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Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review
Women's Health Issues xxx-xx (2016) 1–9
www.whijournal.com
Original article
Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review Andrea Carter, MD a, Sonya Borrero, MD, MS a,b,*, Charles Wessel, MLS c, Donna L. Washington, MD, MPH d,e, Bevanne Bean-Mayberry, MD, MHS d,e, Jennifer Corbelli, MD, MS a, and the VA Women’s Health Disparities Research Workgroup a
Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania c Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania d Veterans Affairs Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California e Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California b
Article history: Received 24 November 2015; Received in revised form 4 March 2016; Accepted 23 March 2016
a b s t r a c t Background: Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA. Methods: We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity. Results: Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n ¼ 3), treatment of low bone mass (n ¼ 1), hormone therapy (n ¼ 1), use of mental health or substance abuse–related services (n ¼ 2), trauma exposure and use of various services (n ¼ 1), and satisfaction with primary care (n ¼ 1). Five of nine studies showed evidence of a significant racial or ethnic difference. Conclusion: In contrast with the wealth of literature examining disparities both among the male veterans and women in nonVA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users. Published by Elsevier Inc. on behalf of the Jacobs Institute of Women's Health.
Women are a rapidly growing segment of patients who receive care in the Veterans Affairs (VA) Healthcare System: 6.5% of all VA users are women and the number of women receiving
Funding and conflict of interest statement: This work was supported in part by the VA Women’s Health Research Network (VA HSR&D SDR 10–012). The contents of this manuscript do not represent the views of the Department of Veterans Affairs or the United States Government. To the best of our knowledge, there are no conflicts of interest. * Correspondence to: Sonya Borrero, MD, MS, 230 McKee Place, Suite 600, Pittsburgh, PA 15213. Phone: (412) 692-4841; fax: (412) 692-4828. E-mail address: [email protected] (S. Borrero).
health care in the VA has doubled since 2000 (Frayne et al., 2014). This growth has outpaced that of the male veteran population. More than one-half of women veterans returning from the conflicts in Iraq and Afghanistan (Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn) have received VA health care (U.S. Department of Veterans Affairs, 2012). However, most research conducted within the VA has not included women participants, and many questions regarding woman veterans’ health care experiences and outcomes remain unanswered. Female VA users are a vulnerable population with unique health care needs. Compared with civilian women and male VA
1049-3867/$ - see front matter Published by Elsevier Inc. on behalf of the Jacobs Institute of Women’s Health. http://dx.doi.org/10.1016/j.whi.2016.03.009
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users, they have a higher prevalence of mental illness and medical comorbidities (Frayne et al., 2014; Haskell et al., 2010; Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012). Additionally, women veterans who use the VA are disproportionately from racial and ethnic minority groups. Almost 40% of women veterans who use VA services are from a racial or ethnic minority group compared with 23% of male veterans who use the VA (Frayne et al., 2014). Thus, an increased effort to understand the current state of care for women veterans, across all racial and ethnic groups, is imperative to guide future operations, policy, and research efforts. The burden of racial and ethnic disparities among veterans within the VA Healthcare System has been previously systematically reviewed (Saha et al., 2008) and was recently updated in an evidence brief (U.S. Department of Veterans Affairs Health Services Research & Development, 2015). The majority of studies included in the review showed that significant racial or ethnic disparities exist, and that these disparities existed across a range of clinical areas including arthritis/pain management, cancer, diabetes, cardiovascular disease, human immunodeficiency virus, hepatitis C, mental health/substance abuse, preventative/ambulatory care, rehabilitation, and palliative care. However, the vast majority of the 171 studies included in the initial VA systematic review included either no women or a very small number (5% of total study participants) of women, and none of the clinical content areas presented in the review were areas specific to women’s health (such as cervical cancer screening or contraception). We systematically reviewed the literature on racial and ethnic disparities in health care among women who receive care in the VA Healthcare System. Although we report on any significant difference in health care by race or ethnicity, we recognize that differences may not always indicate a disparity. The term “health disparity” has been defined as “a particular type of health difference that is closely linked with social or economic disadvantage” (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objective for 2020, 2008) and, as such, implies an injustice. Because it is common practice in the field of disparities research to begin with the identification of differences between vulnerable and less vulnerable populations, with further inquiry to determine if differences represent inequitable or lower quality care for the vulnerable population, we simply report on observed differences in this report and use the terms “disparity” and “difference” somewhat interchangeably. Our primary aims were to identify and summarize existing work in this area and to elucidate areas in which future research efforts should be focused to ultimately work toward the goal of reducing racial and ethnic disparities among women veterans. Methods Search Strategy A formalized protocol was written prior to initiation of the systematic review. A health sciences librarian (C.W.) developed, revised, translated, and performed literature searches in PubMed (1946–present), EMBASE (1974–present), and the American Psychological Association’s PsycINFO (1967–present). We constructed searches using the command language of each database and the applicable search fields (Appendix 1). MeSH, EMTREE, and American Psychological Association’s Thesaurus of Psychological Index Terms vocabulary were used. For this search, health
disparities and racial and ethnic population group search terms were considered synonymous concepts and were combined together with a Boolean operator “OR.” These synonymous concepts were combined with a Boolean operator “AND” to the veteran/VA and women search terms. No search limits were applied and all languages were included. We ran all three database searches and citations were downloaded on June 30, 2014. Study Selection We removed duplicate citations and screened citations by both title and abstract for relevance. We selected studies that met the following criteria: 1) conducted solely within the VA Healthcare System, 2) reported data on women exclusively or stratified data by gender, 3) reported data on use, quality of health care services, or satisfaction, 4) stratified results by patient race or ethnicity, 5) contained original data, and 6) published in a peer-reviewed journal. Two authors (A.C. and J.C.) independently confirmed study eligibility. Any discrepancies were resolved through discussion and group consensus. Data Abstraction We abstracted data from all studies meeting inclusion criteria using a structured form, which included study design, study period, number enrolled, source of race/ethnicity data, race/ ethnicity of study population, source of outcome data, and outcomes. Studies were summarized in tables and classified according to clinical area. Because no standardized or validated quality measures to evaluate cross sectional data exist, we were unable to perform study quality and risk of bias scoring. Furthermore, a meta-analysis was not performed given the marked heterogeneity of both outcomes and outcome measures used in the studies included in our systematic review. Results Search Yield Our search located 1,622 citations in PubMED, 1,859 citations in EMBASE, and 584 citations in PsychINFO. After duplicate citations were identified and removed, 2,591 citations were screened by both title and abstract and 2,446 of these were eliminated. The remaining 145 citations were reviewed in full text, and 9 studies were identified for inclusion (Figure 1). Description of Evidence We identified nine studies that examine racial and ethnic disparities in health care among women in the VA Healthcare System (Table 1). Five studies were retrospective cohort studies using VA administrative databases, two studies were crosssectional surveys, and two studies were combination cohort and survey studies. Overall, five of the nine studies showed evidence of a significant racial or ethnic difference in a quality of care or use of care outcome (Table 2). Of the five studies that showed evidence of a significant racial or ethnic difference, one was a single VA study and four used national VA data. The studies examined the following health care domains: contraception provision/access, treatment of low bone mass, hormone therapy, use of mental health or substance abuse–related services, trauma exposure and use of various VA services, and satisfaction with primary care.
Included
Eligibility
Screening
IdenƟficaƟon
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
Records idenƟfied through searching PubMed n = 1,622
Records idenƟfied through searching Embase n = 1,859
Records idenƟfied through searching PsychINFO n = 584
Total records idenƟfied by searching databases n = 4,065
Duplicate records excluded n = 1,474
Records screened n = 2,591
Records excluded by Ɵtle/abstract n = 2,446
Records assessed for eligibility n = 145
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Records excluded aŌer full text review: Not conducted solely within the VA Not exclusively women or data not straƟfied by gender No data on uƟlizaƟon, quality, or saƟsfacƟon Data not straƟfied by race or ethnicity No original data Not in peer reviewed journal
n=9 n = 112 n=2 n=7 n=5 n=1
Studies included in review n=9
Figure 1. PRISMA flow diagram (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009).
Contraception provision/access (n ¼ 3) Of the three retrospective cohort studies examining contraception provision/access, two found evidence of a significant racial or ethnic difference. One study of 805 woman veterans in the San Diego VA Healthcare System who received a new prescription for hormonal contraception during the study period found no racial or ethnic difference in hormonal contraception adherence (defined as obtaining 12 months of refills of hormonal contraception in a 12-month time period; Kazerooni, Takizawa, & Vu, 2014). Another study of all woman veterans in the national VA system between age 18 and 45 who made at least one visit to a VA primary care or women’s health clinic in fiscal year 2008 and had hormonal contraceptive coverage during the first week of the study period (n ¼ 6,946) found that Hispanic women were significantly more likely than White women to experience gaps between refills of hormonal contraception, and that Hispanic women and Black women received significantly fewer overall months of contraceptive coverage in a 12-month period than White women (Borrero et al., 2013). A third study of all woman veterans in the national VA system between age 18 and 45 who made at least one visit to a VA primary care or women’s health clinic fiscal year 2008 (n ¼ 103,950) found that Hispanic and Black women were significantly less likely than White women to have documented receipt of any contraception (Borrero et al., 2012). However, this same study found that, when Black women were using a form of contraception, they were significantly more likely than White women to use a highly effective method of contraception (intrauterine device, implant, or surgical sterilization).
Treatment of low bone mass (n ¼ 1) This cross-sectional survey study of 75 women who underwent dual-energy x-ray absorptiometry testing at the Washington DC VA Medical Center found that Black women were significantly less likely than White women to receive an antiresorptive drug for treatment of low bone mass after controlling for severity of low bone mass and prior fractures (Wei, Jackson, & Herbers Jr, 2003). Hormone therapy (n ¼ 1) This retrospective cohort study of all woman veterans in the national VA system using menopausal hormone therapy (MHT) in 2001 (n ¼ 36,222) examined discontinuation of MHT after the publication of the Women’s Health Initiative, which was the first major publication to describe risks of MHT (Rossouw et al., 2002). They found that perimenopausal and postmenopausal Black and Hispanic women were more likely than White women to discontinue MHT (Haskell et al., 2008) by 2 years after the Women’s Health Initiative publication. Use of mental health or substance abuse–related services (n ¼ 2) One combined survey and retrospective cohort study of 526 woman veterans at a primary care clinic at the Durham VA Medical Center found no evidence of racial or ethnic difference in use of mental health services in a 12-month period. However, this study did find that Black women reported wanting a mental health referral more frequently than White women (34% vs. 27%; p ¼ .01; Bosworth et al., 2000). The second retrospective cohort study of 854 woman veterans in the national VA system
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Table 1 Study Characteristics Title
Study Design
Study Period
N
Level of Analysis
Source of Race or Ethnicity Data
Race or Ethnicity of Study Population
Kazerooni 2014
Predictors of adherence to hormonal contraceptives in a female veteran population
Retrospective cohort study
April 2010–March 2012
805 women
Single VA (San Diego)
Administrative data
Borrero 2013
Adherence to hormonal contraception among women veterans: differences by race/ ethnicity and contraceptive supply Contraceptive care in the VA health care system
Retrospective cohort study
October 2007– September 2008
6,946 women
National VA system
Administrative data
White 62% Black 14% Asian 7% Native American/ Alaskan 1% Mixed race 2% Unknown 13% White 47% Hispanic 6% Black 22% Other 3% Unknown 22%
Retrospective cohort study
2008
103,950 women
National VA system
Administrative data
Determinants of hormone therapy discontinuation among female veterans nationally Racial disparities in trauma exposure, psychiatric symptoms, and service use among female patients in VA primary care clinics Brief report: lack of a race effect in primary care ratings among women veterans Ethnic disparity in the treatment of women with established low bone mass Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic Age, ethnicity, and comorbidity in a national sample of hospitalized alcoholdependent women veterans
Retrospective cohort study
2001–2004
36,222 women
National VA system
Not reported
Cross-sectional survey and retrospective cohort study
January 2000– December 2002
183 women
Multiple VAs (Charleston, SC; Columbia SC; Tuscaloosa, AL; Birmingham, AL)
Self-identified during phone interview
White 55% Black 46%
Cross-sectional survey
Not reported
1,447 women
Multiple Vas (systems in DE, KY, PA, TN, WV)
Self-identified on survey
White 85% Black 11% Other 3%
Cross-sectional survey
January 1998–October 2001
75 women
Single VA (Washington, DC)
Self-identified on survey
White 55% Black 35% Other 10%
Survey and retrospective cohort study
July 1994–December 1996
526 women
Single VA (Durham, NC)
Self-identified on survey
White 46% Black 54%
Retrospective cohort study
October 1992– September 1993
854 women
National VA system
Administrative data
White 62% Black 33% Hispanic 2% Native American 3%
Borrero 2012
Haskell 2008
Grubaugh 2008
Bean-Mayberry 2006
Wei 2003
Bosworth 2000
Ross 1998
Abbreviation: VA, Veteran’s Affairs.
White 40% Hispanic 6% Black 25% Other 3% Unknown 26% White 58% Black 12% Hispanic 2% Other/unknown 27%
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First Author, Year
Table 2 Study Outcome Data Source of Use or Quality Outcome Data
Quality/Use Outcome(s)
Adjusted OR/HR (Referent, White Women; 95% CI if Reported, p-value if Reported)
Kazerooni 2014
Pharmacy/ administrative data
Adherence to hormonal contraception (defined as having a medication possession ratio 0.9; a patient would need to have obtained 12 months’ worth of refills within a 1-year time frame)
Borrero 2013
Pharmacy/ administrative data
Nonadherence to hormonal contraception (defined as having gaps 7 days between refills)
Black Asian Mixed Native American Hispanic Black Hispanic Black Hispanic Black Other Hispanic Black Other Hispanic Black Other
0.73 1.11 0.54 0.40 1.18 1.04 0.76 0.95 0.82 0.85 0.87 0.89 1.10 0.88 1.41 1.13 1.08
(0.44–1.22, p (0.60–2.03, p (0.16–1.77, p (0.08–2.08, p (1.03–1.34, p (0.95–1.13, p (0.57–1.01, p (0.81–1.12, p (0.76–0.88, p (0.81–0.89, p (0.79–0.95, p (0.77–1.03, p (1.01–1.20, p (0.73–1.05, p (1.19–1.67)* (1.05–1.22)* (1.02–1.12)*
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
Black Black Black Black
0.13 1.36 1.64 1.73
(0.94–1.04, (0.69–2.68, (0.75–3.55, (0.87–3.42,
¼ ¼ ¼ ¼
Black Other Black Other Black Other Black Other Black Other Whitez
0.7 0.5 0.7 0.7 1.9 0.9 0.7 0.9 0.7 0.5 3.71
(0.4–1.3) (0.1–1.6) (0.5–1.1) (0.4–1.4) (0.8–4.4) (0.2–4.9) (0.3–1.2) (0.5–1.6) (0.4–1.1) (0.2–1.5) (1.24–11.1)*
Black
1.21 (0.79–1.86)
Black Hispanic Native American Black Hispanic Native American Black Hispanic Native American
0.79 0.99 4.18 1.27 4.62 3.39 0.69 0.36 2.28
Borrero 2012
Pharmacy/ administrative data
Adherence to hormonal contraception (defined as obtaining all 12 months of contraception in a year without gaps) Documented receipt of any contraception (defined as receiving prescription or undergoing procedure indicating contraceptive use) Use of most effective method of contraception (defined as using IUD, implant, or surgical sterilization)
Haskell 2008
Grubaugh 2008
Bean-Mayberry 2006
Pharmacy/ administrative data Administrative data
Survey
Discontinuation of hormone therapy (defined as having been prescribed and distributed hormone therapy in 2001 but no longer in 2004) Use of various VA services (defined as 1 visit in prior 12 months) Inpatient services Urgent ER services Women’s clinic Mental health services Satisfaction with primary care in various domains (defined as perfect score on survey) Patient preference for usual provider Satisfaction with provider interpersonal communication Satisfaction with provider accumulated knowledge Satisfaction with coordination of care Overall excellent satisfaction
Wei 2003
Survey
Bosworth 2000
Administrative data Administrative data
Ross 1998
Use of antiresorptive drug for treatment of low bone mass adjusted for severity and prior fractures (defined as using estrogen replacement, alendronate, risedronate, nasal calcitonin, or raloxifine) Use of mental health services (defined as visit within last 12 months) Use of alcohol-related services among hospitalized veterans with alcohol-related disorders Receive alcohol treatment services
Enter formal alcohol treatment
Complete formal alcohol treatment
.23) .77) .31) .27) .02)* .38) 0.06) .56) <.001)* <.001)* .003)* .12) .04)* .16)
Significant Racial or Ethnic Difference in Quality/Use Outcome? No
Yes
Yes
Yes
No p p p p
.06)y .37) .21) .12) No
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
First Author, Year
Yes
No Yes
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
not significant) not significant) < .05)* not significant) not significant) not significant) not significant) not significant) not significant)
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Abbreviations: CI, confidence interval; ER, emergency room; HR, hazard ratio; IUD, intrauterine device; OR, odds ratio; VA, Veteran’s Administration. * Statistically significant value. y Results as listed in study (Black, 0.13; 95% CI, 0.94–1.04; p ¼ 0.06). z Adjusted odds ratio reported with Black women as reference.
(p (p (p (p (p (p (p (p (p
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diagnosed with alcohol dependence found that Native American women (n ¼ 22) were more likely than White women (n ¼ 532) to receive formal alcohol treatment, but there was no difference in receiving formal alcohol treatment between Hispanic or African American women compared with White women (Ross, Fortney, Lancaster, & Booth, 1998). Trauma exposure and use of various VA services (n ¼ 1) A cross-sectional survey and retrospective cohort study of 183 woman veterans randomly selected from 4 VA medical centers (Charleston, SC; Columbia, SC; Tuscaloosa, AL; and Birmingham, AL) assessed racial or ethnic differences in trauma exposure, psychiatric symptoms, and VA services use among women veterans and reported no racial or ethnic difference in the use of various VA services (including inpatient, emergency room, women’s clinic, primary care, and mental health services) over a 12-month period (Grubaugh, Slagle, Long, Frueh, & Magruder, 2008). Satisfaction with primary care (n ¼ 1) A cross-sectional survey study of 1,447 women using VA primary care or women’s health clinics in 5 states (Delaware, Kentucky, Pennsylvania, Tennessee, and West Virginia) asked veterans about their satisfaction with primary care and found no significant racial or ethnic difference in overall rating of excellent satisfaction, patient preference for maintaining a relationship with her health care provider, patient perceptions of her provider’s interpersonal communication, accumulation of knowledge, or coordination of care (Bean-Mayberry, Chang, & Scholle, 2006). Discussion The results of our systematic review demonstrate that there are only nine studies that examine racial and ethnic disparities specifically among female VA users. Many clinical areas with known racial and ethnic disparities among male VA users and among women outside the VA have not been studied in female VA users. Multiple groups and policymakers, including the VA, have called for the identification and eradication of racial and ethnic disparities in health care to be a national priority (Fine & Demakis, 2003; Institute of Medicine, 2003; Koh, Blakey, & Roper, 2014; U.S. Department of Health and Human Services, 2011). The VA is an ideal place to examine racial and ethnic differences among women for several reasons. The VA provides care to a racially and ethnically diverse population, taking care of 360,000 women veterans of whom 29% are Black, 1% are Asian, 1% are Native American/Alaska Native, 1% are Native Hawaiian/other Pacific Islander, and 6% are of Hispanic origin (Frayne et al., 2014). Many of the financial confounders present in the private sector, such as insurance coverage and ability to pay for care, are removed in the VA setting. Furthermore, administrative databases in the VA contain extensive national data on quality and use. These factors make the VA an optimal and uniquely informative place to identify and understand racial and ethnic health care disparities. Thus, the relative paucity of data on racial and ethnic disparities among woman veterans is concerning. A majority of studies included in our review showed evidence of a racial or ethnic difference. The clinical area with the most studies (n ¼ 3) was contraception. Of the three studies on contraception, two showed a significant racial or ethnic difference in adherence to or receipt of contraception and one showed
no difference. The study that showed no difference was based on a much smaller sample (n ¼ 805; Kazerooni et al., 2014) than the other two (n ¼ 6,946 and n ¼ 103,950; Borrero et al., 2012; Borrero et al., 2013). The smaller study did show, however, a nonsignificant trend toward lower adherence to contraception in Black and Hispanic women and may have been simply underpowered to detect statistical significance. Additionally, this study was conducted in a single VA as opposed to the other two, which were national VA samples, so the results of this study may reflect factors specific to an individual VA Healthcare System. Overall, these findings of racial and ethnic differences in adherence to and receipt of contraception among women VA users aged 18 to 45 are broadly consistent with the observed racial and ethnic differences in use of contraception and unintended pregnancy in the general U.S. population of teens and women aged 15 to 44 (Dehlendorf et al., 2014; Finer & Zolna, 2014). Racial and ethnic differences in patient satisfaction among male veterans has been examined in at least five studies (Saha et al., 2008), and three of these showed significant racial or ethnic disparities (Flaherty, Naidu, Lawton, & Pathak, 1981; Ohldin et al., 2004; Young, Meterko, & Desai, 2000). Our systematic review revealed only one study on satisfaction among women at the VA (Bean-Mayberry et al., 2006). This survey study showed no racial or ethnic differences in satisfaction with primary care, which is encouraging. However, the response rate was 55%, and it is unclear if respondent characteristics were different from those of nonresponders. Given that this is the only published study on racial or ethnic differences in satisfaction among women at the VA, it is unclear if racial or ethnic satisfaction differences exist in care received outside of primary care. Although there are challenges with using patient satisfaction as an outcome measure, such as variability in scales used and a high degree of subjectivity, patient satisfaction studies may nonetheless be especially relevant given the increasing importance of patient satisfaction measures in quality metrics. Interestingly, some of the racial or ethnic differences we found among women at the VA appear on the surface to favor racial or ethnic minority groups. In particular, Black women were found to use contraception belonging in the category of “most effective” methods (intrauterine devices, implants, or surgical sterilization) more often than White women (Borrero et al., 2012). However, this difference is likely driven by higher rates of surgical sterilization among African American women (Borrero et al., 2010; Dehlendorf et al., 2014), who may have higher rates of post-sterilization regret (Borrero et al., 2008). A second difference that may seem to favor Blacks and Hispanics is that perimenopasual and postmenopausal Black and Hispanic women were more likely than White women to discontinue hormone therapy (Haskell et al., 2008) by 2 years after the Women’s Health Initiative publication, which was the first publication to emphasize the risks of MHT (Rossouw et al., 2002). Again, the implication of this difference is unclear, because use of hormone therapy is highly sensitive to patient preference and because reasons for disparate discontinuation rates are unclear. Finally, Native American women completed inpatient alcohol treatment programs more often than White women (Ross et al., 1998), perhaps owing to clinician awareness that Native Americans are disproportionately burdened by alcohol-related problems like binge drinking (Akins, Lanfear, Cline, & Mosher, 2013) and alcohol-attributable mortality (Landen, Roeber, Naimi, Nielsen, & Sewell, 2014). However, it may be difficult to draw significant conclusions from this study given the small number (n ¼ 22, 3% of study population) of Native American women.
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Additional work is needed to understand the clinical significance of these findings. Although the majority of the studies included in our review evaluate gender-specific topics (contraception, low bone mass, hormone therapy), the fact that there were only five studies on these topics demonstrates the dearth of disparities literature in the area of gender-specific health conditions among women veterans. Racial and ethnic disparities have been shown to exist in non-VA settings in multiple gender-specific areas that have not yet been examined within the VA, including cervical cancer screening, mammography, prenatal care, and annual preventive visits (Kaiser Family Foundation, 2009; National Healthcare Quality and Disparities Report, 2011). In the non-VA setting, White and Hispanic women are less likely than Black and Asian women to receive a mammogram, Asian women are less likely than White women to receive a pap smear, and Native American women are less likely to receive prenatal care during the first trimester than White women (National Healthcare Quality and Disparities Report, 2011). Given that patients who receive care at the VA have a higher burden of illness and lower income as compared with the general population (Agha, Lofgren, VanRuiswyk, & Layde, 2000), findings from studies in the private sector may not be generalizable to the VA population. Our findings of racial and ethnic differences in contraception, hormone therapy, and low bone mass woman veterans, however, do raise concerns about health inequities for other gender-specific outcomes. Additionally, there are many clinical areas in which racial or ethnic disparities have been demonstrated among male veterans in the VA system that have not yet been examined among women VA users. In the prior systematic review (Saha et al., 2008) that was recently updated in a policy brief (U.S. Department of Veterans Affairs Health Services Research & Development, 2015), multiple studies have found racial or ethnic disparities among men who use the VA in the clinical areas of chronic pain, diabetes, and heart and vascular disease. Additionally, in the prior reviews, disparities were very prevalent in the use of surgery or invasive procedures. Thus, our search parameters were deliberately broad to identify health disparities of any kind. The fact that many of the studies that met our inclusion criteria were focused on gender-specific health conditions reflects the dearth of literature on disparities across the range of medical diseases that occur in women veterans. This is particularly concerning given that the most common health conditions affecting women in the VA system in fact include chronic pain, diabetes, and heart and vascular disease (Frayne et al., 2014). Another area of focus should be examining which disparities among women veterans occur locally and which are present at a national level. Because the VA health care system comprises geographically disparate sites across all 50 states and Puerto Rico and because geographic variation in health care has been identified as an important contributor to disparities, it will be important to discern whether observed racial or ethnic differences reflect variation in practice in regions or sites that primarily serve women from one racial or ethnic group versus those that result from systemic inequities. Several limitations deserve mention. First, we were unable to perform a meta-analysis owing to the heterogeneity of studies. Additionally, we cannot rule out the potential for publication bias in this research area that, if present, could have had a significant impact on our findings given that we are interested in both the presence and absence of racial and ethnic disparities. However, a funnel plot to visualize the effect of publication bias could not be generated owing to distinct outcome measures in each included
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study. Additionally, women veterans who receive care in VA system have worse overall physical and mental health than women who receive care in the private sector (Frayne et al., 2006; Washington, Farmer, Mor, Canning, & Yano, 2015). Given these differences, the results of our review may not generalizable to women veterans receiving care outside the VA. Last, the objective of this review was to summarize the extent to which published literature examines racial or ethnic differences in VA women’s health care to guide future VA research efforts, not to determine the full presence and distribution of racial or ethnic disparities. When a difference represents a disparity and whether this disparity ultimately is of clinical significance must take into account social context, patient preference, and many other factors, which cross-sectional studies are often unable to elucidate and which are beyond the scope of this review. Given that only nine studies met our inclusion criteria despite our broad approach, this clearly underscores the extent to which a comprehensive understanding of racial and ethnic disparities among woman veterans will not be possible until further research is done. Implications for Practice, Policy, and Future Research In contrast with the wealth of literature examining racial and ethnic health care disparities both among male veterans and women in non-VA settings, there are only nine published studies examining disparities specifically among women in the VA Healthcare System. The results of this systematic review demonstrate that there is a need to further study racial and ethnic disparities among female VA users. Specifically, evidence of racial and ethnic health care disparities among women have been shown in non-VA settings in cervical cancer screening, prenatal care, mammograms, and annual preventive visits, but these areas have not been examined among female VA users. Also, among male VA users, disparities have been shown in areas of mental health and substance abuse, cardiovascular disease, surgical procedures, and pain management, but these areas have not been examined among female VA users. Our results thus highlight important knowledge gaps in the fields of VA health equity and women’s health research. Fortunately, an infrastructure to support and facilitate addressing these knowledge gaps currently exists. The VA requires that special efforts be made to include women and members of minority groups in all VA research studies including research that is unfunded, funded by non-VA entities, or funded by the VA Office of Research and Development (U.S. Department of Veterans Affairs, 2013). Additionally, VA Health Service Research & Development has funded the development of the Women’s Health Practice Based Research Network (Frayne et al., 2013). The Practice Based Research Network establishes a readyto-use infrastructure to conduct multisite studies of women veterans, which encourage the inclusion of women in research studies by helping to overcome the issue of small numbers of women at any one facility. Currently, the Practice Based Research Network comprises 60 VA sites across the country and has purposefully included many sites with racially and ethnically diverse female patient populations. The VA Office of Health Equity is also working across the agency to champion the advancement of health equity and elimination of health disparities for all vulnerable veteran populations. Because the VA is dedicated to optimizing women’s health care, additional research to understand and address racial and ethnic disparities among women will help to achieve VA’s
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mission to provide high-quality, equitable health care for all women veterans. Acknowledgments Contributors include members of the VA Women’s Health Disparities Research Workgroup, including Bryan C. Batch, MD, Jessica Y. Breland, MS, PhD, Brooke DiLeone, PhD, Melissa Ming Foynes, PhD, Robin Keene, PhD, RN, Leslie Hausmann, PhD, Kristen Mattocks, PhD, MPH, Michelle Mengeling, PhD, MS, Leslie Moreland, PsyD, Phyllis Nsiah-Kumi, MD, MPH, Uche Uchendu, MD, Sharon Kelly West, RN MHS, CCE, Karen Patricia Williams, PhD, and Susan Zickmund, PhD. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.whi.2016.03.009. References Agha, Z., Lofgren, R. P., VanRuiswyk, J. V., & Layde, P. M. (2000). Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine, 160(21), 3252–3257. Akins, S., Lanfear, C., Cline, S., & Mosher, C. (2013). Patterns and correlates of adult American Indian substance use. Journal of Drug Issues, 43(4), 497–516. Bean-Mayberry, B., Chang, C. C., & Scholle, S. H. (2006). Brief report: Lack of a race effect in primary care ratings among women veterans. Journal of General Internal Medicine, 21(10), 1105–1108. Borrero, S., Moore, C. G., Qin, L., Schwarz, E. B., Akers, A., Creinin, M. D., & Ibrahim, S. A. (2010). Unintended pregnancy influences racial disparity in tubal sterilization rates. Journal of General Internal Medicine, 25(2), 122–128. Borrero, S., Mor, M. K., Zhao, X., McNeil, M., Ibrahim, S., & Hayes, P. (2012). Contraceptive care in the VA health care system. Contraception, 85(6), 580–588. Borrero, S., Zhao, X., Mor, M. K., Schwarz, E. B., Good, C. B., & Gellad, W. F. (2013). Adherence to hormonal contraception among women veterans: Differences by race/ethnicity and contraceptive supply. American Journal of Obstetrics and Gynecology, 209(2), 103.e101–103.e111. Borrero, S. B., Reeves, M. F., Schwarz, E. B., Bost, J. E., Creinin, M. D., & Ibrahim, S. A. (2008). Race, insurance status, and desire for tubal sterilization reversal. Fertility and Sterility, 90(2), 272–277. Bosworth, H. B., Parsey, K. S., Butterfield, M. I., McIntyre, L. M., Oddone, E. Z., Stechuchak, K. M., & Bastian, L. A. (2000). Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic. Journal of the National Medical Association, 92(5), 231–236. Dehlendorf, C., Park, S. Y., Emeremni, C. A., Comer, D., Vincett, K., & Borrero, S. (2014). Racial/ethnic disparities in contraceptive use: Variation by age and women’s reproductive experiences. American Journal of Obstetrics and Gynecology, 210(6), 526.e521–526.e529. Fine, M. J., & Demakis, J. G. (2003). The Veterans Health administration’s promotion of health equity for racial and ethnic minorities. American Journal of Public Health, 93(10), 1622–1624. Finer, L. B., & Zolna, M. R. (2014). Shifts in intended and unintended pregnancies in the United States, 2001-2008. American Journal of Public Health, 104(Suppl 1), S43–S48. Flaherty, J. A., Naidu, J., Lawton, R., & Pathak, D. (1981). Racial differences in perception of ward atmosphere. American Journal of Psychiatry, 138(6), 815–817. Frayne, S., Phibbs, C. S., Saechao, F., Maisel, N. C., Berg, E., Hayes, P., Haskell, S., & Sourcebook: Women Veterans in the Veterans Health Administration (2014). Sociodemographics, Utilization, Costs of Care, and Health Profile, Volume 3. Veterans Health Administration, Washington, DC. Frayne, S. M., Carney, D. V., Bastian, L., Bean-Mayberry, B., Sadler, A., Klap, R., . Yano, E. M. (2013). The VA Women’s Health Practice-Based Research Network: Amplifying women veterans’ voices in VA research. Journal of General Internal Medicine, 28(Suppl 2), S504–S509. Frayne, S. M., Parker, V. A., Christiansen, C. L., Loveland, S., Seaver, M. R., Kazis, L. E., & Skinner, K. M. (2006). Health status among 28,000 women veterans. The VA Women’s Health Program Evaluation Project. Journal of General Internal Medicine, 21(Suppl 3), S40–S46. Grubaugh, A. L., Slagle, D. M., Long, M., Frueh, B. C., & Magruder, K. M. (2008). Racial disparities in trauma exposure, psychiatric symptoms, and service use among female patients in Veterans Affairs primary care clinics. Womens Health Issues, 18(6), 433–441.
Haskell, S. G., Bean-Mayberry, B., Goulet, J. L., Skanderson, M., Good, C. B., & Justice, A. C. (2008). Determinants of hormone therapy discontinuation among female veterans nationally. Military Medicine, 173(1), 91–96. Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal, M., Erdos, J., Justice, A., & Brandt, C. A. (2010). Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut War Veterans of Iraq and Afghanistan. Journal of Women’s Health (Larchmont), 19(2), 267–271. Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Available: www.nap.edu/catalog/10260/unequaltreatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed: March 15, 2015. Kaiser Family Foundation. (2009). Putting women’s health care disparities on the map. Available: http://kff.org/disparities-policy/report/putting-womenshealth-care-disparities-on-the/. Accessed: March 4, 2015. Kazerooni, R., Takizawa, A., & Vu, K. (2014). Predictors of adherence to hormonal contraceptives in a female veteran population. Contraception, 89(4), 292–298. Koh, H. K., Blakey, C. R., & Roper, A. Y. (2014). Healthy People 2020: A report card on the health of the nation. JAMA, 311(24), 2475–2476. Landen, M., Roeber, J., Naimi, T., Nielsen, L., & Sewell, M. (2014). Alcoholattributable mortality among American Indians and Alaska Natives in the United States, 1999-2009. American Journal of Public Health, 104(Suppl 3), S343–S349. Lehavot, K., Hoerster, K. D., Nelson, K. M., Jakupcak, M., & Simpson, T. L. (2012). Health indicators for military, veteran, and civilian women. American Journal of Preventive Medicine, 42(5), 473–480. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. National Healthcare Quality and Disparities Report. (2011). Disparities in healthcare quality among minority women. Available: www.ahrq.gov/research/findings/ nhqrdr/nhqrdr11/minority-women.pdf. Accessed: March 6, 2015. Ohldin, A., Young, B., Derleth, A., McDonell, M., Diehr, P., Kiefe, C., & Fihn, S. (2004). Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. Journal of the National Medical Association, 96(6), 799–808. Ross, R., Fortney, J., Lancaster, B., & Booth, B. M. (1998). Age, ethnicity, and comorbidity in a national sample of hospitalized alcohol-dependent women veterans. Psychiatric Services, 49(5), 663–668. Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., Kooperberg, C., Stefanick, M. L., . Ockene, J., & Writing Group for the Women’s Health Initiative, I (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333. Saha, S., Freeman, M., Toure, J., Tippens, K. M., Weeks, C., & Ibrahim, S. (2008). Racial and ethnic disparities in the VA health care system: A systematic review. Journal of General Internal Medicine, 23(5), 654–671. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objective for 2020. (2008). Phase I report. Recommendations for the framework and format of Healthy People 2020. Available: www. healthypeople.gov/sites/default/files/PhaseI_0.pdf. Accessed: July 23, 2015. U.S. Department of Health and Human Services. (2011). Action plan to reduce racial and ethnic health disparities. Available: http://minorityhealth.hhs.gov/ npa/files/Plans/HHS/HHS_Plan_complete.pdf. Accessed: March 27, 2015. U.S. Department of Veterans Affairs. (2012). Women Veterans Health Care Fact Sheet. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/WH_ facts_FINAL.pdf. Accessed: March 3, 2015. U.S. Department of Veterans Affairs. (2013). VHA handbook 1200.09. Inclusion of women and minorities in research. Available: www.va.gov/vhapublications/ ViewPublication.asp?pub_ID¼2920. Accessed: July 13, 2015. U.S. Department of Veterans Affairs Health Services Research & Development. (2015). Evidence brief: Update on prevalence of and interventions to reduce racial and ethnic disparities within the VA. Available: http://vaww.hsrd.research.va. gov/publications/esp/HealthDisparities.cfm. Accessed: July 3, 2015. Washington, D. L., Farmer, M. M., Mor, S. S., Canning, M., & Yano, E. M. (2015). Assessment of the healthcare needs and barriers to VA use experienced by women veterans: Findings from the national survey of women Veterans. Medical Care, 53(4 Suppl 1), S23–S31. Wei, G. S., Jackson, J. L., & Herbers, J. E., Jr. (2003). Ethnic disparity in the treatment of women with established low bone mass. Journal of the American Medical Women’s Association (1972), 58(3), 173–177. Young, G. J., Meterko, M., & Desai, K. R. (2000). Patient satisfaction with hospital care: Effects of demographic and institutional characteristics. Medical Care, 38(3), 325–334.
Author Descriptions Andrea Carter, MD is a chief resident in internal medicine at the University of Pittsburgh. She has presented nationally on topics in women’s health and education. She is starting a fellowship in general medicine, perusing a master’s degree in medical education.
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9 Sonya Borrero, MD, MS is an Associate Professor of Medicine at the VA Pittsburgh Healthcare System and the University of Pittsburgh School of Medicine. She is a general internist, a core faculty in the VA Center for Health Equity Research and Promotion (CHERP), and the Director of the Center for Women’s Health Research and Innovation (CWHRI).
Charles Wessel, MLS is the Head of Reference Initiatives and a faculty librarian at the Health Science Library System at the University of Pittsburgh Medical School. He has expertise in literature searching and providing support for systematic reviews.
Donna L. Washington, MD, MPH is a Professor of Medicine at the VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine. She is a
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general internist whose research focuses on healthcare access and quality for women and racial/ethnic minorities.
Bevanne Bean-Mayberry, MD, MHS is a Clinical Associate Professor of Medicine at the VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine. She is a general internist whose research focuses on gender differences in quality measures and patient satisfaction.
Jennifer Corbelli, MD, MS is an Assistant Professor of Medicine at the University of Pittsburgh Medical School. She is a general internist and clinician educator with women’s health expertise, and an Associate Program Director for inpatient general internal medicine.
www.whijournal.com
Original article
Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review Andrea Carter, MD a, Sonya Borrero, MD, MS a,b,*, Charles Wessel, MLS c, Donna L. Washington, MD, MPH d,e, Bevanne Bean-Mayberry, MD, MHS d,e, Jennifer Corbelli, MD, MS a, and the VA Women’s Health Disparities Research Workgroup a
Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania c Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania d Veterans Affairs Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California e Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California b
Article history: Received 24 November 2015; Received in revised form 4 March 2016; Accepted 23 March 2016
a b s t r a c t Background: Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA. Methods: We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity. Results: Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n ¼ 3), treatment of low bone mass (n ¼ 1), hormone therapy (n ¼ 1), use of mental health or substance abuse–related services (n ¼ 2), trauma exposure and use of various services (n ¼ 1), and satisfaction with primary care (n ¼ 1). Five of nine studies showed evidence of a significant racial or ethnic difference. Conclusion: In contrast with the wealth of literature examining disparities both among the male veterans and women in nonVA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users. Published by Elsevier Inc. on behalf of the Jacobs Institute of Women's Health.
Women are a rapidly growing segment of patients who receive care in the Veterans Affairs (VA) Healthcare System: 6.5% of all VA users are women and the number of women receiving
Funding and conflict of interest statement: This work was supported in part by the VA Women’s Health Research Network (VA HSR&D SDR 10–012). The contents of this manuscript do not represent the views of the Department of Veterans Affairs or the United States Government. To the best of our knowledge, there are no conflicts of interest. * Correspondence to: Sonya Borrero, MD, MS, 230 McKee Place, Suite 600, Pittsburgh, PA 15213. Phone: (412) 692-4841; fax: (412) 692-4828. E-mail address: [email protected] (S. Borrero).
health care in the VA has doubled since 2000 (Frayne et al., 2014). This growth has outpaced that of the male veteran population. More than one-half of women veterans returning from the conflicts in Iraq and Afghanistan (Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn) have received VA health care (U.S. Department of Veterans Affairs, 2012). However, most research conducted within the VA has not included women participants, and many questions regarding woman veterans’ health care experiences and outcomes remain unanswered. Female VA users are a vulnerable population with unique health care needs. Compared with civilian women and male VA
1049-3867/$ - see front matter Published by Elsevier Inc. on behalf of the Jacobs Institute of Women’s Health. http://dx.doi.org/10.1016/j.whi.2016.03.009
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A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
users, they have a higher prevalence of mental illness and medical comorbidities (Frayne et al., 2014; Haskell et al., 2010; Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012). Additionally, women veterans who use the VA are disproportionately from racial and ethnic minority groups. Almost 40% of women veterans who use VA services are from a racial or ethnic minority group compared with 23% of male veterans who use the VA (Frayne et al., 2014). Thus, an increased effort to understand the current state of care for women veterans, across all racial and ethnic groups, is imperative to guide future operations, policy, and research efforts. The burden of racial and ethnic disparities among veterans within the VA Healthcare System has been previously systematically reviewed (Saha et al., 2008) and was recently updated in an evidence brief (U.S. Department of Veterans Affairs Health Services Research & Development, 2015). The majority of studies included in the review showed that significant racial or ethnic disparities exist, and that these disparities existed across a range of clinical areas including arthritis/pain management, cancer, diabetes, cardiovascular disease, human immunodeficiency virus, hepatitis C, mental health/substance abuse, preventative/ambulatory care, rehabilitation, and palliative care. However, the vast majority of the 171 studies included in the initial VA systematic review included either no women or a very small number (5% of total study participants) of women, and none of the clinical content areas presented in the review were areas specific to women’s health (such as cervical cancer screening or contraception). We systematically reviewed the literature on racial and ethnic disparities in health care among women who receive care in the VA Healthcare System. Although we report on any significant difference in health care by race or ethnicity, we recognize that differences may not always indicate a disparity. The term “health disparity” has been defined as “a particular type of health difference that is closely linked with social or economic disadvantage” (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objective for 2020, 2008) and, as such, implies an injustice. Because it is common practice in the field of disparities research to begin with the identification of differences between vulnerable and less vulnerable populations, with further inquiry to determine if differences represent inequitable or lower quality care for the vulnerable population, we simply report on observed differences in this report and use the terms “disparity” and “difference” somewhat interchangeably. Our primary aims were to identify and summarize existing work in this area and to elucidate areas in which future research efforts should be focused to ultimately work toward the goal of reducing racial and ethnic disparities among women veterans. Methods Search Strategy A formalized protocol was written prior to initiation of the systematic review. A health sciences librarian (C.W.) developed, revised, translated, and performed literature searches in PubMed (1946–present), EMBASE (1974–present), and the American Psychological Association’s PsycINFO (1967–present). We constructed searches using the command language of each database and the applicable search fields (Appendix 1). MeSH, EMTREE, and American Psychological Association’s Thesaurus of Psychological Index Terms vocabulary were used. For this search, health
disparities and racial and ethnic population group search terms were considered synonymous concepts and were combined together with a Boolean operator “OR.” These synonymous concepts were combined with a Boolean operator “AND” to the veteran/VA and women search terms. No search limits were applied and all languages were included. We ran all three database searches and citations were downloaded on June 30, 2014. Study Selection We removed duplicate citations and screened citations by both title and abstract for relevance. We selected studies that met the following criteria: 1) conducted solely within the VA Healthcare System, 2) reported data on women exclusively or stratified data by gender, 3) reported data on use, quality of health care services, or satisfaction, 4) stratified results by patient race or ethnicity, 5) contained original data, and 6) published in a peer-reviewed journal. Two authors (A.C. and J.C.) independently confirmed study eligibility. Any discrepancies were resolved through discussion and group consensus. Data Abstraction We abstracted data from all studies meeting inclusion criteria using a structured form, which included study design, study period, number enrolled, source of race/ethnicity data, race/ ethnicity of study population, source of outcome data, and outcomes. Studies were summarized in tables and classified according to clinical area. Because no standardized or validated quality measures to evaluate cross sectional data exist, we were unable to perform study quality and risk of bias scoring. Furthermore, a meta-analysis was not performed given the marked heterogeneity of both outcomes and outcome measures used in the studies included in our systematic review. Results Search Yield Our search located 1,622 citations in PubMED, 1,859 citations in EMBASE, and 584 citations in PsychINFO. After duplicate citations were identified and removed, 2,591 citations were screened by both title and abstract and 2,446 of these were eliminated. The remaining 145 citations were reviewed in full text, and 9 studies were identified for inclusion (Figure 1). Description of Evidence We identified nine studies that examine racial and ethnic disparities in health care among women in the VA Healthcare System (Table 1). Five studies were retrospective cohort studies using VA administrative databases, two studies were crosssectional surveys, and two studies were combination cohort and survey studies. Overall, five of the nine studies showed evidence of a significant racial or ethnic difference in a quality of care or use of care outcome (Table 2). Of the five studies that showed evidence of a significant racial or ethnic difference, one was a single VA study and four used national VA data. The studies examined the following health care domains: contraception provision/access, treatment of low bone mass, hormone therapy, use of mental health or substance abuse–related services, trauma exposure and use of various VA services, and satisfaction with primary care.
Included
Eligibility
Screening
IdenƟficaƟon
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
Records idenƟfied through searching PubMed n = 1,622
Records idenƟfied through searching Embase n = 1,859
Records idenƟfied through searching PsychINFO n = 584
Total records idenƟfied by searching databases n = 4,065
Duplicate records excluded n = 1,474
Records screened n = 2,591
Records excluded by Ɵtle/abstract n = 2,446
Records assessed for eligibility n = 145
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Records excluded aŌer full text review: Not conducted solely within the VA Not exclusively women or data not straƟfied by gender No data on uƟlizaƟon, quality, or saƟsfacƟon Data not straƟfied by race or ethnicity No original data Not in peer reviewed journal
n=9 n = 112 n=2 n=7 n=5 n=1
Studies included in review n=9
Figure 1. PRISMA flow diagram (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009).
Contraception provision/access (n ¼ 3) Of the three retrospective cohort studies examining contraception provision/access, two found evidence of a significant racial or ethnic difference. One study of 805 woman veterans in the San Diego VA Healthcare System who received a new prescription for hormonal contraception during the study period found no racial or ethnic difference in hormonal contraception adherence (defined as obtaining 12 months of refills of hormonal contraception in a 12-month time period; Kazerooni, Takizawa, & Vu, 2014). Another study of all woman veterans in the national VA system between age 18 and 45 who made at least one visit to a VA primary care or women’s health clinic in fiscal year 2008 and had hormonal contraceptive coverage during the first week of the study period (n ¼ 6,946) found that Hispanic women were significantly more likely than White women to experience gaps between refills of hormonal contraception, and that Hispanic women and Black women received significantly fewer overall months of contraceptive coverage in a 12-month period than White women (Borrero et al., 2013). A third study of all woman veterans in the national VA system between age 18 and 45 who made at least one visit to a VA primary care or women’s health clinic fiscal year 2008 (n ¼ 103,950) found that Hispanic and Black women were significantly less likely than White women to have documented receipt of any contraception (Borrero et al., 2012). However, this same study found that, when Black women were using a form of contraception, they were significantly more likely than White women to use a highly effective method of contraception (intrauterine device, implant, or surgical sterilization).
Treatment of low bone mass (n ¼ 1) This cross-sectional survey study of 75 women who underwent dual-energy x-ray absorptiometry testing at the Washington DC VA Medical Center found that Black women were significantly less likely than White women to receive an antiresorptive drug for treatment of low bone mass after controlling for severity of low bone mass and prior fractures (Wei, Jackson, & Herbers Jr, 2003). Hormone therapy (n ¼ 1) This retrospective cohort study of all woman veterans in the national VA system using menopausal hormone therapy (MHT) in 2001 (n ¼ 36,222) examined discontinuation of MHT after the publication of the Women’s Health Initiative, which was the first major publication to describe risks of MHT (Rossouw et al., 2002). They found that perimenopausal and postmenopausal Black and Hispanic women were more likely than White women to discontinue MHT (Haskell et al., 2008) by 2 years after the Women’s Health Initiative publication. Use of mental health or substance abuse–related services (n ¼ 2) One combined survey and retrospective cohort study of 526 woman veterans at a primary care clinic at the Durham VA Medical Center found no evidence of racial or ethnic difference in use of mental health services in a 12-month period. However, this study did find that Black women reported wanting a mental health referral more frequently than White women (34% vs. 27%; p ¼ .01; Bosworth et al., 2000). The second retrospective cohort study of 854 woman veterans in the national VA system
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Table 1 Study Characteristics Title
Study Design
Study Period
N
Level of Analysis
Source of Race or Ethnicity Data
Race or Ethnicity of Study Population
Kazerooni 2014
Predictors of adherence to hormonal contraceptives in a female veteran population
Retrospective cohort study
April 2010–March 2012
805 women
Single VA (San Diego)
Administrative data
Borrero 2013
Adherence to hormonal contraception among women veterans: differences by race/ ethnicity and contraceptive supply Contraceptive care in the VA health care system
Retrospective cohort study
October 2007– September 2008
6,946 women
National VA system
Administrative data
White 62% Black 14% Asian 7% Native American/ Alaskan 1% Mixed race 2% Unknown 13% White 47% Hispanic 6% Black 22% Other 3% Unknown 22%
Retrospective cohort study
2008
103,950 women
National VA system
Administrative data
Determinants of hormone therapy discontinuation among female veterans nationally Racial disparities in trauma exposure, psychiatric symptoms, and service use among female patients in VA primary care clinics Brief report: lack of a race effect in primary care ratings among women veterans Ethnic disparity in the treatment of women with established low bone mass Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic Age, ethnicity, and comorbidity in a national sample of hospitalized alcoholdependent women veterans
Retrospective cohort study
2001–2004
36,222 women
National VA system
Not reported
Cross-sectional survey and retrospective cohort study
January 2000– December 2002
183 women
Multiple VAs (Charleston, SC; Columbia SC; Tuscaloosa, AL; Birmingham, AL)
Self-identified during phone interview
White 55% Black 46%
Cross-sectional survey
Not reported
1,447 women
Multiple Vas (systems in DE, KY, PA, TN, WV)
Self-identified on survey
White 85% Black 11% Other 3%
Cross-sectional survey
January 1998–October 2001
75 women
Single VA (Washington, DC)
Self-identified on survey
White 55% Black 35% Other 10%
Survey and retrospective cohort study
July 1994–December 1996
526 women
Single VA (Durham, NC)
Self-identified on survey
White 46% Black 54%
Retrospective cohort study
October 1992– September 1993
854 women
National VA system
Administrative data
White 62% Black 33% Hispanic 2% Native American 3%
Borrero 2012
Haskell 2008
Grubaugh 2008
Bean-Mayberry 2006
Wei 2003
Bosworth 2000
Ross 1998
Abbreviation: VA, Veteran’s Affairs.
White 40% Hispanic 6% Black 25% Other 3% Unknown 26% White 58% Black 12% Hispanic 2% Other/unknown 27%
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
First Author, Year
Table 2 Study Outcome Data Source of Use or Quality Outcome Data
Quality/Use Outcome(s)
Adjusted OR/HR (Referent, White Women; 95% CI if Reported, p-value if Reported)
Kazerooni 2014
Pharmacy/ administrative data
Adherence to hormonal contraception (defined as having a medication possession ratio 0.9; a patient would need to have obtained 12 months’ worth of refills within a 1-year time frame)
Borrero 2013
Pharmacy/ administrative data
Nonadherence to hormonal contraception (defined as having gaps 7 days between refills)
Black Asian Mixed Native American Hispanic Black Hispanic Black Hispanic Black Other Hispanic Black Other Hispanic Black Other
0.73 1.11 0.54 0.40 1.18 1.04 0.76 0.95 0.82 0.85 0.87 0.89 1.10 0.88 1.41 1.13 1.08
(0.44–1.22, p (0.60–2.03, p (0.16–1.77, p (0.08–2.08, p (1.03–1.34, p (0.95–1.13, p (0.57–1.01, p (0.81–1.12, p (0.76–0.88, p (0.81–0.89, p (0.79–0.95, p (0.77–1.03, p (1.01–1.20, p (0.73–1.05, p (1.19–1.67)* (1.05–1.22)* (1.02–1.12)*
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
Black Black Black Black
0.13 1.36 1.64 1.73
(0.94–1.04, (0.69–2.68, (0.75–3.55, (0.87–3.42,
¼ ¼ ¼ ¼
Black Other Black Other Black Other Black Other Black Other Whitez
0.7 0.5 0.7 0.7 1.9 0.9 0.7 0.9 0.7 0.5 3.71
(0.4–1.3) (0.1–1.6) (0.5–1.1) (0.4–1.4) (0.8–4.4) (0.2–4.9) (0.3–1.2) (0.5–1.6) (0.4–1.1) (0.2–1.5) (1.24–11.1)*
Black
1.21 (0.79–1.86)
Black Hispanic Native American Black Hispanic Native American Black Hispanic Native American
0.79 0.99 4.18 1.27 4.62 3.39 0.69 0.36 2.28
Borrero 2012
Pharmacy/ administrative data
Adherence to hormonal contraception (defined as obtaining all 12 months of contraception in a year without gaps) Documented receipt of any contraception (defined as receiving prescription or undergoing procedure indicating contraceptive use) Use of most effective method of contraception (defined as using IUD, implant, or surgical sterilization)
Haskell 2008
Grubaugh 2008
Bean-Mayberry 2006
Pharmacy/ administrative data Administrative data
Survey
Discontinuation of hormone therapy (defined as having been prescribed and distributed hormone therapy in 2001 but no longer in 2004) Use of various VA services (defined as 1 visit in prior 12 months) Inpatient services Urgent ER services Women’s clinic Mental health services Satisfaction with primary care in various domains (defined as perfect score on survey) Patient preference for usual provider Satisfaction with provider interpersonal communication Satisfaction with provider accumulated knowledge Satisfaction with coordination of care Overall excellent satisfaction
Wei 2003
Survey
Bosworth 2000
Administrative data Administrative data
Ross 1998
Use of antiresorptive drug for treatment of low bone mass adjusted for severity and prior fractures (defined as using estrogen replacement, alendronate, risedronate, nasal calcitonin, or raloxifine) Use of mental health services (defined as visit within last 12 months) Use of alcohol-related services among hospitalized veterans with alcohol-related disorders Receive alcohol treatment services
Enter formal alcohol treatment
Complete formal alcohol treatment
.23) .77) .31) .27) .02)* .38) 0.06) .56) <.001)* <.001)* .003)* .12) .04)* .16)
Significant Racial or Ethnic Difference in Quality/Use Outcome? No
Yes
Yes
Yes
No p p p p
.06)y .37) .21) .12) No
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9
First Author, Year
Yes
No Yes
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
not significant) not significant) < .05)* not significant) not significant) not significant) not significant) not significant) not significant)
5
Abbreviations: CI, confidence interval; ER, emergency room; HR, hazard ratio; IUD, intrauterine device; OR, odds ratio; VA, Veteran’s Administration. * Statistically significant value. y Results as listed in study (Black, 0.13; 95% CI, 0.94–1.04; p ¼ 0.06). z Adjusted odds ratio reported with Black women as reference.
(p (p (p (p (p (p (p (p (p
6
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diagnosed with alcohol dependence found that Native American women (n ¼ 22) were more likely than White women (n ¼ 532) to receive formal alcohol treatment, but there was no difference in receiving formal alcohol treatment between Hispanic or African American women compared with White women (Ross, Fortney, Lancaster, & Booth, 1998). Trauma exposure and use of various VA services (n ¼ 1) A cross-sectional survey and retrospective cohort study of 183 woman veterans randomly selected from 4 VA medical centers (Charleston, SC; Columbia, SC; Tuscaloosa, AL; and Birmingham, AL) assessed racial or ethnic differences in trauma exposure, psychiatric symptoms, and VA services use among women veterans and reported no racial or ethnic difference in the use of various VA services (including inpatient, emergency room, women’s clinic, primary care, and mental health services) over a 12-month period (Grubaugh, Slagle, Long, Frueh, & Magruder, 2008). Satisfaction with primary care (n ¼ 1) A cross-sectional survey study of 1,447 women using VA primary care or women’s health clinics in 5 states (Delaware, Kentucky, Pennsylvania, Tennessee, and West Virginia) asked veterans about their satisfaction with primary care and found no significant racial or ethnic difference in overall rating of excellent satisfaction, patient preference for maintaining a relationship with her health care provider, patient perceptions of her provider’s interpersonal communication, accumulation of knowledge, or coordination of care (Bean-Mayberry, Chang, & Scholle, 2006). Discussion The results of our systematic review demonstrate that there are only nine studies that examine racial and ethnic disparities specifically among female VA users. Many clinical areas with known racial and ethnic disparities among male VA users and among women outside the VA have not been studied in female VA users. Multiple groups and policymakers, including the VA, have called for the identification and eradication of racial and ethnic disparities in health care to be a national priority (Fine & Demakis, 2003; Institute of Medicine, 2003; Koh, Blakey, & Roper, 2014; U.S. Department of Health and Human Services, 2011). The VA is an ideal place to examine racial and ethnic differences among women for several reasons. The VA provides care to a racially and ethnically diverse population, taking care of 360,000 women veterans of whom 29% are Black, 1% are Asian, 1% are Native American/Alaska Native, 1% are Native Hawaiian/other Pacific Islander, and 6% are of Hispanic origin (Frayne et al., 2014). Many of the financial confounders present in the private sector, such as insurance coverage and ability to pay for care, are removed in the VA setting. Furthermore, administrative databases in the VA contain extensive national data on quality and use. These factors make the VA an optimal and uniquely informative place to identify and understand racial and ethnic health care disparities. Thus, the relative paucity of data on racial and ethnic disparities among woman veterans is concerning. A majority of studies included in our review showed evidence of a racial or ethnic difference. The clinical area with the most studies (n ¼ 3) was contraception. Of the three studies on contraception, two showed a significant racial or ethnic difference in adherence to or receipt of contraception and one showed
no difference. The study that showed no difference was based on a much smaller sample (n ¼ 805; Kazerooni et al., 2014) than the other two (n ¼ 6,946 and n ¼ 103,950; Borrero et al., 2012; Borrero et al., 2013). The smaller study did show, however, a nonsignificant trend toward lower adherence to contraception in Black and Hispanic women and may have been simply underpowered to detect statistical significance. Additionally, this study was conducted in a single VA as opposed to the other two, which were national VA samples, so the results of this study may reflect factors specific to an individual VA Healthcare System. Overall, these findings of racial and ethnic differences in adherence to and receipt of contraception among women VA users aged 18 to 45 are broadly consistent with the observed racial and ethnic differences in use of contraception and unintended pregnancy in the general U.S. population of teens and women aged 15 to 44 (Dehlendorf et al., 2014; Finer & Zolna, 2014). Racial and ethnic differences in patient satisfaction among male veterans has been examined in at least five studies (Saha et al., 2008), and three of these showed significant racial or ethnic disparities (Flaherty, Naidu, Lawton, & Pathak, 1981; Ohldin et al., 2004; Young, Meterko, & Desai, 2000). Our systematic review revealed only one study on satisfaction among women at the VA (Bean-Mayberry et al., 2006). This survey study showed no racial or ethnic differences in satisfaction with primary care, which is encouraging. However, the response rate was 55%, and it is unclear if respondent characteristics were different from those of nonresponders. Given that this is the only published study on racial or ethnic differences in satisfaction among women at the VA, it is unclear if racial or ethnic satisfaction differences exist in care received outside of primary care. Although there are challenges with using patient satisfaction as an outcome measure, such as variability in scales used and a high degree of subjectivity, patient satisfaction studies may nonetheless be especially relevant given the increasing importance of patient satisfaction measures in quality metrics. Interestingly, some of the racial or ethnic differences we found among women at the VA appear on the surface to favor racial or ethnic minority groups. In particular, Black women were found to use contraception belonging in the category of “most effective” methods (intrauterine devices, implants, or surgical sterilization) more often than White women (Borrero et al., 2012). However, this difference is likely driven by higher rates of surgical sterilization among African American women (Borrero et al., 2010; Dehlendorf et al., 2014), who may have higher rates of post-sterilization regret (Borrero et al., 2008). A second difference that may seem to favor Blacks and Hispanics is that perimenopasual and postmenopausal Black and Hispanic women were more likely than White women to discontinue hormone therapy (Haskell et al., 2008) by 2 years after the Women’s Health Initiative publication, which was the first publication to emphasize the risks of MHT (Rossouw et al., 2002). Again, the implication of this difference is unclear, because use of hormone therapy is highly sensitive to patient preference and because reasons for disparate discontinuation rates are unclear. Finally, Native American women completed inpatient alcohol treatment programs more often than White women (Ross et al., 1998), perhaps owing to clinician awareness that Native Americans are disproportionately burdened by alcohol-related problems like binge drinking (Akins, Lanfear, Cline, & Mosher, 2013) and alcohol-attributable mortality (Landen, Roeber, Naimi, Nielsen, & Sewell, 2014). However, it may be difficult to draw significant conclusions from this study given the small number (n ¼ 22, 3% of study population) of Native American women.
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Additional work is needed to understand the clinical significance of these findings. Although the majority of the studies included in our review evaluate gender-specific topics (contraception, low bone mass, hormone therapy), the fact that there were only five studies on these topics demonstrates the dearth of disparities literature in the area of gender-specific health conditions among women veterans. Racial and ethnic disparities have been shown to exist in non-VA settings in multiple gender-specific areas that have not yet been examined within the VA, including cervical cancer screening, mammography, prenatal care, and annual preventive visits (Kaiser Family Foundation, 2009; National Healthcare Quality and Disparities Report, 2011). In the non-VA setting, White and Hispanic women are less likely than Black and Asian women to receive a mammogram, Asian women are less likely than White women to receive a pap smear, and Native American women are less likely to receive prenatal care during the first trimester than White women (National Healthcare Quality and Disparities Report, 2011). Given that patients who receive care at the VA have a higher burden of illness and lower income as compared with the general population (Agha, Lofgren, VanRuiswyk, & Layde, 2000), findings from studies in the private sector may not be generalizable to the VA population. Our findings of racial and ethnic differences in contraception, hormone therapy, and low bone mass woman veterans, however, do raise concerns about health inequities for other gender-specific outcomes. Additionally, there are many clinical areas in which racial or ethnic disparities have been demonstrated among male veterans in the VA system that have not yet been examined among women VA users. In the prior systematic review (Saha et al., 2008) that was recently updated in a policy brief (U.S. Department of Veterans Affairs Health Services Research & Development, 2015), multiple studies have found racial or ethnic disparities among men who use the VA in the clinical areas of chronic pain, diabetes, and heart and vascular disease. Additionally, in the prior reviews, disparities were very prevalent in the use of surgery or invasive procedures. Thus, our search parameters were deliberately broad to identify health disparities of any kind. The fact that many of the studies that met our inclusion criteria were focused on gender-specific health conditions reflects the dearth of literature on disparities across the range of medical diseases that occur in women veterans. This is particularly concerning given that the most common health conditions affecting women in the VA system in fact include chronic pain, diabetes, and heart and vascular disease (Frayne et al., 2014). Another area of focus should be examining which disparities among women veterans occur locally and which are present at a national level. Because the VA health care system comprises geographically disparate sites across all 50 states and Puerto Rico and because geographic variation in health care has been identified as an important contributor to disparities, it will be important to discern whether observed racial or ethnic differences reflect variation in practice in regions or sites that primarily serve women from one racial or ethnic group versus those that result from systemic inequities. Several limitations deserve mention. First, we were unable to perform a meta-analysis owing to the heterogeneity of studies. Additionally, we cannot rule out the potential for publication bias in this research area that, if present, could have had a significant impact on our findings given that we are interested in both the presence and absence of racial and ethnic disparities. However, a funnel plot to visualize the effect of publication bias could not be generated owing to distinct outcome measures in each included
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study. Additionally, women veterans who receive care in VA system have worse overall physical and mental health than women who receive care in the private sector (Frayne et al., 2006; Washington, Farmer, Mor, Canning, & Yano, 2015). Given these differences, the results of our review may not generalizable to women veterans receiving care outside the VA. Last, the objective of this review was to summarize the extent to which published literature examines racial or ethnic differences in VA women’s health care to guide future VA research efforts, not to determine the full presence and distribution of racial or ethnic disparities. When a difference represents a disparity and whether this disparity ultimately is of clinical significance must take into account social context, patient preference, and many other factors, which cross-sectional studies are often unable to elucidate and which are beyond the scope of this review. Given that only nine studies met our inclusion criteria despite our broad approach, this clearly underscores the extent to which a comprehensive understanding of racial and ethnic disparities among woman veterans will not be possible until further research is done. Implications for Practice, Policy, and Future Research In contrast with the wealth of literature examining racial and ethnic health care disparities both among male veterans and women in non-VA settings, there are only nine published studies examining disparities specifically among women in the VA Healthcare System. The results of this systematic review demonstrate that there is a need to further study racial and ethnic disparities among female VA users. Specifically, evidence of racial and ethnic health care disparities among women have been shown in non-VA settings in cervical cancer screening, prenatal care, mammograms, and annual preventive visits, but these areas have not been examined among female VA users. Also, among male VA users, disparities have been shown in areas of mental health and substance abuse, cardiovascular disease, surgical procedures, and pain management, but these areas have not been examined among female VA users. Our results thus highlight important knowledge gaps in the fields of VA health equity and women’s health research. Fortunately, an infrastructure to support and facilitate addressing these knowledge gaps currently exists. The VA requires that special efforts be made to include women and members of minority groups in all VA research studies including research that is unfunded, funded by non-VA entities, or funded by the VA Office of Research and Development (U.S. Department of Veterans Affairs, 2013). Additionally, VA Health Service Research & Development has funded the development of the Women’s Health Practice Based Research Network (Frayne et al., 2013). The Practice Based Research Network establishes a readyto-use infrastructure to conduct multisite studies of women veterans, which encourage the inclusion of women in research studies by helping to overcome the issue of small numbers of women at any one facility. Currently, the Practice Based Research Network comprises 60 VA sites across the country and has purposefully included many sites with racially and ethnically diverse female patient populations. The VA Office of Health Equity is also working across the agency to champion the advancement of health equity and elimination of health disparities for all vulnerable veteran populations. Because the VA is dedicated to optimizing women’s health care, additional research to understand and address racial and ethnic disparities among women will help to achieve VA’s
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mission to provide high-quality, equitable health care for all women veterans. Acknowledgments Contributors include members of the VA Women’s Health Disparities Research Workgroup, including Bryan C. Batch, MD, Jessica Y. Breland, MS, PhD, Brooke DiLeone, PhD, Melissa Ming Foynes, PhD, Robin Keene, PhD, RN, Leslie Hausmann, PhD, Kristen Mattocks, PhD, MPH, Michelle Mengeling, PhD, MS, Leslie Moreland, PsyD, Phyllis Nsiah-Kumi, MD, MPH, Uche Uchendu, MD, Sharon Kelly West, RN MHS, CCE, Karen Patricia Williams, PhD, and Susan Zickmund, PhD. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.whi.2016.03.009. References Agha, Z., Lofgren, R. P., VanRuiswyk, J. V., & Layde, P. M. (2000). Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine, 160(21), 3252–3257. Akins, S., Lanfear, C., Cline, S., & Mosher, C. (2013). Patterns and correlates of adult American Indian substance use. Journal of Drug Issues, 43(4), 497–516. Bean-Mayberry, B., Chang, C. C., & Scholle, S. H. (2006). Brief report: Lack of a race effect in primary care ratings among women veterans. Journal of General Internal Medicine, 21(10), 1105–1108. Borrero, S., Moore, C. G., Qin, L., Schwarz, E. B., Akers, A., Creinin, M. D., & Ibrahim, S. A. (2010). Unintended pregnancy influences racial disparity in tubal sterilization rates. Journal of General Internal Medicine, 25(2), 122–128. Borrero, S., Mor, M. K., Zhao, X., McNeil, M., Ibrahim, S., & Hayes, P. (2012). Contraceptive care in the VA health care system. Contraception, 85(6), 580–588. Borrero, S., Zhao, X., Mor, M. K., Schwarz, E. B., Good, C. B., & Gellad, W. F. (2013). Adherence to hormonal contraception among women veterans: Differences by race/ethnicity and contraceptive supply. American Journal of Obstetrics and Gynecology, 209(2), 103.e101–103.e111. Borrero, S. B., Reeves, M. F., Schwarz, E. B., Bost, J. E., Creinin, M. D., & Ibrahim, S. A. (2008). Race, insurance status, and desire for tubal sterilization reversal. Fertility and Sterility, 90(2), 272–277. Bosworth, H. B., Parsey, K. S., Butterfield, M. I., McIntyre, L. M., Oddone, E. Z., Stechuchak, K. M., & Bastian, L. A. (2000). Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic. Journal of the National Medical Association, 92(5), 231–236. Dehlendorf, C., Park, S. Y., Emeremni, C. A., Comer, D., Vincett, K., & Borrero, S. (2014). Racial/ethnic disparities in contraceptive use: Variation by age and women’s reproductive experiences. American Journal of Obstetrics and Gynecology, 210(6), 526.e521–526.e529. Fine, M. J., & Demakis, J. G. (2003). The Veterans Health administration’s promotion of health equity for racial and ethnic minorities. American Journal of Public Health, 93(10), 1622–1624. Finer, L. B., & Zolna, M. R. (2014). Shifts in intended and unintended pregnancies in the United States, 2001-2008. American Journal of Public Health, 104(Suppl 1), S43–S48. Flaherty, J. A., Naidu, J., Lawton, R., & Pathak, D. (1981). Racial differences in perception of ward atmosphere. American Journal of Psychiatry, 138(6), 815–817. Frayne, S., Phibbs, C. S., Saechao, F., Maisel, N. C., Berg, E., Hayes, P., Haskell, S., & Sourcebook: Women Veterans in the Veterans Health Administration (2014). Sociodemographics, Utilization, Costs of Care, and Health Profile, Volume 3. Veterans Health Administration, Washington, DC. Frayne, S. M., Carney, D. V., Bastian, L., Bean-Mayberry, B., Sadler, A., Klap, R., . Yano, E. M. (2013). The VA Women’s Health Practice-Based Research Network: Amplifying women veterans’ voices in VA research. Journal of General Internal Medicine, 28(Suppl 2), S504–S509. Frayne, S. M., Parker, V. A., Christiansen, C. L., Loveland, S., Seaver, M. R., Kazis, L. E., & Skinner, K. M. (2006). Health status among 28,000 women veterans. The VA Women’s Health Program Evaluation Project. Journal of General Internal Medicine, 21(Suppl 3), S40–S46. Grubaugh, A. L., Slagle, D. M., Long, M., Frueh, B. C., & Magruder, K. M. (2008). Racial disparities in trauma exposure, psychiatric symptoms, and service use among female patients in Veterans Affairs primary care clinics. Womens Health Issues, 18(6), 433–441.
Haskell, S. G., Bean-Mayberry, B., Goulet, J. L., Skanderson, M., Good, C. B., & Justice, A. C. (2008). Determinants of hormone therapy discontinuation among female veterans nationally. Military Medicine, 173(1), 91–96. Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal, M., Erdos, J., Justice, A., & Brandt, C. A. (2010). Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut War Veterans of Iraq and Afghanistan. Journal of Women’s Health (Larchmont), 19(2), 267–271. Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Available: www.nap.edu/catalog/10260/unequaltreatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed: March 15, 2015. Kaiser Family Foundation. (2009). Putting women’s health care disparities on the map. Available: http://kff.org/disparities-policy/report/putting-womenshealth-care-disparities-on-the/. Accessed: March 4, 2015. Kazerooni, R., Takizawa, A., & Vu, K. (2014). Predictors of adherence to hormonal contraceptives in a female veteran population. Contraception, 89(4), 292–298. Koh, H. K., Blakey, C. R., & Roper, A. Y. (2014). Healthy People 2020: A report card on the health of the nation. JAMA, 311(24), 2475–2476. Landen, M., Roeber, J., Naimi, T., Nielsen, L., & Sewell, M. (2014). Alcoholattributable mortality among American Indians and Alaska Natives in the United States, 1999-2009. American Journal of Public Health, 104(Suppl 3), S343–S349. Lehavot, K., Hoerster, K. D., Nelson, K. M., Jakupcak, M., & Simpson, T. L. (2012). Health indicators for military, veteran, and civilian women. American Journal of Preventive Medicine, 42(5), 473–480. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. National Healthcare Quality and Disparities Report. (2011). Disparities in healthcare quality among minority women. Available: www.ahrq.gov/research/findings/ nhqrdr/nhqrdr11/minority-women.pdf. Accessed: March 6, 2015. Ohldin, A., Young, B., Derleth, A., McDonell, M., Diehr, P., Kiefe, C., & Fihn, S. (2004). Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. Journal of the National Medical Association, 96(6), 799–808. Ross, R., Fortney, J., Lancaster, B., & Booth, B. M. (1998). Age, ethnicity, and comorbidity in a national sample of hospitalized alcohol-dependent women veterans. Psychiatric Services, 49(5), 663–668. Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., Kooperberg, C., Stefanick, M. L., . Ockene, J., & Writing Group for the Women’s Health Initiative, I (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333. Saha, S., Freeman, M., Toure, J., Tippens, K. M., Weeks, C., & Ibrahim, S. (2008). Racial and ethnic disparities in the VA health care system: A systematic review. Journal of General Internal Medicine, 23(5), 654–671. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objective for 2020. (2008). Phase I report. Recommendations for the framework and format of Healthy People 2020. Available: www. healthypeople.gov/sites/default/files/PhaseI_0.pdf. Accessed: July 23, 2015. U.S. Department of Health and Human Services. (2011). Action plan to reduce racial and ethnic health disparities. Available: http://minorityhealth.hhs.gov/ npa/files/Plans/HHS/HHS_Plan_complete.pdf. Accessed: March 27, 2015. U.S. Department of Veterans Affairs. (2012). Women Veterans Health Care Fact Sheet. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/WH_ facts_FINAL.pdf. Accessed: March 3, 2015. U.S. Department of Veterans Affairs. (2013). VHA handbook 1200.09. Inclusion of women and minorities in research. Available: www.va.gov/vhapublications/ ViewPublication.asp?pub_ID¼2920. Accessed: July 13, 2015. U.S. Department of Veterans Affairs Health Services Research & Development. (2015). Evidence brief: Update on prevalence of and interventions to reduce racial and ethnic disparities within the VA. Available: http://vaww.hsrd.research.va. gov/publications/esp/HealthDisparities.cfm. Accessed: July 3, 2015. Washington, D. L., Farmer, M. M., Mor, S. S., Canning, M., & Yano, E. M. (2015). Assessment of the healthcare needs and barriers to VA use experienced by women veterans: Findings from the national survey of women Veterans. Medical Care, 53(4 Suppl 1), S23–S31. Wei, G. S., Jackson, J. L., & Herbers, J. E., Jr. (2003). Ethnic disparity in the treatment of women with established low bone mass. Journal of the American Medical Women’s Association (1972), 58(3), 173–177. Young, G. J., Meterko, M., & Desai, K. R. (2000). Patient satisfaction with hospital care: Effects of demographic and institutional characteristics. Medical Care, 38(3), 325–334.
Author Descriptions Andrea Carter, MD is a chief resident in internal medicine at the University of Pittsburgh. She has presented nationally on topics in women’s health and education. She is starting a fellowship in general medicine, perusing a master’s degree in medical education.
A. Carter et al. / Women's Health Issues xxx-xx (2016) 1–9 Sonya Borrero, MD, MS is an Associate Professor of Medicine at the VA Pittsburgh Healthcare System and the University of Pittsburgh School of Medicine. She is a general internist, a core faculty in the VA Center for Health Equity Research and Promotion (CHERP), and the Director of the Center for Women’s Health Research and Innovation (CWHRI).
Charles Wessel, MLS is the Head of Reference Initiatives and a faculty librarian at the Health Science Library System at the University of Pittsburgh Medical School. He has expertise in literature searching and providing support for systematic reviews.
Donna L. Washington, MD, MPH is a Professor of Medicine at the VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine. She is a
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general internist whose research focuses on healthcare access and quality for women and racial/ethnic minorities.
Bevanne Bean-Mayberry, MD, MHS is a Clinical Associate Professor of Medicine at the VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine. She is a general internist whose research focuses on gender differences in quality measures and patient satisfaction.
Jennifer Corbelli, MD, MS is an Assistant Professor of Medicine at the University of Pittsburgh Medical School. She is a general internist and clinician educator with women’s health expertise, and an Associate Program Director for inpatient general internal medicine.