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Bean-Mayberry B, Huang C, Batuman F, et al. Systematic Review of Women Veterans Health Research 2004–2008 [Internet]. Washington (DC): Department of Veterans Affairs (US); 2010 Oct.

Cover of Systematic Review of Women Veterans Health Research 2004–2008

Systematic Review of Women Veterans Health Research 2004–2008 [Internet].

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SUMMARY AND DISCUSSION

The growth in the number of women in the military is reshaping the veteran population, with women now constituting one of the fastest growing segments of eligible VA healthcare users. This trend has been accelerated by the unexpectedly high VA enrollment of women veterans from recent wars in Iraq and Afghanistan. As women veterans have entered the VA healthcare system in increasing numbers, VA managers and providers have been challenged to organize and deliver gender-specific and gender-sensitive services in a system that has otherwise historically focused on treating men. Gender-specific care also imposes considerable training and experience requirements on a VA workforce with limited exposure to female patients.

VA’s health services research enterprise has been designed to map to high priority topics, women veterans’ health and health care among them. Yano and colleagues led the leadership efforts for the first mapping of VA research priorities to the needs of women veterans with the VA Women’s Health Research Agenda Setting Conference in late 2004200. This initial women’s health research agenda was the product of a national consensus development meeting, which (a) brought together researchers from various fields (laboratory, clinical science, rehabilitation and health services) to focus on establishing an evidence base for a women’s health agenda and (b) to incorporate results of the first VA systematic review of the literature on women veterans1. That review identified 182 relevant articles published between 1978 and 2004. Most were descriptive in nature, using observational study designs; only 2 were randomized controlled trials. About 45% of the studies were VA funded, with the majority of the literature focusing on women veterans’ mental health (mostly risk, prevalence and treatment of PTSD) and general health services research (8 on quality of care, 5 on patient satisfaction, 25 on use and organization of care).

In the current updated systematic review, we identified 195 articles from 2004–2008–more articles in 5 years than we identified in the previous 25 years. This sharp increase in volume is likely due to VA’s increased focus on research funding in these priority areas. Consistent with the previous systematic review, most VA women’s health research continues to be observational; however, more articles are shifting from a descriptive to an analytical focus (i.e., determinants of care or health), and there were 5 clinical trials, a modest increase from the first review.

While the focus on mental health among women in the military and women veterans remains high, with a continuing emphasis on PTSD and MST, important new work has been published on prevalence of mental health conditions in different settings and for different subgroups and on non-trauma-related mental health problems (e.g., depression, serious mental illness). Emphasis on access, utilization and quality of care for women veterans has also increased, with a rapidly emerging focus on post-deployment health. These topic areas clearly map to ongoing VA research priorities, demonstrated in part by the fact that about 60% of the articles were VA funded in whole or in part, up from 45% in the review published in 2006.

BUILDING KNOWLEDGE: NOTABLE RESEARCH ADVANCES

To what extent has the more recent literature closed the gaps identified in the previous review? Previous notable gaps included very limited information on the prevalence of chronic diseases, women veterans’ preferences and self-reported care needs, research on utilization patterns within and outside the VA health care system, transitions from military to veteran status, studies of the quality of care women veterans receive, and studies on how to improve their quality of care. These gaps served as the basis for more targeted solicitations for new research.

We highlight 3 areas with the noteworthy impact:

  1. Treatment outcomes in PTSD: The Schnurr study is the first multi-centered, VA funded cooperative trial focused on outcomes of women veterans with PTSD using a comparison of prolonged exposure therapy to a previous standard of care. Due to the quality of the research and significant clinical findings, prolonged exposure therapy is being considered by VA administration as part of the revised guidelines for PTSD standards of care due out later this year, used to train clinical providers, and implemented across the field nationally6.
  2. Access to care: We now know more about barriers, perceptions and utilization of VA care among women veterans, and this information should be used as a foundation to remove barriers and consider methods for restructuring care to meet healthcare needs. Chief barriers include knowledge gaps and incorrect assumptions about VA services among women veterans outside the VA and high use of care once enrolled in VA among women with various co-morbidities. This knowledge should direct us toward potential interventions among subgroups of women veterans to decrease barriers and documented and improved care outcomes among women in VA with significant co-morbidities.
  3. Organizational determinants of quality care: Advances in research describing how care is organized for women in VA demonstrate variations in service availability and their determinants as well as the importance of practice environment for women veterans care. Better attention to gynecologic access (staff, clinic, services) appears to be important for types of services a woman has access to and a key area for future research in VA. The impact of local leadership on women veteran services also appears essential. Future quality improvement interventions need to consider the integration of leadership or other diverse stakeholders in care of women.

Separately, the PTSD trial impacts the literature on women veterans in another manner. Few studies had an adequate sample for comparing women to men or VA users to non-users and evaluating outcomes. The Schnurr trial overcame this challenge and future studies should use similar methods (multi-site approach, cooperative study, practice based research network) to achieve adequate patient samples for clinical and health services research Schnurr trial6. The Schnurr trial tackles the historical research dilemma of insufficient sampling strategies for performing primary or subgroup analyses of women in VA and demonstrates that it is feasible to conduct robust clinical trials in women veterans201.

With the current systematic review, we found increases in the number of articles on access, utilization and quality of care studies. Collectively, this research provides an evidence base for detecting barriers to VA care that women soldiers may encounter, defining optimal women’s healthcare delivery arrangements, and adopting best practices. In these areas, the field as a whole is now ready to move toward identifying and implementing interventions to promote best practices. This identification of interventions and promotion of best practices fits within the VA Quality Enhancement Research Initiative (QUERI) model for translational research and quality improvement202. The VA QUERI program promotes the linking of research and clinical practice to improve the quality and outcomes of care among veterans across the VA system by a series of quality improvement steps and interventions that involve researchers, providers, and clinical managers203. These steps include: (1) identifying high-risk or high burden conditions or problems; (2) identify best practices or clinical guidelines; (3)define variations from best practices and their determinants; (4) identify and implement interventions to promote best practices; (5) assess intervention program feasibility, outcomes and impacts on patient, provider, and system; and (6) assess intervention program impacts on health releated quality of life outcomes203, 204. VA women veterans’ health research now stands solidly within the VA QUERI framework at steps 3 and 4, where variations can be identified and explicitly understood so that appropriate interventions will be designed for women veterans.

ONGOING GAPS: FUTURE VA RESEARCH TARGETS

In contrast to the growth in the scientific literature on access, utilization and quality, recently funded VA studies have not yet made their mark in the published literature on prevalence of chronic diseases or on transitions from military to veteran status. Additional areas that stand as new or ongoing gaps in the literature for our women veteran population are included below:

  1. Limited clinical and intervention outcome data for chronic physical or mental health conditions and complex combinations of diseases
  2. Limited information on transitions from military to civilian life
  3. Minimal information of military duty and transitions on families
  4. Health issues for women veterans across the life span (e.g., pregnancy, aging)
  5. New information on general care or gender differences for veterans with polytrauma or traumatic brain injury
  6. Challenges and strategies for comanaging mental health and general preventive health

We anticipate that the increases in VA women’s health services research funding over the past 5 years will continue to affect the topical coverage and methodological diversity and rigor seen in the coming 5 years. Ongoing efforts to continually update the literature, augmented by interactive search capabilities, will enhance the value and application of this growing evidence base to ongoing care improvements in health care settings within and outside the VA. Separately, we suggest that internal final reports of VA supported research should document if the study contained findings reportable by gender (whether the same or different) even if that was not one of the research aims of the study. Such detailing offers insight to unknown areas of disparity or equity in veteran health and healthcare.

The primary limitation of this systematic review, as with any review, is the potential for having missed salient articles. Search terms for our topic area of women veterans’ health and health care have not been standardized in such as way that authors routinely select consistent terms. We thus augmented traditional computerized search strategies with contacts among leading researchers in the field in the hopes of enhancing our yield. Now that we have a significant database of relevant articles, we hope that authors not represented herein will forward their articles for inclusion. As with any systematic review, we are also limited by publication bias.

CONCLUSIONS

The areas more fully developed in women veterans’ research (access, utilization, and quality of care) will serve as a foundation for future intervention and implementation research in VA. In addition, the already substantial scope of women veteran mental health literature should be expanded with future VA studies on treatment modalities and outcomes and should explore ways in which veteran, provider, or practice settings can incorporate potential treatments.

FUTURE RESEARCH

Continued need exists for clinical trials data involving women veteran health issues and women veteran populations.

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