Women Veterans’ Healthcare Delivery Preferences and Use by Military Service Era: Findings from the National Survey of Women Veterans

Donna L. Washington 1 2 3 Bevanne Bean-Mayberry MHS 1 2 Alison B. Hamilton 0 2 Kristina M. Cordasco MSHS 1 2 5 Elizabeth M. Yano MSPH 2 4 0 , Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA) David Geffen School of Medicine , Los Angeles, CA, USA 1 , Department of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine , Los Angeles, CA, USA 2 , VA Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behavior , Sepulveda, CA, USA 3 , VA Greater Los Angeles Healthcare System , Los Angeles, CA, USA 4 Department of Health Policy and Management, UCLA Fielding School of Public Health , Los Angeles, CA, USA 5 , The RAND Corporation, Santa Monica, CA, USA - BACKGROUND: The number of women Veterans (WVs) utilizing the Veterans Health Administration (VA) has doubled over the past decade, heightening the importance of understanding their healthcare delivery preferences and utilization patterns. Other studies have identified healthcare issues and behaviors of WVs in specific military service eras (e.g., Vietnam), but delivery preferences and utilization have not been examined within and across eras on a population basis. OBJECTIVE: To identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness. DESIGN AND PARTICIPANTS: Cross-sectional 2008 2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population. MAIN MEASURES: Healthcare delivery preferences measured as importance of selected healthcare features; types of healthcare services and number of visits used; use of VA or non-VA; all by military service era. KEY RESULTS: Military service era differences were present in types of healthcare used, with World War II and Korea era WVs using more specialty care, and Vietnam era-to-present WVs using more womens health and mental health care. Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) WVs made more healthcare visits than WVs of earlier military eras. The greatest healthcare delivery concerns were location convenience for Vietnam and earlier WVs, and cost for Gulf War 1 and OEF/OIF/OND WVs. Colocated gynecology with general healthcare was also rated important by a sizable proportion of WVs from all military service eras. CONCLUSIONS: Our findings point to the importance of ensuring access to specialty services closer to home for WVs, which may require technology-supported care. Younger WVs higher mental health care use reinforces the need for integration and coordination of primary care, reproductive health and mental health care. BACKGROUND The Veterans Health Administration (VA)the largest integrated healthcare delivery system in the United States (U.S.)is a forerunner of the Accountable Care Organization (ACO) model.1,2 ACOs, such as the VA, need to design services that map to the healthcare needs and delivery preferences of the different population groups they serve.3 Among the fastest growing segment of VA users are women Veterans (WVs), who account for more than one-half million enrollees and whose numbers have doubled in the past decade.4 Despite the growth in size of the WV population, women currently comprise less than 10 % of U.S. Veterans, and therefore planning for the needs of this market segment requires separate and/or gender-stratified population-based assessments.5 Much prior research has documented gender differences in Veterans characteristics, healthcare needs, healthcare delivery preferences, and receipt of evidence-based care.610 However, heterogeneity within the WV population (e.g., by military service era) was not addressed.11 A burgeoning literature on specific Veteran military service era groups (e.g., Vietnam) highlights salient health issues for these population segments,1114 but delivery preferences and utilization have not been examined across eras on a population basis. Healthcare providers within and outside the VA would benefit from more knowledge distinguishing health and healthcare characteristics of different military groups. Understanding and accounting for era of military service among WVs may be important for considerations of how to tailor access and healthcare for women. The purpose of this paper is to examine healthcare delivery preferences and healthcare use of WVs by military service era, and identify implications for improving WVs care. WWII, Korea, Vietnam, Gulf War pre-9/11 (GW1), and Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). Design and Sample Our methods have been described previously.15,16 Briefly, we conducted a cross-sectional national survey, enrolling a population-based, stratified random sample of WVs. Stratification was based on VA use/nonuse and military service period.16 Inclusion criteria were being a WV of the regular armed forces, or a member of the National Guard or Reserves who had been called to active duty. Exclusion criteria were current active military duty, VA employment, hospitalization or residence in a long-term care facility. Eighty-six percent of screened and eligible WVs consented to survey participation.16 We conducted computer-assisted telephone interviews over a 9-month period through May 2009. This study was approved by the Institutional Review Board of the VA Greater Los Angeles Healthcare System, and the survey was also approved by the U.S. Office of Management and Budget. Main Measures Survey items included previously validated measures and measures developed for the NSWV. Healthcare delivery preferences were assessed using items derived from an earlier regional study of WVs ambulatory care decision-making.17 These items were 4-point Likert scales on the importance of different healthcare delivery features in decision-making about healthcare. They were dichotomized to very important versus less than very important. Healthcare use in the prior 12 months was characterized by use of VA or non-VA healthcare, having a regular source and provider for healthcare (yes/no for each), type of healthcare services used (womens health [WH], other primary care, mental health [MH], specialty care), and number of healthcare visits.1719 WH services could include genderspecific preventive care (such as cervical cancer screening), gynecologic care, and obstetrical care. Military service era was the main independent variable. We asked participants when they served in the military, allowing respondents to select multiple date ranges or service periods. Using established dates for U.S. military wartimes and peacetimes,20,21 we defined military service eras as starting with the beginning of a wartime period, and ending with the end of the subsequent peacetime. Given the small number of living WVs with service prior to the start of World War 2 (WWII), we combined pre-WWII veterans with the WWII group. For this analys (...truncated)