The 2% limit on women serving in military branches has meant that historically, there was a low number of women in the military. 1 The 2% limit on the number of women serving in the military was lifted by Congress at the end of the Vietnam era. Women were allowed to serve in almost all fields except combat details. According to the Department of Defense, military women make up 15% of active-duty personnel, 17% of reserve or guard personnel, and 20% of recruits. Nearly 30% of the 505,366 Operation Enduring Freedom or Operation Iraqi Freedom veterans that have separated from service have received health care through the Department of Veterans Affairs (Veterans Health Administration, VA), and 13% of these new VA users have been female.
Consequently, women veterans have grown to be one of the fastest-growing segments of the VA population. They currently make up over 10% of 22.8 million veterans who use VA. Women now account for 10% of VA users, which is a faster increase than was previously expected. According to new projections, 14% of VA users by 2010 will be female. It is therefore imperative that we assess the delivery of healthcare to military women who might enter the VA to better understand how they may be cared for.
The United States civilian and VA systems for comprehensive primary care (PC), for women, have been described as "a patchwork quilt with gaps", consisting of fragmented services. This can lead to overuse (outpatient services), underuse (gender-specific screening for cancer), and omissions (intimate partner abuse screening). The fragmentation in PC for women partly stemmed from the segregation and specialization of general medical care. This was reinforced by one-third to one-half of American women receiving care from multiple providers, most commonly a generalist for routine care and an obstetrician for gender-specific services. The evolution of women’s health care delivery towards more gender-sensitive models of care was possible due to increased awareness of the inherent fragmentation in women's PC. A common model is the creation of separate women's clinics (WHCs), that have grown in number to provide more gender-sensitive, and less fragmented, care for women. The current data shows a nationwide increase in WHCs, from 19% to 43% during 1990 and 2000.
This study evaluated the organizational factors that affect the availability of WHCs in VA-wide PC settings. We based our hypothesis on the VA Comprehensive Women's Health Centers' models. To develop a separate PC model that is accessible to women veterans, we needed an environment that encourages women's healthcare through academic partnerships (i.e. access to experts and trainers), leadership that supports resource reallocation, a provider mix that allows for assignment to alternative clinic practice and sufficient resources and caseload that it would be feasible to reorganize.
The presence of WHCs for computers in VAMCs was significantly more common than those without. WHCs for PC had fewer authority measures. They reported less authority to terminate staff or to contract out for medical services (e.g. community providers, lab providers). Other authority measures such as the ability to establish administrative policy for PCs or to evaluate administrative staff were similar between both groups. Separate PC budgets were not common and were similar between the groups.
Multiple logistic regression analyses showed that only distinct PC leadership had a positive, significant relationship with WHC availability. The presence of separate WHCs at VA locations showed an inverse trend or relationship with authority to purchase PC contract services. Although the OR for PC teams was large in the adjusted analysis, it was not associated with WHC availability. The availability of WHCs in PC was not affected by the existence of a specific staff organization or staffing (e.g. dieticians, pharmacists, etc.).
The significant factor that has contributed to the VA's availability of WHCs before 2000 is the separate PC leadership. A leader who is solely focused on PC could allow the VAMC to concentrate on PC patients (e.g. women veterans) rather than those in specialty or subspecialty care (e.g. human immunodeficiency viruses patients). Moreover, PC leadership can occur simultaneously in larger facilities with a higher organizational hierarchy. An increase in the organizational hierarchy could result in a decreased ability to create contractual services outside of the institution or modify policy for the PC service. Leaders in PC might be expected to implement complex policies for the organization, rather than introduce new measures.
It is not surprising that the authority to contract with PCs showed an inverted relationship with WHCs. This may be because WHC-infected PC practices have a greater need to keep their services within the medical center. They may also have more complex administrations and may need additional authorization, procedures, or funds to contract outside the VA. While WHCs were more readily available at sites with higher female caseloads and academic centers, this did not explain the existence of WHCs in multivariable modeling. Moreover, although variation in staff types and the PC team concept are more common at WHC sites, they didn't predict WHC availability. In particular, even though PC teams were associated with WHCs during bivariate analyses (99 percent of sites with WHCs versus 90 percent of those without), this feature of care was present at most sites. This resulted in the non-significant CI in multivariate regression. Sites with and without WHCs had similar patterns of resource utilization and guideline implementation, showing no differences in their potential ability to provide care.
The limitations of the methodological approach used in this study should be considered. First, the cross-sectional study does not reveal if the identified trend and association contributed to the longevity or development of WHCs. This study did not attempt to determine if WHCs were made available due to a threshold patient volume, or whether WHCs attracted more female patients to VAMC. We are unable to calculate site-specific patient workloads over time. However, we did calculate the absolute change in female patients per facility between FY 1996 and FY 2000. We found no significant differences in the numbers of female patients who were treated at facilities with or without WHCs over this period. We also focused on the caseload and workload of female outpatients. Since the VA may have different numbers and proportions, we did not include facilities features like bed size or patient admissions. In 1999, the VA survey did not include specific services or organizational factors that are gender-specific. It is therefore unclear if they provide more than just basic PC practice features.
Despite these limitations, our study is the first to analyze organizational features that are associated with the history of WHCs within the VA. The next steps in the logic of this study are to assess health outcomes according to whether PC service is delivered separately or as an integrated service to women veterans. Additionally, we will evaluate outcomes based upon the presence of other organizational factors that may not be related to PC service delivery to women veterans. Current research is underway to determine the effectiveness of different models, and different organizational factors in delivering high-quality women's healthcare in VA. These new insights will help to design interventions that optimize care delivery for women veterans.
Sources:
https://academic.oup.com/milmed/article/172/8/824/4283384
https://link.springer.com/article/10.1007/s11606-013-2699-33
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