Background: As a historical minority within the VA health care system, women veterans (WVs) have faced significant barriers to accessing needed services. Having complex health care needs (e.g., higher burden of mental health and reproductive health needs) and utilization patterns different from their male counterparts further complicates VA's ability to provide quality care to WVs. Gender-sensitive care models that offer comprehensive care delivery integrating gender-specific (e.g. gynecological care), primary care (PC) and mental health services have been shown to yield better outcomes. For example, VAs that adopted women's health (WH) clinics had better gender-specific quality of care, higher WV ratings of care, and higher satisfaction with care. With WVs now among the fastest growing segments of new VA users, VA is highlighting the delivery of comprehensive WH care as a top priority. Yet, the VA faces considerable challenges in providing comprehensive WH care. Hence, it is critical that the VA understands how VA facilities organize gender-focused care delivery, and identify factors that facilitate or hinder the provision of comprehensive WH care. Objectives:
Aims for the proposed study are: (1) To assess determinants of variations in the delivery of comprehensive WH care; and (2) To study the impact of comprehensive WH care delivery on WVs' quality of and experience with care. Methods: We propose an observational study using both primary and secondary data sources to assess comprehensive WH care delivery and its impact on quality and patient experience with care. A national key informant organizational survey of VISN Directors, Chiefs of Staff, Senior WH Clinicians will be administered to collect information about comprehensive WH care delivery, organizational structure and process characteristics, and resources. Survey data will be linked to previously fielded VA organizational surveys, area/community characteristics, patient- and facility-level performance and quality indicators to create the study analytic dataset.
For Aim #1, we will compute descriptive statistics and analyze bivariate associations to understand variations in comprehensive WH care delivery. We will conduct multiple regression analyses to model comprehensive care delivery as a function of structure and resources. We will also examine changes in care delivery over time using a two-period panel analysis differencing the dependent and independent variables.
For Aim #2, we will analyze both facility- and patient-level outcomes. For facilities, we will conduct a series of path analyses to understand the relationships among organizational factors, comprehensive care delivery, and quality and patient experience outcomes. At patient-level, we will examine the impact of comprehensive care delivery on quality and patient experience outcomes using hierarchical linear modeling. Our main quality outcomes will include process of care measures (e.g., flu shot, cancer screening), intermediate health outcomes (e.g., LDL<100), and patient experience with care, including measures of access, coordination, and continuity of care in addition to patient- centeredness. We will model the achievement of these metrics, constructed either as binary variables or scores, as a function of comprehensive WH care delivery, controlling for patient, facility, and community/area characteristics.
A better understanding of organizational delivery systems supporting comprehensive WH care will allow us to identify organizational factors that can improve VA's ability to provide comprehensive WH care at all facilities, and assess the achievement and improvement of quality of and patient experience with care. These findings will inform VA leadership at the national, VISN, and local levels in strategies for the ongoing design, implementation, evaluation, and improvement of WH programs that create gender-sensitive environments, enhance WVs' experiences with care, and contributing to the evidence base for improvement in WH care.
