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Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CaliforniaHealth Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CaliforniaDepartment of Pediatrics, Stanford University School of Medicine, Palo Alto, California
Correspondence to: Susan M. Frayne, MD, MPH, Center for Health Care Evaluation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025. Phone: 650/493-5000, x23369; fax: 650/617-2690.
Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CaliforniaDivision of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California
The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period.
Methods
We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. “New” patients in a given year had no outpatient use within the prior 3 years. Patients were “retained” if they continued to use VHA in subsequent years.
Main Findings
Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years.
Conclusion
The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services.
Background
As the Veterans Health Administration (VHA) refines services to keep pace with the needs of the rapidly rising numbers of women veterans seeking care, questions remain: Who are the new women veterans entering VHA for care, and how do they use VHA? Access to VHA care for women veterans is among the top priorities of the Secretary of Veterans Affairs (
Shinseki, E. K. (2010). Remarks by Secretary of Veterans Affairs at Forum on Women Veterans Women in Military Service for America Memorial, July 28, 2010. Available: http://www1.va.gov/opa/speeches/2010/07_28_2010.asp. Accessed December 1, 2010.
). Greater understanding of the needs of new women VHA patients, in the year they transition into VHA care, can inform VHA’s preparations for future entering cohorts of women veteran patients.
New women patients are an important group from a clinical perspective. By initiating timely interventions aimed at prevention and disease management for women new to the VHA, clinicians have an opportunity to optimize long-term health across their subsequent trajectory of care. Women recently returned from war zones who are newly joining VHA may have confronted unique physical exposures and emotional stressors impacting current health (
), connecting new women veteran patients with convenient and relevant services in their first year of VHA use is apt to improve their satisfaction with care and retention within VHA (
), thereby enhancing the VHA’s opportunity to provide them with long-term continuity care.
Sociodemographic characteristics, such as age and service-connected status, can influence the healthcare needs and expected use of VHA by new women patients. Burden of illness increases with advancing age (
U.S. Preventive Services Task Force. (2010). The guide to clinical preventive services 2010–2011. Recommendations of the U.S. Preventive Services Task Force. Available: http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf.
). Likewise, documented service-connected disability (a medical condition deemed by the Veterans Benefits Administration to have occurred during or been aggravated by military service) reliably predicts VHA use (
). This is not surprising, because veterans receive free VHA care for service-connected conditions. Indeed, those with service-connected ratings of 50% or higher receive free VHA care for conditions unrelated to military service as well, and those with very high ratings may receive additional services at no charge, such as dental services. The VHA offers specialized clinical programs for a variety of conditions common after military service, such as posttraumatic stress disorder (PTSD;
National Center for PTSD. (2010). PTSD treatment programs in the U.S. Department of Veterans Affairs. Available: http://www.ptsd.va.gov. Accessed April, 2011.
U.S. Veterans Health Administration (VHA). (2011). Polytrauma/TBI system of care. Benefits and services. Available: http://www.polytrauma.va.gov. Accessed April 2011.
), which may attract some women with SC disabilities to VHA. Awareness of age distribution and service-connected ratings can guide VHA’s planning for the future needs of new women patients.
Primary care and mental health utilization during the first year in the VHA may also provide clues about service accessibility and healthcare requirements of new patients. Primary care clinics’ comprehensive purview make them an ideal point of entry for many new patients (
Frayne SM, Yu W, Yano EM, Ananth L, Iqbal S, Thrailkill A, Phibbs CS. (2007) Gender and use of care: planning for tomorrow's Veterans Health Administration. Journal of Womens Health (Larchmont), 6, 1188–99.
), but it is unclear how quickly patients with mental illness begin accessing mental health services after joining VHA.
The current study characterizes women veterans new to VHA. We present longitudinal trends in the number and sociodemographic characteristics of new and returning women veteran patients using VHA outpatient services, and describe their utilization patterns and retention rates in primary care and mental health settings. For 2009, we also report the distribution of new women veteran patients across VHA facilities nationally.
Methods
Overview
For all women veterans who use outpatient VHA care nationally, this longitudinal study describes the sociodemographic characteristics, utilization patterns, and retention of new and returning patients. To do this, it draws on three VHA administrative data sources: Assistant Deputy Under Secretary for Health Monthly Enrollment File (“Enrollment File,” to identify the cohort and assess sociodemographic characteristics), the VHA’s National Patient Care Database Outpatient Utilization Files (to identify new/returning patients and to characterize utilization), and the VHA Vital Status Files (to identify dates of death). We use the term “index year” to refer to the VHA fiscal year for each annual cohort, fiscal year 2003 to 2009. For example, the fiscal year 2009 cohort consists of those women veterans who used VHA outpatient services in fiscal year 2009 (October 1, 2008, to September 30, 2009). We describe index-year sociodemographic characteristics for the fiscal year 2003 to 2009 cohorts, utilization patterns for the fiscal year 2003 to 2008 cohorts, and 3-year retention rates for the fiscal year 2003 to 2006 cohorts. In addition, for fiscal year 2009, we examine the distribution of new patients across VHA facilities nationally. This work was approved by the Stanford University Institutional Review Board.
Study Cohort
For each index year, we identified all VHA patients appearing in the Enrollment File, and then, from that list, selected all women veteran VHA outpatients for our analytic cohort. We identified gender from the Enrollment File, resolving cross-year discrepancies by assigning the most recent non-missing gender value to the patient, and supplementing with the gender value from the outpatient Utilization File if gender was unavailable across all years of Enrollment data. We identified veteran status from the Enrollment File priority status variable or, if missing, from the Enrollment File eligibility variable. We identified patients who had used VHA outpatient care in the index year from the outpatient Utilization File.
Variables: New and Returning Patients
A woman veteran was considered to be a “new” VHA patient in the index year if she had no outpatient use in the 3 years before her first outpatient visit in the index year, consistent with a typical VHA method for identifying new patients (
). All other women veteran patients in the index year were “returning” VHA patients. We restricted our focus to new users of outpatient services, because including patients whose only VHA use was a hospitalization would have increased the number of new patients in fiscal year 2009 by only 43 patients.
Variables: Location of Care
Each woman in the fiscal year 2009 study cohort was assigned to 1 of 140 VHA “home facilities,” based on where she received most of her care. For 89% of women, the home facility was the facility where they received all or most of their primary care in fiscal year 2009, or, in cases of a tie, where they attended primary care most frequently and most recently. Among patients not receiving primary care in VHA, the home facility was based on where they received other services.
Variables: Sociodemographic Characteristics
We calculated age on the first day of the index year, from date of birth in the Enrollment File. We counted date of birth as missing if it yielded an age younger than 18 or older than 110 years, because there is substantial risk that these outlier ages reflect data entry errors. We assigned the most recent non-missing, within-range date of birth available across all years of Enrollment File data, supplementing with date of birth from the outpatient file when it was missing or out of range in the Enrollment File. Age was categorized as 18 to 44, 45 to 64, or 65 years or older.
We also used the Enrollment File for the index year to determine whether a patient had a service-connected disability in a given fiscal year, and, if so, the disability compensation rating. Among those with a service-connected disability status, we categorized service-connected ratings as 0% to 49%, 50% to 99%, or 100%.
Variables: Utilization
To measure utilization within each index year, we used codes indicating clinic type to create a count of primary care visits (general primary care clinics or women’s clinics) and a count of mental health outpatient visits in individual or group face-to-face settings. From the count variables, we created indicators for one, two, or three or more visits in each index year. (Clinic code specifications for primary care and mental health care are in Appendices A and B.)
The utilization variables apply person-specific timelines, starting with the woman’s first VHA outpatient visit. For example, the tally of primary care visits starts with the first outpatient visit in the index year, and counts all primary care visits occurring in the 365 days starting with that first visit. Utilization is examined in fiscal year 2003 to 2008. (Use in fiscal year 2009 could not be assessed because capture of fiscal year 2009 utilization, applying the person-specific timeline, would require fiscal year 2010 data, which were not available.)
Variables: Retention
We measured 3-year retention within three categories of VHA services: All outpatient care, primary care, and mental health outpatient care. As with utilization variables, the retention variables use person-specific timelines, starting with the first outpatient visit in the index year. The period spanning 365 days from the first visit in the index fiscal year is the “first year” of the retention ascertainment period. The period from the end of the “first year” to 365 days later is the “second year,” and the next 365 days, the “third year.” For example, if a new patient’s first VHA outpatient use was on April 14, 2006, then the first year spans from April 14, 2006, to April 13, 2007, the second year spans from April 14, 2007, to April 13, 2008, and the third year spans from April 14, 2008, to April 13, 2009. A woman was considered retained in the second year if she continued to use the service examined (outpatient care, primary care, mental health outpatient care) in the second year, and considered to be retained in the third year if she used the service examined in the third year. One variable identifies “any retention” (use of the specified service in the second or third years) and another identifies “consistent retention” (use of the specified service in the second and third years). These variables were created for the fiscal year 2003 through 2006 index-year cohorts. The retention variables were not created for more recent cohorts, because creating them would have required data from fiscal year 2010 and beyond, which were not available.
Analyses
These population-based analyses on annual cohorts of new and returning women veteran VHA patients are purely descriptive; no statistical tests were conducted. Even trivial between-group differences are likely to be significant with such large sample sizes.
Results
Number of Women Veteran Patients
The number of women veterans using VHA outpatient services grew by 47% between fiscal year 2003 and 2009. Among the 287,447 women veteran outpatients in fiscal year 2009, 56% of them (162,407 women) were identified as new to VHA at some point between fiscal year 2003 and 2009 (data not shown).
In fiscal year 2003, 31,658 new women veteran VHA patients sought VHA services. The greatest year-to-year increase in new women veteran patients occurred in fiscal year 2009, when more than 40,000 new women veterans joined VHA patients (Table 1).
Table 1Number of New and Returning Women Veterans Using VHA Outpatient Care, and Their Age and Service-Connected Rating Distributions, Fiscal Years 2003–2009
A woman was considered to be a “new” VHA patient in the index year if she had no outpatient VHA use in the 3 years before her first outpatient visit in the index year. Otherwise, she was considered to be a “returning” patient.
Modest differences in the n for age and service-connected status exist owing to differences in missing data between these 2 variables.
New patients, n
31,071
31,709
32,630
32,257
33,071
33,098
39,784
Any SC rating
32.5%
30.8%
32.7%
32.5%
39.5%
33.2%
43.4%
SC: 0%–49%
24.8%
23.3%
24.3%
24.6%
28.9%
23.8%
30.9%
SC: 50%–99%
6.8%
6.7%
7.6%
7.3%
9.7%
8.5%
11.4%
SC: 100%
0.9%
0.8%
0.8%
0.7%
0.9%
0.9%
1.1%
Returning patients, n
161,014
175,886
191,023
202,574
213,921
226,709
246,869
Any SC rating
50.7%
50.2%
50.8%
51.6%
53.2%
54.9%
57.5%
SC: 0%–49%
29.6%
28.3%
27.9%
28.1%
28.7%
28.9%
29.4%
SC: 50%–99%
16.2%
16.9%
17.9%
18.7%
19.6%
20.8%
22.6%
SC: 100%
4.9%
5.0%
5.0%
4.9%
5.0%
5.2%
5.5%
Abbreviation: SC, service-connected; for those with a Service-Connected rating, percent categories refer to SC rating level. Note that SC 0% indicates that the patient does have a Service-Connected condition, but that its rating level is 0%.
∗ A woman was considered to be a “new” VHA patient in the index year if she had no outpatient VHA use in the 3 years before her first outpatient visit in the index year. Otherwise, she was considered to be a “returning” patient.
† Modest differences in the n for age and service-connected status exist owing to differences in missing data between these 2 variables.
Figure 1 shows where these 40,000 new women veterans sought VHA care nationally in fiscal year 2009. The number of new women veteran VHA patients ranged from 32 to 972 across 140 VHA facilities (median, 207 women). The three facilities with the largest number of new women veterans in fiscal year 2009 were San Antonio, Texas (n = 972), San Diego, California (n = 934), and Washington, DC (n = 924). Across all facilities, new women constituted 8% to 23% of all women veterans (median, 13%).
Figure 1Number of New Women Veteran Patients by Home Facility - FY09.
Sociodemographic Characteristics of New and Returning Patients
In Table 1, the proportion of women veteran VHA patients in each of the age categories and service-connected categories are stratified by new and returning status. More than half of each year’s new women veteran cohort was younger than 45 years, growing from 57% in fiscal year 2003 to 64% in fiscal year 2009. The proportion of new women veteran patients who were in the 45- to 64-year-old age group also grew slightly over the period, whereas the proportion in the 65 years and older age group dropped. In each year, a higher proportion of new than returning patients were in the younger than 45-year-old age group.
A substantial proportion of new women veteran patients had a service-connected status, growing from 33% in fiscal year 2003 to 43% in fiscal 2009 (Table 1). However, in each year, a smaller proportion of new than returning patients had a service-connected rating. A lag in receipt of service-connected status among women recently discharged from the military may partially explain this difference: Among women new in fiscal year 2008, 25% of those who did not have a service-connected status in fiscal year 2008 subsequently obtained service-connected status within the following year (data not shown).
Utilization by New and Returning Patients
Table 2 characterizes use of primary care and mental health clinics, stratified by new and returning status. The proportion of new women veteran patients attending VHA primary care clinics increased to 88% in fiscal year 2008. Frequent use of primary care by new women patients was increasingly common over the period: Nearly half (46%) had at least three primary care visits in fiscal year 2008. This was modestly lower than the proportion of returning women patients who were frequent users of primary care.
Table 2Use of VHA Primary Care and Outpatient Mental Health Services Among New and Returning Women Veterans, Fiscal Years 2003 Through 2008
Although new/returning status is identified within an index fiscal year, utilization is measured using a person-specific time line. The use reported above occurred within the “first year” of use, that is, within the 365 days after a patient’s first VHA outpatient visit in the index fiscal year. Fiscal year 2008 is the last year examined for utilization analyses, owing to data availability (see text).
Includes women who used outpatient VHA care in the index fiscal year and were alive at the end of their first year of VHA use. A woman was considered to be a “new” VHA patient in the index year if she had no outpatient VHA use in the 3 years before her first outpatient visit in the index year.
Numerators include all women who used mental health outpatient care in their first year of VHA use and were alive at the end of their first year of VHA use.
New patients
Any mental health clinic visit, %
24.0
27.5
29.3
31.2
36.2
39.8
1 visit
9.6
10.6
11.7
12.6
13.9
14.4
2 visits
3.0
3.7
3.9
4.3
5.0
5.3
≥3 visits
11.3
13.3
13.8
14.3
17.3
20.1
Returning patients
Any mental health clinic visit, %
32.2
32.7
33.3
33.7
35.3
37.1
1 visit
6.8
6.9
7.0
7.1
7.4
7.5
2 visits
4.4
4.4
4.6
4.7
4.9
5.0
≥3 visits
21.0
21.4
21.8
21.9
23.1
24.6
∗ Although new/returning status is identified within an index fiscal year, utilization is measured using a person-specific time line. The use reported above occurred within the “first year” of use, that is, within the 365 days after a patient’s first VHA outpatient visit in the index fiscal year. Fiscal year 2008 is the last year examined for utilization analyses, owing to data availability (see text).
† Includes women who used outpatient VHA care in the index fiscal year and were alive at the end of their first year of VHA use. A woman was considered to be a “new” VHA patient in the index year if she had no outpatient VHA use in the 3 years before her first outpatient visit in the index year.
‡ Numerators include all women who used primary care in their first year of VHA use and were alive at the end of their first year of VHA use.
§ Numerators include all women who used mental health outpatient care in their first year of VHA use and were alive at the end of their first year of VHA use.
The proportion of new women veteran patients receiving mental health outpatient care increased rapidly over the same period, from 24% in fiscal year 2003 to 40% in fiscal year 2008. Repeated use of mental health services also increased: The proportions of new patients with three or more mental health clinic visits increased from 11% in fiscal year 2003 to 20% in fiscal year 2008.
Retention of New Versus Returning Patients
As Table 3 shows, the majority of new and returning outpatient women were retained in subsequent years. In fiscal year 2006, the proportion of new women veterans with any outpatient retention (outpatient use in the second or third year) was 70%, whereas the proportion with consistent retention (outpatient use in both the second year and third year) as 52%. The proportion with any primary care retention was 68% and the proportion with any mental health retention was 57%.
Table 3Three-Year Retention of New and Returning Women Veteran Patients in Outpatient Care, Primary Care, and Mental Health Outpatient Care Settings, Fiscal Years 2003 Through 2006
Although new/returning status is identified within an index fiscal year, retention is measured using a person-specific time line. Using the person-specific time line, “second year” refers to the year starting 1 year after the women’s first VHA outpatient visit, and “third year” refers to the year starting 2 years after the women’s first VHA outpatient visit. The fiscal year 2006 cohort is the last cohort for which retention can be assessed, owing to data availability (see text). A patient using outpatient care in the index fiscal year is considered to be retained in outpatient care based on use of outpatient care in subsequent years. A patient using primary care in the index fiscal year is considered to be retained in primary care based on use of primary care in subsequent years. A patient using mental health care in the index fiscal year is considered to be retained in mental health care based on use of mental health care in subsequent years.
Number of women veterans who used mental health outpatient care in the index fiscal year, and who were alive throughout a 3-year observation period.
51,031
56,776
62,994
67,830
Retained in second or third year, %
78.9
78.8
78.6
79.0
Retained in second and third year, %
60.8
60.2
59.3
60.7
∗ Although new/returning status is identified within an index fiscal year, retention is measured using a person-specific time line. Using the person-specific time line, “second year” refers to the year starting 1 year after the women’s first VHA outpatient visit, and “third year” refers to the year starting 2 years after the women’s first VHA outpatient visit. The fiscal year 2006 cohort is the last cohort for which retention can be assessed, owing to data availability (see text). A patient using outpatient care in the index fiscal year is considered to be retained in outpatient care based on use of outpatient care in subsequent years. A patient using primary care in the index fiscal year is considered to be retained in primary care based on use of primary care in subsequent years. A patient using mental health care in the index fiscal year is considered to be retained in mental health care based on use of mental health care in subsequent years.
† Number of women veterans who used outpatient care in the index fiscal year, and who were alive throughout a 3-year observation period.
‡ Number of women veterans who used primary care in the index fiscal year, and who were alive throughout a 3-year observation period.
§ Number of women veterans who used mental health outpatient care in the index fiscal year, and who were alive throughout a 3-year observation period.
In every year, the proportions of new women veteran patients with any or consistent retention were lower than the same proportions for returning women veteran patients. This was true for all three categories of care.
Discussion
The number of new women veteran patients entering the VHA system each year increased from 32,000 in 2003 to 40,000 in 2009, and varied considerably by facility. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. By the end of the study period, most new patients were enrolled in primary care and 40% were receiving mental health services. Over this 6-year period, the proportion of new women veterans with at least three mental health clinic visits nearly doubled. In every year studied, we found a high rate of VHA retention among new patients.
Each of these 40,000 new women represents a patient who needs to be oriented to the VHA system, and whose medical and psychosocial issues must be assessed at intake. At some VHA facilities, close to 1,000 women join in a single year: Such locations must be prepared to ramp up services rapidly in response to such heavy influx. Conversely, facilities with very low numbers of new women may also face challenges, such as how to launch targeted services for a small subgroup of patients. With the number of women veterans in the United States growing from 1.6 million in 2003 to a projected 2.0 million in 2020 (
), and with 358,620 women still actively serving in the military (including the Reserve and National Guard) as of 2009 (Personal Communication, Captain Lory Manning, Director, Women in the Military Project, March 8, 2011), it is likely that more women veterans will be entering VHA in the future. If so, the VHA will need to continue its commitment to coordinating with the Department of Defense to facilitate a seamless transition between military and civilian care (U.S.
U.S. Government Accountability Office VA and DOD health care: Effects to provide seamless transition for care for OEF and OIF servicemembers and veterans (GAO-06-794R).
This study sheds light on who these new women veteran VHA patients are, in terms of their age and service-connected disability status. The relatively young age of many new women patients suggests VHA must ensure it has the structural capacity and appropriately trained workforce to address their reproductive health care needs. Ongoing initiatives like the VHA’s national Women’s Health Miniresidency training program, Women’s Health Fellowship program, and Women’s Health Cyberseminar series are expected to promote this objective (
). This study does not quantify the number of new women veterans returning from the wars in Iraq and Afghanistan. However, the young age of many new women patients suggests recent deployment. Therefore, many new women patients may require post-deployment services aiding adjustment to civilian life, as well as care for sequelae of recent physical injury or psychological trauma (
Committee on the Initial Assessment of Readjustment Needs of Military Personnel Veterans and Their Families, & Board on the Health of Select Populations Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of veterans, service members, and their families.
Institute of Medicine of the National Academies,
Washington, DC2010
Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.
National Center for PTSD. (2010). PTSD treatment programs in the U.S. Department of Veterans Affairs. Available: http://www.ptsd.va.gov. Accessed April, 2011.
U.S. Veterans Health Administration (VHA). (2011). Polytrauma/TBI system of care. Benefits and services. Available: http://www.polytrauma.va.gov. Accessed April 2011.
), among others. Such programs will need to remain attuned to the needs of women veterans, who are returning from war at high rates.
New women VHA patients had high levels of service-connected disability, and these rates have been increasing. Although the data available to us do not include the specific condition(s) responsible for each patient’s service-connected status, our findings suggest the need for accessible care for conditions common after military service. Because of lags between application for service-connected status and receipt of service-connected status, our data probably underestimate the proportion of new patients who will ultimately receive service-connected disability status; our finding that 25% of new women patients without service-connected status went on to receive service-connected status in the following year supports this expectation. Outreach to women without a service-connected disability may also be important. The National Survey of Women Veterans reports that about 40% of women veterans who served in the recent conflicts in Iraq and Afghanistan believe that only those with service-connected disability are eligible for VHA care (
); this misconception could dissuade some from seeking care.
These data begin to clarify how new patients are using VHA care during their first year in the system. By 2009, nearly 90% of new women veterans were enrolled in primary care, suggesting that VHA has been effective in its efforts over this period to connect patients with a clinician who can oversee their health care (
). Not only do new women patients enroll in primary care, they also continue in primary care, with the majority retained in primary care for 3 continuous years after they first initiated VHA use. Despite this success, new patients who do not return for primary care in future years merit attention. Some may have decided to leave the VHA because of dissatisfaction with care, emphasizing the potential value of gender-sensitivity training of VHA staff (
). Alternatively, some may have discontinued VHA care, been redeployed to war zones, or believe that they do not require care every 2 to 3 years. The latter group raises concerns about whether they are receiving preventative services: Women require consistent primary care services at every stage of their lives, and lack of a usual source of care may delay receipt of essential services (
The proportion of new women VHA patients using mental health services has increased notably. This increase could reflect a rising prevalence of mental illness as more women return from war (
U.S. Veterans Health Administration (VHA) Implementation of National Clinical Reminder for Afghan and Iraq post-deployment screening. (VHA Directive 2005-055).
) and easily accessible mental health providers embedded in the primary care setting. Alternatively, it could indicate higher reliance on VHA care-seeking among women with mental illness, who may face barriers to mental health care outside VHA (
). Not only are more new women patients using mental health services, they are also making more mental health visits in a year than did women earlier in the decade. It is noteworthy that the majority of new women veteran patients who used mental health services in one year continued to require mental health services beyond one year; indeed, over one third used mental health services in both of the following 2 years. This suggests a high degree of chronicity (and perhaps severity) of mental illness for many women veterans served by VHA, consistent with evidence that mental health issues can be chronic (
). For them, the VHA’s continued investment in mental health infrastructure is critical.
What has driven the remarkable growth in number of women veterans using the VHA? Not surprisingly, the large number of women entering the VHA each year has been a factor. But, our work goes further, demonstrating that another essential factor is also at play: The VHA is retaining these new patients at high rates. Indeed, over half of the 287,000 women veterans using the VHA in 2009 were new to the VHA at some point over the 7 year period. This represents both a success and a challenge. On the one hand, it means that women veterans are choosing to return to the VHA once they see what it has to offer them, consistent with evidence that women who have received care in the VHA tend to have more positive perceptions of the VHA’s services than do those who have never used the VHA (
). At the same time, it also means that the VHA must adapt nimbly to the requirements of a rapidly evolving population with distinct health care needs.
This work is subject to several limitations. First, conclusions about new patients only apply to care provided at VHA facilities. Women veterans may also receive care on a “fee-basis” at non-VHA facilities, although in fiscal year 2009, only 1.8% of women veteran VHA patients received fee-basis care exclusively (
). Second, some patients categorized as “new” may have used VHA more than 3 years before the index year, representing patients who do not use VHA care consistently. However, the VHA would consider such patients to be new in the sense that they would need to re-enroll in primary care. Furthermore, in the fiscal year 2006 cohort, 84% of patients categorized as “new” were confirmed to have no prior VHA use, searching as far back as fiscal year 2000. Among them, main findings were generally similar to those presented above: 65% were younger than 45, 29% had a service-connected rating, 84% had any primary care visit, 27% had any mental health visit, 70% had any outpatient retention, and 53% had consistent outpatient retention. Finally, several sociodemographic indicators, such as race/ethnicity (which suffers from a high rate of missing data;
), marital status, and military rank were not included in this analysis. Integrating such characteristics into the analysis would reveal whether there are differences in primary care and mental health use and retention within other important subpopulations of new women veteran patients, who may have special barriers to access or unique health care needs.
Conclusion
More than half of outpatient women veterans currently treated in VHA joined VHA in the 7-year period between 2003 and 2009. Ongoing military operations will likely result in additional annual influxes of new women VHA patients in the foreseeable future; if the high retention rates that we observed persist, this will generate continuing expansion of the women veteran patient population, many of whom may be frequent users of VHA. This calls for the VHA to continue to innovate high-quality, cost-effective delivery systems responsive to an emerging population of women that includes many of reproductive age or with mental health needs. The VHA has been recognized as a quality leader in U.S. health care (
). Ensuring that the system is responsive to these new women will enable the VHA to further widen its doors to women veterans in need of its services.
Acknowledgments
Maureen Murdoch, MD, MPH, Xiaoyu Bi, PhD, Eric Berg, MS, and Lakshmi Ananth, MS, all contributed expertise to this manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the United States government.
Appendix.
Appendix AStop Codes Used to Create the Primary Care Variable
Committee on the Initial Assessment of Readjustment Needs of Military Personnel Veterans and Their Families, & Board on the Health of Select Populations
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Institute of Medicine of the National Academies,
Washington, DC2010
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Sarah A. Friedman, MSPH, coordinates the Women’s Health Evaluation Initiative at the Center for Health Care Evaluation, VA Palo Alto HCS. She studied health policy at the University of North Carolina, Chapel Hill. Her interests are access disparities and economic incentives.
Ciaran S. Phibbs, Ph.D. is a Health Economist in the Health Economics Resource Center and the Center for Health Care Evaluation, VA Palo Alto HCS; Health Research and Policy Department, and Pediatrics Department, Stanford University. His research includes perinatal care, nurse staffing, and hospital markets.
Susan K. Schmitt, Ph.D. a statistical programmer at the Health Economics Resource Center and the Center for Health Care Evaluation, VA Palo Alto HCS, works on a variety of research projects to improve the quality of health care for Veterans.
Patricia M. Hayes, Ph.D. is the Chief Consultant, Women Veterans Health Strategic Health Care Group in Patient Care Services for the Department of Veteran Affairs. She has worked throughout the VA to expand initiatives for women Veterans.
Laura Herrera, MD, MPH is the Acting Deputy Chief Officer, Office of Public Health and Environmental Hazards for the Veterans Health Administration.
Susan M. Frayne, MD, MPH, at Center for Health Care Evaluation, VA Palo Alto, directs the Women’s Health Practice-Based Research Network and Women’s Health Evaluation Initiative. She is Associate Director, VA Palo Alto Women’s Health Center, and Associate Professor of Medicine, Stanford University.
Article info
Publication history
Accepted:
April 20,
2011
Received in revised form:
April 20,
2011
Received:
December 2,
2010
Footnotes
Based on work supported in part by the Department of Veterans Affairs, Women Veterans Health Strategic Health Care Group.
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