual care for women.
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Affiliation(s)
- Karen M. Goldstein
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Dhara B. Patel
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Katherine A. Van Loon
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Abigail Shapiro
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Sharron Rushton
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Allison A. Lewinski
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Tiera J. Lanford
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Sarah Cantrell
- School of Medicine, Duke University Medical Center Library, Durham, North Carolina, USA
| | - Leah L. Zullig
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Sarah M. Wilson
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- Duke Margolis Center for Health Policy, Durham, North Carolina, USA
- VA VISN-6 Mid-Atlantic Mental Illness Research and Education Clinical Center, Durham, North Carolina, USA
| | - Susan Alton Dailey
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Catherine Sims
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Duke University, Durham, North Carolina, USA
| | - Cheryl Robinson
- Clinical Translational Sciences Institute, School of Medicine, Duke University, Durham, North Carolina, USA
- Veteran Research Engagement Panel, VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Neetu Chawla
- VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, California, USA
| | - Hayden B. Bosworth
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Alison Hamilton
- VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Jennifer Naylor
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
- VA VISN-6 Mid-Atlantic Mental Illness Research and Education Clinical Center, Durham, North Carolina, USA
| | - Jennifer M. Gierisch
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
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