VA emergency health care for women: Condition—critical or stable?

Women’s Health Issues 16 (2006) 133–138

VA EMERGENCY HEALTH CARE FOR WOMEN: CONDITION— CRITICAL OR STABLE? Donna L. Washington, MD, MPHa,b,c*, Elizabeth M. Yano, PhDc,d, Caroline Goldzweig MD, MSHSa,b,c, and Barbara Simon, MAc a

VA Greater Los Angeles Healthcare System, Los Angeles, California University of California, Los Angeles, Department of Medicine, Los Angeles, California c VA Greater Los Angeles HSR&D Center of Excellence, Los Angeles, California d UCLA School of Public Health, Los Angeles, California

b

Received 28 May 2004; accepted 12 September 2005

Background. Veteran’s Affairs (VA) facilities have reconfigured themselves to address the health care needs of the growing number of women veterans. However, the challenge of providing comprehensive care to a group that is an extreme minority within VA may still leave gaps in the delivery of necessary health care services. Objectives and methods. We sought to assess the availability of women’s health care specialists for emergency gynecologic problems (emergency-GYN) and for emergency mental health conditions specific to women (emergency-WMH), we surveyed the Chief of Staff and senior clinician at each VA site serving 400 or more women veterans. Results. Emergency-GYN expertise was usually available at all times for 39.8% of sites, and only during usual clinic hours for 24.6% of sites. An emergency-WMH specialist was available at all times for 51.7% of sites, and only during usual clinic hours for 31.0% of sites. VA sites that had a separate women’s health clinic were more likely to have emergency-GYN expertise available. Sites in regions with higher managed care penetration were less likely to have emergency-WMH specialist availability. Conclusions. Our data suggest a limited availability of specialists for gynecologic and women’s mental health emergencies at some VA sites. How this may affect overall quality of care for women in the VA system is unknown. Further work is needed to determine actions clinicians take when expertise is emergently needed for health care issues unique to women. Options for expanding VA availability of such expertise include internal development of women’s health expertise and telemedicine access to experts to aid in emergency women’s health care decision making.

Background

W

omen are a small but rapidly growing segment of the veteran population, with estimates that they will comprise 10% of Department of Veterans

Funded by the Department of Veterans Affairs, Office of Public Health and Environmental Hazards, #XVA-65-003; Department of Veterans Affairs, Health Services Research and Development Service, #RCD-00-017 (Dr. Washington). * Correspondence to: Donna L. Washington, MD, MPH; VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., 111G, Los Angeles, CA 90073. E-mail: [email protected] Copyright © 2006 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Affairs (VA) users within the next decade (US General Accounting Office [GAO], 1999). The provision of high-quality, comprehensive services for women veterans has been promoted through legislation that authorized VA to provide gender-specific services (Veterans Health Care Act of 1992; Veterans’ Health Care Eligibility Reform Act of 1996). Although VA facilities have reconfigured themselves to address this legislative mandate, the challenge of providing comprehensive care to a group that is an extreme minority within the VA may leave gaps in the delivery of necessary health care services (Kizer, Fonseca, & Long, 1997; US GAO, 1982, 1992, 1999). 1049-3867/06 $-See front matter. doi:10.1016/j.whi.2005.12.003

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Prior research characterizing VA availability and organization of nonemergent women’s health care services found that virtually all large VA sites have developed arrangements, either directly or through off-site contracts, to ensure availability of comprehensive women’s health care (Washington, Caffrey, Goldzweig, Simon, & Yano, 2003; Yano, Washington, Goldzweig, Caffrey, & Turner, 2003). On-site care, however, is routinely available only for basic women’s health care services. Centralizing specialized services at large referral centers, and utilizing non-VA sites to increase specialized service availability, are useful strategies for ensuring access to specialized nonacute care. However, dependence on off-site referrals could lead to potentially harmful delays in the delivery of emergency services. The VA prioritizes care to veterans with military service-connected disabilities and those with low income (Skydell, 1998). Because a large proportion of women veteran VA users have low income, lack medical insurance, and rely on the VA as their sole source of health care (Skinner & Furey, 1998), the availability of emergency health care services is a critical component of VA care. Our primary objective was to assess the VA availability of women’s health care specialists for emergency gynecologic problems and VA availability of women’s health care specialists for emergency mental health conditions specific to women. Our secondary objective was to determine facility-level characteristics that predict the VA availability of these specialists for women’s emergency care.

Methods Study Design and Subjects In August 2001, we conducted a nationwide census of all VA health care sites that delivered outpatient care to 400 or more unique women veterans in fiscal 2000 (October 1999 through September 2000). Health care sites include VA medical centers (VAMCs) and community-based outpatient clinics (CBOCs). Some sites have more than 1 hospital or CBOC affiliated with the medical center, and are considered an integrated health care system. Using VA administrative data to determine caseloads at each site, our cross-sectional census resulted in an eligible frame of 166 distinct sites, comprising 140 medical centers or integrated health care systems (Department of Veterans Affairs). On-site emergency departments (EDs) are present at 89% of VAMCs (Metlay, Camargo, Bos, & Gonzales, 2005). To assess different perspectives regarding specialist availability and facility characteristics, we used a key informant approach, surveying both the chief of staff and the senior women’s health clinician at each site. For integrated health care systems, each site’s senior

women’s health clinician was surveyed regarding facility characteristics at distinct sites within the integration. The chief of staff was surveyed regarding characteristics for the medical center or integrated health care system. To identify the senior women’s health clinician, we asked the chief of staff at each VAMC to name the person most responsible for or knowledgeable of delivery of women’s health care at each affiliated site. The VA Greater Los Angeles Healthcare System Institutional Review Board approved this study. The funding organization had no role in the collection of data, its analysis and interpretation, or in the right to approve or disapprove publication of the finished manuscript. Measures We determined the availability of women’s health care specialists for emergency gynecologic problems and women’s health care specialists for emergency mental health conditions specific to women from the senior clinician survey. Specifically, we asked, “To what extent are clinicians with specific expertise in women’s health available to manage the following types of health care emergencies: emergency gynecologic problems (e.g., vaginal hemorrhaging); emergency mental health conditions specific to women (e.g., post-partum depression, posttraumatic stress disorder related to sexual trauma)?” Response options were always, usually, sometimes, rarely, or never available. Because health care providers other than physicians may deliver emergency care and acute unscheduled care may be delivered in clinics outside of the ED, respondents could employ a liberal definition of specialist availability that was not limited to specialist physician availability in the ED (Young, 1993). For each of these types of emergencies, we assessed specialist availability during usual clinic hours (Monday–Friday, 8:00 am– 4:30 pm) and after hours. Guided by a conceptual model of organizational factors influencing care delivery for women veterans (Yano et al., 2003), we assessed women’s health program organizational features from the 2 surveys. These features included having a separate women’s health clinic for primary care (in contrast to women’s primary care service delivery being fully integrated within general primary care clinics), having a women’s health care fellowship training program, and facility tracking of women veterans’ satisfaction. Sitespecific characteristics assessed from the senior clinician survey included perceived sufficiency of resources for the women’s health program, having designated providers for women in general primary care and mental health clinics, and the proportion of women veterans at that site who relied on the general primary care clinic for most of their primary care. From other data sources, we determined degree of

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Table 1. Emergency availability of women’s health care specialists (% of sites reporting) Always/Usually Available

Emergency Gynecologic Problems Specialist

Emergency Mental Health Specialist

At all times (during and after usual clinic hours) Only during usual clinic hours Neither after nor during usual clinic hours

39.8% 24.6% 35.6%

51.7% 31.0% 17.2%

facility complexity (a composite score comprised of facility size, scope of practice, and academic intensity) (Stefos, LaVallee, & Holden, 1992), level of managed care penetration in the geographic region (US GAO, 1998), and urban versus rural location (Yano, Simon, Gonzalez, Wang, Lanto, & Rubenstein, 1999). Statistical Analysis For all analyses, our unit of analysis was the VA site. To create the dependent variables for these analyses—VA availability of women’s health care specialists for emergency gynecologic problems and for emergency mental health conditions specific to women—we dichotomized responses to the women’s health specialist emergency availability questions into the categories always/usually available and sometimes/rarely/never available. We conducted bivariate comparisons of each potential predictor with each of the 2 dependent variables using ␹2 and analysis of variance tests. We developed separate logistic regression models to predict the availability of women’s health care specialists for emergency gynecologic problems and women’s health care specialists for emergency mental health conditions specific to women. All facility-level characteristics significant at p ⬍ .10 were considered for the models as potential independent predictors. Only one of any group of highly correlated (Pearson correlation 2-sided p ⬍ .05) variables was included. We conducted forward stepwise logistic regression for each model to identify independent predictors. All analyses were conducted using SPSS/PC (version 11.5, SPSS, Inc; Chicago, Ill, USA).

sites had gynecologic and women’s mental health specialists available for emergencies occurring during usual clinic hours (64.4% and 82.7% of sites, respectively). Women’s health care specialists for emergency gynecologic problems were usually available at all times for 39.8% of sites and only during usual clinic hours for 24.6% of sites. Women’s health care specialists for emergency mental health conditions specific to women were available at all times for 51.7% of sites and only during usual clinic hours for 31.0% of sites. Women’s health care specialists for emergency gynecologic problems and emergency mental health conditions specific to women were not usually available, even during clinic hours, for 35.6% and 17.2% of sites, respectively. Independent predictors of having women’s health care specialists available for emergencies are presented in Table 2. Having a separate women’s health clinic was independently associated with availability of women’s health care specialists for emergency gynecologic problems (p ⫽ .023). Having lower local managed care penetration was independently associated with availability of women’s health care specialists for emergency mental health conditions specific to women (p ⫽ .024). The proportion of women using general primary care at that site, having designated providers for women in general primary care and mental health clinics, facility organizational complexity, having a women’s health training program, facility tracking of women veterans’ satisfaction, perceived women’s health resource sufficiency, and urban versus rural location were not independently associated.

Discussion Results During the 12 months ending September 2000, 166 VA sites operating within 140 medical centers or systems each delivered health care services to 400 or more unique women veterans. Collectively, these sites provided care to more than 80% of the women that the VA served. We received responses from 128 of the 140 (91%) chiefs of staff and 136 of the 166 (82%) senior clinicians surveyed. Our analytic data set was comprised of 118 sites for which we had matching data for all chiefs of staff and their associated senior clinicians. The emergency VA availability of women’s health care specialists is described in Table 1. A majority of

A majority of VA facilities reported having women’s health specialists available for gynecologic and mental health emergencies during usual clinic hours. However, a significant proportion rely on general surgeons and existing mental health personnel rather than women’s health care specialists to deliver these services, particularly for after-hours care. Whereas nonspecialists can manage some women’s gynecologic or mental health problems effectively, other problems may require additional expertise. From a managerial standpoint, VA staffing patterns for emergency women’s health services likely represent a practical solution for a health care entity with a small number of

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Table 2. Independent predictors of emergency availability of women’s health care specialists

Practice characteristics Having a separate women’s health clinic Proportion of women using general primary care clinic at that site Having designated providers for women in general primary care clinic Having designated providers for women in mental health clinic Facility characteristics Facility organizational complexity Having a women’s health training program Facility tracking of women veterans’ satisfaction Perceived women’s health resource sufficiency Regional environment characteristics Urban location (in contrast to rural location) Lower local managed care penetration

Gynecologic Problems Specialist

Mental Health Conditions Specific to Women Specialist

Beta

p-Value

Beta

p-Value

.279* ⫺.049 ⫺.123 ⫺.212

.023 .725 .309 .080

⫺.141 .029 .133 .105

.253 .814 .280 .394

.125 .133 .134 .208

.336 .280 .270 .098

.042 .072 ⫺.007 .152

.742 .564 .955 .216

.163 .079

.185 .517

.035 ⫺.282*

.783 .024

*p ⬍ .05.

women patients and an inability to staff reliably or with women’s health care specialists. Policy makers and administrators in the private sector may face the same issues in ensuring access for rare service needs. Further investigation is needed to evaluate the implications of alternative staffing patterns on quality of emergency women’s health care in the VA. Interestingly, sites with women’s health clinics had greater availability of women’s health care specialists for emergency gynecologic problems. This may reflect the fact that these clinics have established formal relationships with these specialists who are then available for off-hours emergency care. Sites in regions with less managed care penetration were more likely to have emergency women’s mental health care specialist availability. In prior research, we found that greater facility complexity, having a separate women’s health budget, and less local preferred-provider organization penetration all independently predicted greater on-site availability of nonemergency specialized women’s health care services (Washington et al., 2003). Because women veterans who use sources of care other than the VA often receive this care from managed care organizations, the greater VA availability of women’s mental health care specialists for emergencies in regions with less managed care penetration may reflect VA sites filling a niche for services less widely available in their local private sector. Alternatively, providers in regions with less managed care penetration may be more likely to affiliate with VA for specialized mental health care, thereby increasing access to these emergency services. The scope of services that the VA currently provides for general emergency care seems to compare with what is available in the private sector at hospitals with basic EDs, with virtually all VA EDs open 24 hours a day, 7 days a week, and 96% of VA EDs capable of

providing care to minor trauma patients (Young, 1993). In the private sector, there are 3 licensing levels for EDs: standby, basic, and comprehensive (California Code of Regulations). Standby EDs provide emergency medical care in a specifically designated area of the hospital that is equipped and maintained at all times to receive patients with urgent medical problems and are capable of providing physician services within a reasonable period of time. A physician need not be present in the hospital at all times, but must be readily available when summoned. Basic EDs, by contrast, must have a physician on the premises and available 24 hours a day (e.g., a community hospital ED). Comprehensive EDs provide a more extensive scope of services than basic EDs, with in-house capability for managing all medical situations on a definitive and continuing basis (e.g., a tertiary care center ED). In California, a recent statewide assessment of the number and type of EDs found that 13.2% are standby, 84.2% are basic, and only 2.5% are comprehensive (Lambe et al., 2002). By contrast, all VA EDs meet at a minimum the basic ED criteria. Nationally, the annual rate of visits to EDs is 38.9 per 100 persons (McCaig, & Burt, 2004). Of these visits, 11.4% are for diseases of the genitourinary system, abdominal pain, or mental disorders. Among women age 15– 44, the annual US ED visit rate is 42.5– 49.7 per 100 persons, accounting for 27.6 million annual ED visits. Obstetric/gynecologic care was provided during 1.6 million visits. Women under age 65, the group most likely to have gynecologic emergencies, were found in prior research to have a trend toward greater exclusive use of VA care compared with older age groups (Bean-Mayberry, Chang, McNeil, Hayes, & Scholle, 2004). With the continuing rapid growth in the number of younger women veterans, these national patterns of ED use and trends toward greater

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exclusive VA use by younger women veterans suggest that demand for VA provision of emergency women’s health care services will likely increase. VA health care users, compared to veterans who receive care in other settings, have greater financial barriers to health care use in the private sector (Washington, Yano, Simon, & Su, in press). Because 53– 61% of women veteran VA users depend on VA facilities for all of their health care, having access to more comprehensive emergency care, particularly for common emergency conditions, may be important to ensuring that VA users do not have barriers to VA care (Washington et al., in press; Bean-Mayberry et al., 2004). For ambulatory care services in general, lack of knowledge of VA eligibility and services and perceived worse quality of VA care predict women veterans’ non-VA use (Washington et al., in press). Whether women VA users perceive barriers specific to emergency care, and the influence of these perceptions on their care-seeking behavior should be the subject of future study. In 1999, Congress provided the VA with new authority to pay for emergency care in non-VA facilities for veterans enrolled in the VA health care system (Veterans’ Millennium Health Care and Benefits Act; Millennium Bill Emergency Care Provision Interim Guidance, 2000). This new benefit will pay for emergency care rendered for non–service-connected conditions for enrolled veterans who have no other source of payment for the care, if VA or other federal facilities were not feasibly available at the time of the emergency. However, VA will only pay to the point of medical stability. This mechanism for ensuring availability of emergency care for enrolled veterans may have greater importance in areas served by VA facilities that do not have emergency availability of women’s health care specialists. If the cost to the VA is substantial for emergency care delivered via this mechanism, then the scope and availability of on-site emergency services is likely to take on even greater VA policy relevance. Limitations This study’s strength is that it selected all VA sites serving 400 or more unique women veterans for our assessment of specialist availability for emergency women’s care. However, our findings must be interpreted within the context of the following limitations. First, we did not stratify sites further with respect to female caseload, or determine how often health care emergencies requiring women’s health expertise arise. The volume of this care and the service delivery arrangements for emergency women’s health care are the subject of future study. We also did not assess patient-level decision making about when and where to seek care for gynecologic and psychiatric emergencies. An additional limitation is that the generalizabil-

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ity of our findings to smaller volume sites (i.e., VAMCs and CBOCs serving less than 400 women) is unknown. However, most if not all of these sites do not have EDs. Management and Policy Implications Many VA facilities rely on general surgeons and existing mental health personnel rather than women’s health care specialists to deliver emergency women’s health services, particularly for after-hours care. Small female caseloads in VA EDs may provide only limited experience for ED providers on gender-specific health problems. Further work is needed to determine if current staffing patterns for emergency care impact quality of care, and the actions clinicians take when additional women’s health expertise is needed. Options for increasing the availability of women’s health specialists for emergencies include internal development of women’s health expertise, telemedicine access to experts to aid in emergency women’s health care decision making, and contracting for outside coverage. Research in this area will further inform strategic planning and guide appropriate resource use for enhancing the delivery of VA women’s health care that fits local care needs.

Acknowledgments The views expressed within are solely those of the authors, and do not necessarily reflect the views of the Department of Veterans Affairs. The authors thank Ismelda Canelo for project direction, MingMing Wang, MPH, and Stephanie Schwarzman for sample development, and Andrew Lanto, MA, for statistical analysis. This paper was presented in part at the VA Health Services Research and Development Service national meeting, February 2003.

References Bean-Mayberry, B., Chang, C., McNeil, M., Hayes, P., & Scholle, S. H. (2004). Comprehensive care for women veterans: indicators of dual use of VA and non-VA providers. Journal of the American Medical Women’s Association, 59, 192–197. Department of Veterans Affairs, VA Information Resource Center. National Patient Care Database (NPCD). Available: http://www. virec.research.med.va.gov. Accessed January 23, 2006. Kizer, K.W., Fonseca, M. L., & Long, L. M. (1997). The Veterans Healthcare System: Preparing for the 21st century. Hospital & Health Services Administration, 42, 283–298. Lambe, S., Washington, D. L., Fink, A., Herbst, K., Liu, H., Fosse, J. S., et. al. (2002). Trends in the use and capacity of California’s emergency departments, 1990 –1999. Annals of Emergency Medicine, 389 –396. McCaig, L. F., & Burt, C. W. (2004). National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Advance data from vital and health statistics; no 340. Hyattsville, Maryland: National Center for Health Statistics. Metlay, J. P., Camargo, C. A., Bos, K., & Gonzales, R. (2005). Assessing the suitability of intervention sites for quality improvement studies in emergency departments. Academy of Emergency Medicine, 12, 667– 670.

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D. L. Washington et al. / Women’s Health Issues 16 (2006) 133–138

Millennium Bill Emergency Care Provision Interim Guidance, IL 10-2000-005. (2000). Available: http://www.va.gov/. Accessed May 28, 2004. Skinner, K. M., & Furey, J. (1998). The focus on women veterans who use Veterans Administration health care: The Veterans Administration Women’s Health Project. Military Medicine, 163, 761–766. Skydell, B. (1998). Restructuring the VA Health Care System: Safety net, training, and other considerations. Issue Brief/No. 716. Washington, DC: National Health Policy Forum. Stefos, T., LaVallee, N., & Holden, F. (1992). Fairness in prospective payment: A clustering approach. Health Services Research, 27, 239–261. U.S. General Accounting Office (GAO). (1982). Actions needed to ensure that female veterans have equal access to VA benefits. GAO/ HRD-82-98. Washington, DC: United States General Accounting Office. U.S. General Accounting Office (GAO). (1992). VA Health Care for Women: Despite Progress, Improvements Needed. GAO/HRD-92-93. Washington, DC: United States General Accounting Office. U.S. General Accounting Office (GAO). (1998). VA Hospitals: Issues and Challenges for the Future. GAO/HEHS-98-32. Washington, DC: United States General Accounting Office. U.S. General Accounting Office (GAO). (1999). VA Health Care for Women: Progress Made in Providing Services to Women Veterans.

GAO/HEHS-99-38. Washington, DC: United States General Accounting Office. Veterans Health Care Act of 1992. PL 102-58. (1992). Veterans’ Health Care Eligibility Reform Act of 1996. PL 104-262. (1996). Veterans’ Millennium Health Care and Benefits Act. H.R. 2116. PL 106-117. (1999). Washington, D. L., Caffrey, C., Goldzweig, C., Simon, B., & Yano, E. M. (2003). Availability of comprehensive women’s health care through Department of Veterans Affairs Medical Centers. Women’s Health Issues, 13, 50 –54. Washington, D. L., Yano, E. M., Simon, B., & Sun, S. (2006). To use or not to use—What influences why women veterans choose VA healthcare? Journal of General Internal Medicine, 21, S11–18. Yano, E. M., Simon, B., Gonzalez, I., Wang, M., Lanto, A., & Rubenstein, L. V. (1999). 1996 VHA survey of delivery models for primary care. Center for the Study of Healthcare Provider Behavior. VA HSR&D Monograph #98-MC802, North Hills, CA. Yano, E. M., Washington, D. L., Goldzweig, C., Caffrey, C., & Turner, C. (2003). The organization and delivery of women’s health care in Department of Veterans Affairs Medical Centers. Women’s Health Issues, 13, 55– 61. Young, G. P. (1993). Status of clinical and academic emergency medicine at 111 Veterans Affairs Medical Centers. Annals of Emergency Medicine, 22, 1304 –1309.