Background - CHC treatment is associated with major gains in health, including reduced risk of progression to end-stage liver disease and hepatocellular carcinoma. Most of our knowledge of CHC care in the VHA is based on studies of men. This is a problem because women's health-care needs differ from men's for several conditions including CHC and barriers to CHC treatment are also likely to vary by gender. Women with CHC have more mental health comorbidities-the leading modifiable barrier to antiviral treatment. Women also have much higher self-reported military sexual trauma, which often leads to mental health issues. Women's care experiences and their perception of care in the VHA are also distinct from those of men. The recent increases in the proportion of women in the VHA and the availability of more effective CHC treatment necessitate a specific focus on modifiable factors that may be contributing to missed treatment opportunities in women Veterans with CHC. Objectives - The proposed project will use a mixed methods design to (1) examine gender differences in access to and receipt of CHC care measured by seeing a CHC specialist and receipt of antiviral treatment, respectively, (2) identify predictors of access to and receipt of CHC care in women Veterans with CHC, (3) characterize women's experiences with accessing CHC care and receiving CHC treatment in the VHA Methods - To achieve Aim 1, we will use existing structured automated data to examine the rate of seeing CHC specialist and receipt of antiviral treatment in a national cohort of Veterans with CHC (n>6000 women and >150,000 men) who are enrolled in the VHA during 2002-2012 to examine the effect of gender on these endpoints. To achieve Aim 2, we will conduct multi-level regression analyses to identify key predictors (especially high-impact, modifiable factors) of access to and receipt of CHC treatment among women Veterans with CHC. We will also construct separate multi-level regression in a parallel cohort of male Veterans with CHC for purposes of benchmarking. To achieve Aim 3, we will conduct a qualitative study consisting of in-depth narrative interviews with women Veterans with CHC at 3 geographically distinct VHA sites who have either, 1) not seen a CHC specialist, 2) seen a specialist once but have not completed clinical evaluation of their CHC, or 3) expressed interest in or received CHC treatment. We expect that the responses from these 3 patient groups will provide complementary insight into the factors that patients consider (or potentially should or could have considered) in engaging in CHC care as well as the perceived barriers to and facilitators of such engagement in quality care from the woman veterans'perspective.

Public Health Relevance

Expanding health care access to women Veterans is one of the top priorities in the Veterans Health Administration (VHA). To date, most VHA women's health research has focused on either primary care or mental health issues. There are fewer data on women Veterans'chronic care needs for conditions traditionally managed in medical specialty clinics. Understanding how the VHA can best serve specialty care needs of the rapidly growing population of women Veterans is an important part of comprehensively addressing women's health care needs. Our multifaceted approach will set the stage for development of strategies to provide patient-centered high quality care to the burgeoning group of women Veterans with chronic hepatitis C (CHC)-- a prevalent and now mostly treatable chronic problem primarily managed in specialty care settings. Our study will have implications extending beyond CHC in that it will provide data on the experiences of women Veterans with chronic health conditions not typically managed in the primary care or mental health settings.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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Michael E Debakey VA Medical Center
United States
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Kramer, J R; Puenpatom, A; Erickson, K F et al. (2018) Real-world effectiveness of elbasvir/grazoprevir In HCV-infected patients in the US veterans affairs healthcare system. J Viral Hepat 25:1270-1279
Kramer, J R; El-Serag, H B; Taylor, T J et al. (2017) Hepatitis C virus-related complications are increasing in women veterans: A national cohort study. J Viral Hepat 24:955-965