National Partnership for Women & Families

Monthly Women's Health Research Review

Study assesses link between organizational factors, comprehensive women's health care at Veterans Health Administration

Summary of "The role of organizational factors in the provision of comprehensive women's health in the Veterans Health Administration," Shivani M. Reddy et al., Women's Health Issues, Oct. 13, 2016.

"Accommodating" the increasing number of female patients at the Veterans Health Administration (VHA), which "historically has served primarily men poses challenges," according to Shivani M. Reddy of VA Boston Healthcare System's Department of General Medicine and colleagues.

The researchers explained that since the 1990s, "there has been a growth of both women's health clinic[s] (WHC) and designated women's health provider[s] in primary care (DWHP) models of health care delivery for women veterans." According to the researchers, a WHC, which provides both primary and gender-specific care, "is a distinct physical location in a VHA facility with dedicated examination rooms and women's health staff, and may include a range of providers from general internists, nurse practitioners, and [OB-GYNs]." In comparison, "a DWHP has a panel of women patients who are seen in the general primary care clinic alongside male veterans," the researchers wrote.

For the study, the researchers "adapted the Greenhalgh model of diffusion of innovations in service organizations, which considers how an organization's structural characteristics, absorptive capacity for change and readiness for change are associated with adoption of innovation, specifically comprehensive women's health care." The researchers defined structural factors as the "size, centralization in decision making, and specialization of the organization"; absorptive capacity as "an organization's ability to identify, assimilate, and integrate new knowledge"; and system readiness for change as "the resources an organization has for adoption and its ability to assess the innovation."

The researchers "hypothesized structural, absorptive capacity, and system readiness organizational factors would be positively associated with adoption of WHC, and that WHC adoption would be positively associated with the availability of a package of women's health services."

Methods

The researchers conducted an analysis of the 2007 VHA National Survey of Women Veterans Health Programs and Practices (WVHP). The survey included data from 193 VHA facilities -- including VHA medical centers (VAMCs) and community-based outpatient clinics (CBOCs) -- that each served "300 or more unique women veterans in 2006."

The researchers tracked "the model of women's health care adopted by the facility" -- such as a WHC, a DWHP, a WHC and DWHP or neither -- and "women's health services available in primary care." The researchers defined women's health services as five "gender-specific services that can be delivered by a primary care provider, specifically cervical cancer screening, contraceptive management, and evaluation and management of vaginitis, menstrual disorders, and menopause." The researchers said they assessed "the availability of each individual service as well as a package of all five services."

The researchers also tracked organizational factors. Specifically, the researchers examined system innovation, measured via the number of women visiting a VHA facility and the presence of a gynecology clinic separate from the WHC; absorptive capacity for change, measured via a facility's "academic affiliation and women's health representation on a high-impact committee," such as pharmacy or building panels; and system readiness for change, measured via "sufficient resources for women's health and ... capacity to evaluate the innovation with quality improvement (QI) activities."

Results

Overall, the researchers found that 68 percent of facilities had a WHC, including 39 percent that had only a WHC and 29 percent that had a WHC and DWHP. In contrast, 20 percent of facilities did not have a WHC or DWHP. According to the researchers, "There was [a] high frequency of available services, ranging from 86 percent (menstrual disorder evaluation and management) to 96 percent (cervical cancer screenings)."

Bivariate analysis

Regarding structural factors, the researchers found that facilities "with a greater caseload of women veterans and sites with a gynecology clinic were more likely to have a WHC or WHC [and] DWHP." Meanwhile, facilities that had only a DWHP "were associated with lower caseloads and were less likely to have a gynecology clinic." The researchers also found that VAMCs were more likely to be associated with WHC or WHC [and] DWHP models, while CBOCs were more likely to have a DWHP."

Regarding absorptive capacity, the researchers found that "[f]acilities with an academic affiliation were associated with a WHC or WHC [and] DWHP (75 percent and 72 percent, respectively), while "[w]omen's health representatives were more frequently on a high-impact committee, 46 percent and 32 percent for WHC and WHC [and] DWHP, respectively, compared with 12 percent for DWHP and 22 percent for neither model."

Regarding system readiness for innovation, the researchers found that "sufficient resources were more likely reported at facilities with WHC [and] DHWP and DWHP (31 percent and 30 percent, respectively, compared with 17 percent [for] WHC only and 5 percent [for] neither)." In addition, WVHP survey respondents at "WHC/DWHP and DWHP sites were more likely to report higher overall clinical expertise (93 percent and 96 percent, respectively), administrative and support staff (64 percent and 78 percent, respectively), and clinic space (71 percent and 78 percent, respectively)." According to the researchers, same-gender provider services also "were more common at facilities with a WHC or WHC [and] DWHP (85 percent and 91 percent, respectively)."

Regarding women's health services, the researchers found that "individual service availability was greatest for facilities with WHCs or WHC [and] DWHP and least for sites with no model of women's health care." According to the researchers, "All five women's health services were available at 89 percent of facilities with WHC and WHC [and] DWHP models of care, whereas this package of services was only available at 71 percent of facilities with DWHP and 66 percent of facilities with no women's health care model."

Multivariable analysis

The researchers also found that academic affiliation and the appointment of at least one female health representative to a high-impact panel "were associated significantly with facilities with a WHC or WHC [and] DWHP compared with sites with no model of women's health care."

In addition, when assessing independent predictors of women's health services, the researchers found that "sites with a WHC or WHC [and] DWHP were three times more likely to provide a package of women's health services compared with sites with no model [of women's health care]." The researchers identified "a positive observed association of some organizational factors -- gynecology clinic, academic affiliation, QI activities, and number of women veterans -- with service availability."

Discussion

Based on the study, the researchers contended that establishing "[a] separate WHC with the mission of providing [comprehensive] gender-focused care" could help address the fragmentation of women's health care into reproductive and non-reproductive care.

According to the researchers, the study showed "that a WHC may be better able to provide comprehensive care to women veterans who use the VHA." They explained, "We are the first investigators to examine a package of women's health services that would better promote 'one-stop shopping' for women veterans, reducing the number of providers and visits needed to access to comprehensive services." Accordingly, they cited the finding that VHA facilities "with a WHC or WHC [and] DWHP were more than three times more likely to provide a package of women's health services as compared with sites with no specific model of women's focused primary care." They pointed out that "a WHC plays an influential role in providing [women's health] services."

The researchers outlined "several reasons [why] a WHC may facilitate the availability of women's health services," such as by facilitating "direct care to patients," "highlight[ing] expertise within the organization," potentially improving team functioning, and fostering "a greater level of gender awareness" among a site's support staff.

The researchers also cited the finding that an on-site WHC "was significantly associated with ... academic affiliation and membership to a high-impact committee." They explained that "increasing absorptive capacity may help the VHA become more of a learning organization." For instance, outlining how academic affiliation could foster the "acquisition and assimilation of new knowledge," the researchers noted that a clinician with a joint appointment at a medical university campus or at a WHC outside of the VHA could help disseminate practical knowledge, while training residents or fellows from academia at WHCs could "promote a culture of women's health education at the VHA." In addition, academic affiliation could promote the development of research programs.

The researchers also outlined how the appointment of a women's health representative to a high-impact committee could be beneficial, by helping draw leadership attention to a minority population, demonstrating "leadership commitment to women's health" and breaking down "resistance to taking care of women veterans instead of referring them outside of the VHA." Further, according to the researchers, "Women's health representatives ... can advocate for resources for women veterans, such as contraceptive medications on a formulary or clinic space for a separate WHC."

Citing prior research that found that "having leadership dedicated to primary care was associated with the presence of a WHC," the researchers added, "Our study, along with previous studies of WHC in the VHA, suggest that strong leadership advocating for women's heath may be necessary to promote the health care of this minority population."

According to the researchers, "Specialized gynecology clinics were most commonly found at sites with both WHC [and] DWHP (50 percent) and sites without either WHC or DWHP (42 percent), followed by WHC only (37 percent), which was unexpected." The researchers noted that sites "may choose to provide women's health care by adding a separate specialty clinic instead of transforming primary care." However, while they cited study findings showing "sites with WHC were more likely to provide a package of basic gynecologic care for patients," they wrote that "[i]ntegrating women's health into a primary care-based WHC may better promote the diffusion of women's health compared with adding another subspecialty clinic" and help curb the "fragmentation of women's health care."

Regarding their findings on system innovation, the researchers wrote that while "gender-specific resources (same gender provider, examination rooms for pelvic examinations, and budget for a women's health program) were more commonly reported in sites with a WHC or WHC [and] DWHP, ... overall clinical expertise, nursing staff, administrative and support staff, and clinic space were more likely sufficient at DWHP sites as compared with sites with a WHC." According to the researchers, "These results suggest that primary care may have more robust resources required for comprehensive care of women beyond their reproductive health" and indicate that "separate WHC clinics may be siloed from the staffing and space resources of general primary care."

According to the researchers, "The apparent absorptive capacity of VHA facilities was associated with the adoption of WHCs ... In turn, WHCs were three times as likely to provide a full package of women's health services, promoting comprehensive care for women veterans." Based on those findings, the researchers concluded that "partnering with academic institutions and placing women's health representatives on high-impact committees so they can influence policies may be interventions that could spur expanded availability of comprehensive primary care for women veterans."