Assuring High Quality Primary Care for Women Veterans: Predictors of Success

Bevanne Bean-Mayberry, MD, MHSChung-Chou Chang, PhDMelissa McNeil, MD, MPHSarah Hudson Scholle, DrPH

VA Pittsburgh & University of Pittsburgh

Why Study Women in the VA?

One of the fastest growing VA populations

Numbers exceed 1.7 million nationally

15% of active military and reserve forces

20% of new recruits prior to current Persian Gulf War

Gaps in care and vulnerable health risks resulted in Public Law 102-585 to improve VA preventive and gender-specific care

Health care issues for women in the VA are different from men and different from civilian women

Background: Women’s Health

In the US, health care for women is often fragmented, and primary care goals such as comprehensiveness and coordination are difficult to achieve

In the VA, reports on women veteran health care have repeatedly documented problems with gender-sensitivity, comprehensiveness and coordination of care

VA promoted specialized women’s clinics or teams to address the issues, yet nearly a quarter of VA facilities lack formal approaches for addressing these primary care goals

Background: Women’s Health

Factors associated with attainment of primary care goals:

Female Providers: » increased gynecological and mammography services» Increased gender-specific counseling and communication

Gynecological Services: » 33-50% of women use a gynecologist and generalist» women prefer gynecological care at the same site where they

obtain general care

Women’s Health Settings: » comparable or better preventive care and satisfaction

Research Question

What is the effect of combining female provider, routine gynecological care from the provider, and women’s health setting on patient ratings of primary care?

Aim and Hypotheses

Specific Aim: To determine if the combined effects of provider gender, routine gynecologic services from the provider, and women’s clinic setting improve patient ratings of primary care quality

Hypotheses: Women in general primary care settings will have higher primary care quality ratings

1. If the regular provider is female

2. If the regular provider manages routine gynecological care

3. If the patient participates in a gender-specific women’s clinic setting

Methods Study Population: Stratified random sample of

women veterans from clinics in 10 VAMCs in VISN 4 (Pennsylvania, West Virginia, and Delaware region) obtained from the VA National Patient Care Database

Eligibility criteria:

» Female veterans» >1 outpatient visit March 1,1999 to March 1, 2000» Use of traditional primary care or women’s clinic

Design: Cross-sectional, anonymous survey (2000)

Methods: Measures

Tool: Components of Primary Care Index (Flocke 1997)

Dependent variables: 4 domains» 1) Patient preference for provider (i.e., continuity)» 2) Interpersonal communication» 3) Coordination of care» 4) Accumulated Knowledge

Domain scoring: » 6 point scale (i.e., strongly disagree to strongly agree)» Summary score adjusted for 1-2 missing items, no imputations» Responses dichotomized to perfect score vs. all other

Methods: Measures cont.

Independent variables:» Gender of VA provider» Routine gynecological care managed by VA provider» Use of a VA women’s clinic setting

• All three items were combined into 6 exclusive

Provider - service – clinic categories

Control variables: age, race, marital status, education, income, health status, and site

Provider-Service-Clinic Categories

Female PCP + GYN + WC

Female PCP + GYN

Female PCP + WC

Female PCP only

Male PCP + GYN +/or WC

Male PCP

Note: PCP = Primary care provider; GYN = Gynecological care by provider; WC = Women’s clinic

Analytic Sample

80D e cea sed

74N o t D e live red

1 080R e g u la r P rov id e r A n a lytic S a m p le

5 0%

1 321O ve ra ll R e sp o n se R a te

6 1%

2 161A n o nym o us S u rve ys M a iled

2 315T o ta l R a nd o m S am p le

Analysis

Patient characteristics were described and patients were grouped along 6 provider – service – clinic categories to look for differences

Multiple logistic regression was used to identify factors independently associated with perfect ratings on each primary care domain

Results: Patient Characteristics

Age Percentage

<40 years 14.8%

40-64 years 44.4%

65+ years 41.8%

Race, white 89.5%

Education -

High school 30.5%

Some college/ technical training 45.7%

College graduate 23.8%

Married 33.6%

Annual income > $20,000 37.7%

Health status (very good/excellent) 31.6%

Enrollment in women’s clinic 52.4%

Results: Provider-Service-Clinic

Female PCP + GYN + WC 29.1%

Female PCP + GYN 11.8%

Female PCP + WC 10.3%

Female PCP only 16.0%

Male PCP + GYN +/or WC 17.0%

Male PCP 16.0%

Note: PCP = Primary care provider; GYN = Gynecological care by provider; WC = Women’s clinic

Adjusted Odds of a Perfect Score: Patient Preference for Provider

Adjusted OR (95%CI)

Female PCP + GYN + WC 4.7 (2.3, 9.7)

Female PCP + GYN 4.0 (1.8, 8.7)

Female PCP + WC 1.8 (0.7, 4.1)

Female PCP only 2.2 (0.9, 4.5)

Male PCP + GYN and/or WC 2.1 (1.0, 4.4)

Male PCP only (referent group) -

Adjusted Odds of a Perfect Score: Interpersonal Communication

Adjusted OR (95%CI)

Female PCP + GYN + WC 2.7 (1.4, 5.3)

Female PCP + GYN 2.7 (1.3, 5.5)

Female PCP + WC 1.8 (0.8, 4.0)

Female PCP only 2.9 (1.4, 5.8)

Male PCP + GYN +/- WC 1.3 (0.6, 2.6)

Male PCP only (referent group) -

Adjusted Odds of a Perfect Score: Coordination of Care

Adjusted OR (95%CI)

Female PCP + GYN + WC 2.3 (1.0, 5.5)

Female PCP + GYN 2.8 (1.1, 7.1)

Female PCP + WC 2.7 (1.0, 7.1)

Female PCP only 3.7 (1.5, 9.0)

Male PCP + GYN +/- WC 3.0 (1.2, 7.0)

Male PCP only (referent group) -

Adjusted Odds of a Nearly Perfect Score: Accumulated Knowledge

Adjusted OR (95%CI)

Female PCP + GYN + WC 6.1 (1.3, 28.5)

Female PCP + GYN 4.6 (0.9, 22.8)

Female PCP + WC 4.0 (0.7, 22.5)

Female PCP only 3.8 (0.8, 19.2)

Male PCP + GYN +/- WC 2.6 (0.5, 13.0)

Male PCP only (referent group) -

Limitations

Data are cross-sectional, retrospective and generalize only to the VA setting

Non-respondents could not be identified

No information on clustering of providers

Provider – clinic – service categories were limited due to size of groups

Findings are based only on patient ratings without additional evidenced-based indicators of quality

Summary of Perfect Ratings

Communication: » strongest association with female PCP

Coordination: » strongest association with female PCP

Preference for provider:» strongest association with female PCP, GYN care, and WC

Accumulated Knowledge:» strongest association with female PCP, GYN care, and WC

Conclusions

Female providers who manage routine gynecological care (within or exclusive of women’s clinic settings) have combined effects associated with high patient primary care ratings

Male providers who manage routine gynecological care or may interact in women’s clinic settings have effects associated with high patient primary care ratings

Implications for Women in VA

Availability of provider choice and comprehensive services (inclusive of routine gynecological care) may result in less fragmentation and better primary care

However…. Data are needed on the structural components of these

organizational models for women in the VA, and….

Data are needed on the clinical outcomes for women in these different health care delivery models

Without these data, health care policy will not reflect quality measures and VA practice structure

FundingDr. Bean-Mayberry’s support:

VA HSR&D Career Development Award #02-039-2VISN 4 Competitive Pilot Project FundsVA Office of Academic Affairs, Women’s Health FellowshipUniversity of Pittsburgh, School of Public Health

Mentors:Dr. Sarah Hudson Scholle, NCQA & University of Pitt.Dr. Michael Fine, Director, CHERP, VA Pittsburgh

Dr. Elizabeth Yano, Deputy Director, VA Greater Los Angeles HSR&D Center of Excellence

Questions

Public Health Law 102-585

The Women Veterans Health Programs Act covered:

counseling for military related sexual traumabroadening clinical services to include reproductive and

gender-specific care (excluding infertility/abortion)expansion of health care services available and

accessible to women veterans; support for women veteran coordinators in each regional

office of the VA (VA Health Care for Women, January 1999; HR 5193; Bill Summary and Status for the 102nd Congress at http://thomas.loc.gov/cgi bin/bdquery/z?d102:HR05193.).

Results: Proportion of Perfect Scores

Primary Care Domains % Perfect Scores

Patient preference for provider 23.1%

Interpersonal communication 25.8%

Coordination of care 16.4%

Accumulated knowledge* 6.8%

*Accumulated Knowledge was based on nearly perfect scores.