Gender & Health
Call for Papers
Assessing & Improving Quality of Care by Gender
Chair: Amal Khoury, University of Florida
Tuesday, June 28 • 8:30 am – 10:00 am
●Are Older Women More Likely to Get Inappropriate
Drugs?
Arlene Bierman, M.D., MS, Mary Jo V. Pugh, Ph.D. , RN, Irfan
Dhalla, M.D., Megan Amuan, MPH, B. Graeme Fincke M.D.,
Amy Rosen, Ph.D., Bei- Hung Chang Sc.D., Dan R. Berlowitz,
M.D., MPH
Presented By: Arlene Bierman, M.D., MS, OWHC Chair in
Women's Health, Inner City Health Research Unit, St.
Michael's Hospital, 30 Bond Street( 70 Richmond Street East,
4th floor), Toronto, M5B 1W8; Tel: (416) 864-6060 X2894;
Fax: (416) 864-5485; Email: arlene.bierman@utoronto.ca
Research Objective: Prior studies have suggested that older
women are more likely to receive inappropriate prescriptions
than older men. A better understanding of gender differences
in inappropriate prescribing may lead to the development of
effective improvement interventions. Therefore, in this study,
we assessed gender differences in rates of inappropriate
prescribing before and after adjusting for potentially
appropriate indications and examined gender differences in
correlates of inappropriate drug use.
Study Design: Retrospective national Veterans Health
Administration (VA) cohort study using linked pharmacy,
inpatient, and outpatient data. We determined the unadjusted
and diagnosis-adjusted prevalence of 33 potentially
inappropriate medications among men and women using the
Beers criteria: overall, by individual drug, and in three
categories grouped by potential indication: always avoid, rarely
appropriate, and some indications according to the Zahn
classification. Using logistic regression we determined the
odds ratios of women receiving inappropriate drugs compared
to men for individual agents and by drug category.
Race/ethnicity, psychiatric comorbidity, physical comorbidity,
number of medications, and care characteristics (long-term
care, medical-surgical and psychiatric admissions, receipt of
geriatric care, and proportion of visits in primary care) were
included as covariates. Logistic regression was used to identify
patient and care characteristics associated with inappropriate
prescribing for men and women.
Population Studied: Veterans 65 years or older, who had
having at least one VA patient health care encounter in both
fiscal year (FY)99 and FY00 (N=965,756; 946,641 men; 19,115
women.
Principal Findings: Women were more likely than men to
receive inappropriate medications overall and in all three
categories, even after adjusting for diagnoses that may have
justified the prescription. The majority of use remained
inappropriate after adjusting for potential indications. For
example, in the “some indications” category, 22.6% of women
and 18.1% of men received a potentially inappropriate
medication. After adjusting for diagnoses that may have
justified the prescription, 18.2% of women and 15.6% of men
received a potentially inappropriate medication. Women were
more likely to receive 16 of 33 medications (psychotropic
drugs, analgesics, anticholinergic agents) and men more likely
to receive 3 of the 33. In adjusted models, women were more
likely to receive any inappropriate drug (OR 1.23 95%CI 1.18,
1.27). The OR for always avoid drugs was 1.73 95%CI 1.55, 1.94.
Psychiatric comorbidity was associated with inappropriate
prescribing for men but not for women.
Conclusions: Older women veterans were more likely to
receive inappropriate medications than older men in the VA,
even after accounting for a liberal set of indications, and even
though some drugs such as indomethacin and dypiridamole
are more likely to be prescribed to men. Analgesic,
psychotropic, and anticholinergic medications contribute to
the higher rates of inappropriate prescribing among older
women. Despite the higher proportion of men in the VA, our
findings suggest that there are gender differences in correlates
of inappropriate prescribing.
Implications for Policy, Delivery, or Practice: Efforts to
improve the quality of medication management in the elderly
should address gender differences in prescribing patterns.
Studies of inappropriate prescribing should examine gender
differences whenever possible.
Primary Funding Source: VA
●Cervical Cancer Screening Practices in the United States
Since the Release of National Guidelines on Genital
Human Papillomavirus (HPV) Testing: Results from a
Recent National Clinician Survey
Kathleen Irwin, M.D., MPH
Presented By: Kathleen Irwin, M.D., MPH, Chief, Health
Services Research, Division of STD Prevention, Centers for
Disease Control and Prevention, 1600 Clifton Road, Mailstop
E-80, Atlanta, GA 30333; Tel: (404) 639-8979; Fax: (404) 6398607; Email: kirwin@cdc.gov
Research Objective: Persistent infection with oncogenic types
of genital human papillomavirus (HPV) causes cervical
intraepithelial neoplasia (CIN) and cancer which result in
4000 US deaths and >$1 billion in cancer screening,
diagnosis, and treatment costs annually. Of the ~3 million
American women diagnosed with borderline Pap test results
(ASC-US) each year, HPV-infected women are at highest risk
of developing CIN and cancer. In 2001, CDC and several
national clinical organizations recommended using a recently
licensed HPV test to guide triage of HPV-infected women with
ASC-US Pap results to colposcopy, an expensive, invasive
procedure not readily available to all women screened for
cervical cancer. HPV testing is not recommended to triage
patients with higher-grade Pap abnormalities because
colposcopy is warranted regardless of HPV test results. By
2003, two national organizations had endorsed HPV testing
as an optional adjunct to Pap testing for women 30+ years to
distinguish HPV-infected women who warrant frequent
followup Pap tests from non-HPV-infected women at low risk
of cervical cancer whose Pap testing intervals could be
lengthened. We conducted a national clinician survey to
evaluate the influence of new guidelines on screening
practices.
Study Design: In 2004, the Centers for Disease Control and
Prevention surveyed nationally representative samples of
primary care clinicians identified through national registries.
The mail survey addressed Pap and HPV testing practices. We
weighted categorical analyses for differences in sampling
fraction and non-response by clinician specialty.
Population Studied: Primary care physicians practicing
internal, adolescent, or family/general medicine or
obstetrics/gynecology; nurse-midwives; nurse-practitioners;
and physician assistants.
Principal Findings: Of the 3365 primary care clinicians who
responded (adjusted response rate=81%), 87% reported
providing Pap tests. Of these, 59% reported using HPV tests
for patients with borderline or abnormal Pap results. Of
clinicians reporting HPV testing of such patients, 84%
reported usually/always ordering HPV tests for patients with
borderline (ASC-US) Pap results, as endorsed by national
guidelines. However, 57% to 78% of these clinicians reported
usually/always ordering HPV tests for patients with highergrade Pap abnormalities, a practice not endorsed by
guidelines. Only 21% of Pap test providers reported ordering
HPV tests as an adjunct to Pap tests, of whom few reported
usually/always testing women aged 30+ (12%) or <30 (15%).
Obstetrician/gynecologists and nurse-midwives and clinicians
with on-site colposcopy were more likely than other clinicians
to report using HPV tests for cancer screening indications that
were and were not recommended by guidelines.
Conclusions: Most Pap test providers report ordering HPV
tests to guide colposcopy triage of women with borderline Pap
results, but many also report providing HPV tests to patients
with higher-grade abnormalties who merit colposcopy
regardless of HPV test results. Few Pap test providers report
using HPV tests as an adjunct to Pap tests, suggesting that
HPV testing has not resulted in lengthening Pap test intervals
among women at low cancer risk.
Implications for Policy, Delivery, or Practice: Survey
findings should be used to update clinical training materials,
decision support tools, and patient education materials to
promote consistency with new guidelines.
Primary Funding Source: CDC
poverty level) below which a woman was eligible for Medicaid.
This policy parameter varies greatly across states and over
time. In addition, we control for the annual state-level welfare
caseloads and unemployment rates as well as for the various
individual characteristics and state and time fixed effects that
might have had an impact on maternal morbidity.
Population Studied: All of our analyses are performed
separately for whites and blacks. Also, in an attempt to verify
the causality of the relationship between Medicaid eligibility
and health, we adopt a difference-in-difference type of
approach and estimate our models separately for two
treatment groups (low-income single and married mothers)
and a control group (high-income married pregnant women).
Principal Findings: We find that the eligibility changes lead to
a higher utilization of prenatal care, less anemia, and possibly
less hypertension among low-income women. In 1997, the
expenditures for hospitalizations due to anemia and
pregnancy-related hypertension were over $962 million and
$1,237 million, respectively. Our results therefore suggest that
the Medicaid expansions may indeed have lead to significant
health improvements and cost savings for one of its key target
groups - the pregnant women themselves.
Conclusions: If maternal health is considered an important
outcome, our results suggest that the conclusions regarding
the effectiveness of the Medicaid eligibility expansions may
need to be reevaluated.
Implications for Policy, Delivery, or Practice: When
designing programs to improve birth outcomes, policymakers
need to be aware of the effects of the implemented policies on
both the infants and their mothers. Viewed from this broader
perspective, interventions targeted at low-income pregnant
women – such as the Medicaid eligibility expansions of the
1990’s - may be more effective than initially thought.
Primary Funding Source: No Funding
●The Forgotten Beneficiary of the Medicaid Expansions
Andrea Kutinova, MA (Ph.D. student), Karen Smith Conway,
Ph.D.
Presented By: Patick Roohan, MS, Director, New York State
Department of Health, Bureau of Quality Management and
Outcomes Research, OMC, 1938 Corning Tower, Albany, NY
12237; Tel: (518) 486-9012; Fax: (518) 486-6098; Email:
pjr02@health.state.ny.us
Research Objective: The objective of this study was to
analyze the relationship of surgical and hospital volume on
three-year and five-year survival for women with breast cancer.
Study Design: Three datasets were used for this study, the
New York State Cancer Registry, the Statewide Planning and
Research Cooperative System (SPARCS) inpatient database
and the SPARCS outpatient surgery database. Records of
women diagnosed with breast cancer from 1995 through 1998
were identified on the Cancer Registry and matched separately
to the SPARCS inpatient and outpatient datasets. Matching
the Cancer Registry to the SPARCS inpatient files yielded a
match rate of 87% for the four year period. Due to limited
matching data elements on the outpatient surgery file in 1995
and 1996, the Cancer Registry and SPARCS outpatient match
was conducted for the years 1997 and 1998, and also had a
match rate of 87%. Two analyses emerged: a five-year
survival study of inpatient surgeries for the years 1995-1998,
and a three-year survival study of inpatient and outpatient
Presented By: Andrea Kutinova, MA (Ph.D. student),
University of New Hampshire, 4 Library Way, Durham, NH
03824; Tel: (603)862-7071; Email: kutinova@cisunix.unh.edu
Research Objective: Empirical evidence on the effectiveness
of the Medicaid eligibility expansions of the 1990’s is mixed.
While it is generally believed that the expansions succeeded in
promoting prenatal care utilization, the effects on pregnancy
outcomes seem to be, at best, modest. So far, however, a key
beneficiary – the mother – has been left completely out of the
analysis. Without considering the effects of the Medicaid
expansions on maternal health, any discussion of the policy
effectiveness is incomplete. Therefore, in this paper, we
contribute to the ongoing debate by focusing on the effects
the eligibility changes had on pregnant women themselves.
Study Design: We use the Natality Detail Files from 1990 to
1996 to study the improvements in maternal morbidity during
pregnancy and delivery attributable to the Medicaid eligibility
increases of the 1990’s. Our key explanatory variable of
interest is the income cutoff (as a percent of the federal
●The Relationship of Surgeon and Hospital Volume with
Long-Term Survival for Women with Breast Cancer
Patrick Roohan, MS
surgeries for the years 1997-1998. The Cancer Registry
included the following information used in modeling: date of
death (through 2001), age, race/ethnicity, socioeconomic
status and stage of cancer. Type of insurance, type of surgery
(breast conserving surgery, mastectomy), excision of lymph
nodes (yes, no), comorbidity, surgeon volume and hospital
volume were derived from the SPARCS inpatient and
outpatient data. The Cox proportional hazard model was used
to evaluate the contributions of surgeon and hospital volume,
while adjusting for risk factors outlined above.
Population Studied: Women in New York State diagnosed
with breast cancer in 1995 through 1998, who had breast
surgery.
Principal Findings: In the five-year survival study after
adjusting for socio-demographic and clinical factors, women
who went to a surgeon with an annual breast cancer surgical
volume of 1-5 were 1.36 times more likely to have a poorer
outcome in five years compared to women who went to a
surgeon that performed over 46 surgeries per year. Similar
increased risk of poorer survival exists for surgeons that
perform 6-10 (Risk ratio 1.34), 11-20 (RR=1.27), 21-45 surgeries
per year (RR=1.21) compared to surgeons that perform 46+
surgeries annually. Hospital volume, after adjusting for
surgeon volume and other factors was not significant. In the
three-year study, women who had surgery performed by a
surgeon with annual volumes of 1-6 (RR=1.39) and 7-12
(RR=1.20) had poorer outcomes compared to women who
went to a surgeon with an annual volume of over 25 surgeries
per year. Similar to the five-year study, hospital volume after
adjusting for other factors, was not significant.
Conclusions: In both studies presented, long-term survival
from breast cancer increases with increased surgeon volume.
This may be due to “practice makes perfect”, the association
of high-volume providers and comprehensive cancer centers,
and/or increased surgical skill for some high volume
surgeons.
Implications for Policy, Delivery, or Practice: Women with
breast cancer should consider the expertise of the surgeon in
breast surgery in her decision-making process.
Primary Funding Source: New York Community Trust
●Gender Differences in Prescribing Drugs Potentially
Harmful to Elderly Managed Care Enrollees
Lok Wong, MHS, Russell Mardon, Ph.D., Arlene Bierman,
M.D.
Presented By: Lok Wong, MHS, Senior Health Care Analyst,
Quality Measurement, National Committee for Quality
Assurance, 2000 L Street NW, Suite 500, Washington, DC
20036; Tel: (202)955-1784; Fax: (202)955-3599; Email:
wong@ncqa.org
Research Objective: Previous population-based studies have
found older women to be more likely to receive potentially
inappropriate drugs than older men. However, it is not known
whether these gender differences in prescribing patterns exist
within Medicare managed care plans. Therefore we evaluated
whether elderly women enrolled in managed care are more
likely than men to receive drugs potentially harmful to the
elderly.
Study Design: Retrospective pharmacy claims data analysis in
9 health plans in the U.S. Calculations included percentages of
elderly enrolled throughout the year who received at least one
drug, or at least two different drugs potentially harmful in the
elderly. Rates were reported by plan, age, gender, across the
study population and various high-risk drug categories.
Potentially harmful drugs are classified as never appropriate,
rarely appropriate or sometimes indicated by Zahn (2001).
Population Studied: Over 433,000 Medicare enrollees ages
65 and older in 9 health plans in different regions across the
United States in 2002 and 2003.
Principal Findings: Nearly half a million elderly enrollees
received more than 3 million prescriptions of drugs potentially
harmful in the elderly, of which more than 500,000 are never
or rarely appropriate in the elderly. Most Medicare enrollees
included in the study were female (63%). Overall, women
were more likely than men to receive drugs potentially harmful
in the elderly, and across a variety of high-risk drug
classifications. Women were more likely than men to receive
at least one never appropriate drug (8.3% vs. 6%) or rarely
appropriate (drugs 28.6% vs. 25.7%) as defined by Zahn.
Women were also more likely to receive at least two different
drugs considered never appropriate or rarely appropriate
(6.9% vs. 4.2%). Prescribing rates were slightly higher in
women for sometimes indicated drugs (30.4% vs. 29.3%).
Differences are statistically significant. Similar results and
patterns were found in 2003 data.
Conclusions: Older women enrolled in Medicare managed
care plans appear to be more likely to receive drugs potentially
harmful in the elderly. High rates of harmful prescribing are of
concern given the majority of Medicare enrollees are women.
Further research is needed to develop drug-risk classification
systems that can determine if there are gender differences in
exposure to patient harms, and if differences in prescribing
rates are affected by differential disease burden and drug
usage.
Implications for Policy, Delivery, or Practice: This study
highlights the need to be aware of potential gender differences
in potential drug harms exposed to managed care enrollees. A
better understanding of the factors associated with these
gender differences is needed. Interventions aimed at
improving the quality of medication management for
Medicare managed care enrollees will need address gender
differences in prescribing patterns.
Primary Funding Source: CMS
Related Posters
Poster Session B
Monday, June 27 • 6:15 pm – 7:30 pm
●Searching for Women’s Health Centers: Yield of Internet
vs. Traditional Telephone Contacts for Identifying
Research Sites
Nichole Bayliss, BA, Bevanne Bean-Mayberry, M.D., MHS,
Elizabeth M. Yano, Ph.D., Judith Navratil, BA, Carol S.
Weisman, Ph.D., Sarah Hudson Scholle, DrPH
Presented By: Nichole Bayliss, BA, Research Assistant, VA
Pittsburgh Center for Health Equity Research and Promotion,
University Drive (151-C), Pittsburgh, PA 15240; Tel: (412)6886000 x815113; Fax: (412)688-6527; Email:
nichole.bayliss@med.va.gov
Research Objective: In anticipation of identifying and
recruiting sites for participation in health services research
studies, we examined and compared Internet vs. traditional
telephone contact strategies to determine their efficiency in
identifying non-federal, hospital-based Women’s Health
Centers or Programs (WHC/P).
Study Design: Using the American Hospital Association’s
(AHA’s) Annual Survey of Hospitals for 2001, we identified the
national sample of hospitals reporting the presence of a
WHC/P, defined as “an area set aside for coordinated
education and treatment services specifically for and
promoted by women that may or may not include obstetrics
but include a range of services other than OB,” (n=2,214). We
excluded both federal comprehensive women’s health centers
and centers of excellence resulting in 2,113 hospitals. We
selected a random sample of 500 hospitals proportionately
stratified by control/ownership (private=375; public=125). By
convenience, sites were then contacted using one of four
methods: (1) web search only (n=53), (2) single call (n=150),
(3) web search with maximum of three calls (n=249), or (4)
unlimited calls and web search (n=48).
Population Studied: Hospital based women's health centers.
Principal Findings: Over half (264/500, 53%) of the hospitals
that self-reported having a WHC/P through the AHA survey
could not be verified through these screening strategies.
Among hospitals with completed screenings (236/500, 47%),
only 173 hospitals confirmed that they had a WHC/P as
defined by the AHA (173/236, 73%). Of the 173 hospitals
reporting a WHC, only 24 (24/173, 14%) reported delivery of
primary care services. Single calls led to the most
indeterminate findings (n=117/150, 78%), and unlimited calls
augmented by a web search led to the least indeterminate
findings (n=11/48, 23%). Unlimited calls with a web search
also led to the highest proportion of sites reporting no
WHC/P (n=21/48, 44%); however, this method also led to the
highest proportion of sites reporting a WHC with
comprehensive primary care services (n=7, 15%). Web
searches identified the most WHC/P (n=31/53, 58%), but
could only find evidence of primary care services for one site.
Conclusions: Multiple telephone calls augmented by a web
search yielded the most complete information and identified
the most comprehensive centers, but this process was timeconsuming, requiring at least two attempts per site and one-
quarter requiring at least 7 contacts. It also led to the
unexpected result that many hospitals denied having a
WHC/P in contradiction to the AHA survey data. Web
searches often confirmed a women’s health center but rarely
found evidence that the center provided primary care services.
Implications for Policy, Delivery, or Practice: Improvements
in search and collection methods include refining the AHA
question on women’s health centers with hospital
identification of specific services provided for women. An
organizational definition of comprehensive women’s health
care or primary care distinction would diminish the use of
“women’s health center” interchangeably when referring to
reproductive health, maternal/neonatal health or primary care
services. Additionally, revision of hospital based websites with
better search options and contact information is key for public
access. Easy access to these clinical services via the Internet
may prove to be an asset for marketing to the local health
consumer, who is often female.
Primary Funding Source: Department of Health and Human
Services (DHHS)
●Assuring High Quality Primary Care for Women
Veterans: Predictors of Success
Bevanne Bean-Mayberry, M.D., MHS, Chung-Chou Chang,
Ph.D., Melissa McNeil, MD. MPH, Sarah Scholle, DrPH
Presented By: Bevanne Bean-Mayberry, M.D., MHS,
Physician, Division of General Medicine, VA Pittsburgh/
University of Pittsburgh, University Drive C (151-C), Pittsburgh,
PA 15240; Tel: (412)688-6477; Fax: (412)688-6527; Email:
Bevanne.Bean-Mayberry@med.va.gov
Research Objective: Provider gender, provider specialty, and
clinical setting affect quality of primary care delivery for
women, but previous research has not looked at these factors
in combination. The purpose of this study is to determine
whether the separate or combined effects of provider gender,
availability of gynecologic services from the provider, and
women’s clinic setting improve patient ratings of primary care
quality.
Study Design: Women veterans receiving care in women’s
clinics or traditional primary care at 10 VA medical centers
completed a mailed questionnaire (N=1321, 61%) rating four
validated domains of primary care (i.e., preference for
provider, communication, coordination, and accumulated
knowledge). For each domain, summary scores were
calculated and dichotomized into perfect score (i.e. maximum
score) versus other. Multiple logistic regressions were used to
estimate the probability of a perfect score in each domain
while controlling for patient characteristics and site.
Population Studied: Women Veterans
Principal Findings: Female provider was significantly
associated with perfect ratings for communication (OR 2.9,
95% CI 1.4, 5.8) and coordination (OR 3.7, 95% CI 1.5, 9.0).
Providing gynecological care among female providers was
significantly associated with an increased number of domains
with perfect ratings: preference for provider (OR 4.0, 95% CI
1.8, 8.7); communication (OR 2.7, 95% CI 1.3, 5.5); and
coordination (OR 2.7, 95% CI 1.1, 7.1). Patients who used a
women’s clinic and had a female provider who gave routine
gynecological care had perfect or nearly perfect ratings for
preference for provider (OR 4.7, 95% CI 2.3, 9.7),
communication (OR 2.7, 95% CI 1.7, 5.3), and accumulated
knowledge (OR 6.1, 95% CI 1.3, 28.5).
Conclusions: Provision of gynecologic services at the provider
or practice level is associated with improved patient ratings of
primary care separate from and in synergy with the effect of
female provider. Male and female providers should consider
offering routine gynecologic services or working in
coordination with a setting that provides gynecological
services. Health care evaluations should assess scope of
services for provider and practice.
Implications for Policy, Delivery, or Practice:
Comprehensive outpatient services are associated with higher
ratings of quality in primary care.
Primary Funding Source: VA
●Contrasting the Program Characteristics at Federally
Supported Comprehensive Women’s Health Centers
Bevanne Bean-Mayberry, M.D., MHS, Elizabeth Yano, Ph.D.,
Judith Navratil, BA, Nichole Bayliss, BA, Carol Weisman,
Ph.D., Sarah Scholle, DrPH
Presented By: Bevanne Bean-Mayberry, M.D., MHS,
Physician, Division of General Medicine, VA Pittsburgh/
University of Pittsburgh, University Drive C (151-C), Pittsburgh,
PA 15240; Tel: (412)688-6477; Fax: (412)688-6527; Email:
Bevanne.Bean-Mayberry@med.va.gov
Research Objective: Fragmentation of women’s health care
has stemmed from the separation of reproductive care needs
from general medical care. To promote the delivery of
comprehensive, integrated clinical care for women, the
Department of Health and Human Services (DHHS) Office of
Women’s Health launched the national Centers of Excellence
(CoE), while the VA initiated the Comprehensive Women’s
Health Centers (CWHC). The purpose of this study was to
compare the organization, staffing, practice setting, and
service availability at federally supported specialized women’s
health centers.
Study Design: 1) Data on the VA women’s health programs
were obtained from the VHA Survey of Women Veterans
Health Programs and Practices: Senior Clinician
Questionnaire. VA hospitals selected had either a CWHC
(n=8) or a VA –designated Clinical Center of Excellence in
Women’s Health (CCoE, n=4). 2) This VA tool was adapted
for use with clinical directors at DHHS CoEs in operation in
June 2003 (n=13). 3) Geographic data and academic affiliation
were abstracted from the 2001 American Hospital Association
hospital survey. Data were reviewed and entered into a
database to make descriptive comparisons.
Population Studied: Comprehensive outpatient women's
centers
Principal Findings: All VA and DHHS women’s health
programs were located in urban areas and nearly all had
academic partnerships, but DHHS sites had mean caseloads
that were triple VA caseloads. Women’s health fellowships
were common, and all offered educational training to
providers in women’s health topics. Preventive screening and
general reproductive services (e.g., STD treatment,
menopause management) were on site at nearly all facilities;
however, the DHHS sites offered more extensive reproductive
services (e.g., on site obstetrical and infertility services). The
VA sites were unique in mental health care with all offering
sexual trauma screening, trauma and rape crisis counseling,
and most with on-site mental health providers. Staff variations
followed these service differences with DHHS sites having
more gynecologists while VA’s had more psychiatrists.
Conclusions: Despite the separate history and development,
the VA and DHHS specialized women’s health programs
share similar organization, education, and clinical services.
The wide range of clinical services available demonstrates the
commitment to multidisciplinary care.
Implications for Policy, Delivery, or Practice: The presence
of these federally recognized centers with common structural
components presents an opportunity to create VA and non-VA
partnerships to evaluate quality of care for women nationally
and benchmark the findings in VA and community standards.
Primary Funding Source: Department of Health and Human
Services
●What Organizational Factors Support the Development
of Women's Health Clinics for Primary Care
Bevanne Bean-Mayberry, M.D., MHS, Cynthia D. Caffrey, MD,
Donna L. Washington, M.D., MPH, Lisa Altman, MD, Andrew
B. Lanto, MPH, Elizabeth M. Yano, PhD, MSPH
Presented By: Bevanne Bean-Mayberry, M.D., MHS,
Physician, Division of General Medicine, VA Pittsburgh/
University of Pittsburgh, University Drive C, Pittsburgh, PA
15240; Tel: (412)688-6477; Fax: (412)688-6527; Email:
Bevanne.Bean-Mayberry@med.va.gov
Research Objective: Within the Department of Veterans
Affairs (VA), there is ongoing debate about the best way to
organize care for women veterans. In response to a rapid
increase in the number of women veterans, many VA facilities
have developed women´s health clinics (WHC) that provide
primary care services. Other facilites deliver primary care to
male and female veterans in the same clinics. Our objective
was to examine health system organizational factors
associated with the development of separate VA Women´s
Health Clinics for primary care. Such information enables us
to understand which environments are conducive to the
development of women´s health clinic settings, which may be
more appropriate for both primary and gender-specific care in
the VA Healthcare System.
Study Design: A national, cross-sectional, survey was mailed
to primary care (PC) directors at each eligible VA facility.
Outpatient health care facilities were compared by
administrative patient data and by VA organizational
characteristics focused on leadership, staffing, training
programs, and affiliations. Each PC director was asked
whether their geographically distinct site of care had a
women´s health clinic (WHC) that delivered primary care.
Multiple logistic regressions were performed to determine the
independent factors associated with the development of a
separate VA WHC for primary care.
Principal Findings: VA facilities offering a separate WHC for
primary care were more likely to have (1) separate primary care
leadership (OR 4.0, 95% CI 1.6, 9.7) and (2) separate authority
to establish administrative PC procedures (OR 2.7, 95% CI 1.4,
5.1). Presence of other allied health staff within the primary
care program (e.g., dietitian and pharmacist) and the
presence of established primary group teams (organized
provider groups for outpatient clinic coverage) showed similar
trends for the development of WHC delivering primary care in
bivariate analyses but were not statistically significant in
multiple logistic regression.
Conclusions: Women´s health clinics that deliver primary
care to women veteran users of VA health care services have a
stronger likelihood of thriving in settings where the primary
care programs are independent and have well-organized
leadership with practice autonomy. Such findings may be
more influential than general female patient volume or
workload.
Implications for Policy, Delivery, or Practice: More research
and practice evaluations are needed to determine the quality
of care afforded to women who choose to attend these clinics
in contrast to general primary care clinics. Such information
will be crucial to designing effective primary care programs for
the rapidly growing female veteran population.
Primary Funding Source: VA
●Differential Effects of QI on Men’s and Women’s
Treatment for Depression
Chloe Bird, Ph.D., Cathy Sherbourne, Ph.D., Rob Weiss, Ph.D.,
Naihua Duan, Ph.D.
Presented By: Chloe Bird, Ph.D., Sociologist, Health Unit,
RAND, 1776 Main Street, PO Box 2138, Santa Monica, CA
90407-2138; Tel: (310)393 0411 x6260; Fax: (310) 260-8159;
Email: chloe@rand.org
Research Objective: To examine whether a quality
improvement (QI) program for depression care effectively
encourages treatment for both men and women, and whether
such interventions lead men and women into different types
of care.
Study Design: A group-level, randomized, controlled trial in
46 primary care practices within six managed care
organizations. Clinics were randomized to usual care or one of
two gender-neutral QI programs that supported QI teams and
provided resources to support medication management (QIMeds) or psychotherapy (QI-Therapy). We conducted intentto-treat analyses; patients were included in the analysis
according to their original assignment, irrespective of whether
or not they remained in the practice, and whether or not they
used intervention resources. Results are presented as odds
ratios comparing the interventions to usual care. We
compared changes in care for those in each treatment arm to
those receiving usual care.
Population Studied: 1,187 primary care patients who screened
positive for depression and completed at least one patient
assessment questionnaire administered at baseline or 6
months later.
Principal Findings: Change in receipt of appropriate care in
the QI-med intervention versus usual care was significant for
both men and women (OR= 2.9, CI 1.1-5.8 for men vs. OR=
2.6, CI 1.7-4.8 for women) and did not differ by gender.
However, QI-therapy improved utilization of appropriate care
for men (OR= 5.3, CI 2.2-12.7), but not for women (OR= 1.4, CI
0.9-2.3). Men benefited more than women (F/M OR= 0.3; CI
0.1-0.7), because for men QI-therapy was associated with
increased odds of utilizing 4 or more specialty mental health
visits (OR= 9.0, CI 3.7-21.7) and of receiving any appropriate
medication for at least two months (OR= 5.6, CI 2.2-14.1). For
women, QI-therapy was associated with increased odds of
having 4 or more specialty mental health visits (OR= 3.3, CI
2.0, 5.5), but not of receiving of appropriate medications (OR=
.9; CI 0.6-1.6). Women benefited more from QI-meds than
QI-therapy (OR= 2.1, CI 1.3-3.3) in terms of their odds of
receiving appropriate care. The interventions had similar
effects on men’s utilization of any antidepressant or specialty
mental health care (QI-meds vs. QI-therapy OR= 0.7, CI 0.31.6). For women, QI-Meds had a larger effect on receiving any
antidepressant or specialty mental health care (OR= 2.8, CI
1.8-4.4).
Conclusions: QI worked for both men and women. However,
men and women responded somewhat differently to the QI
interventions. Men in QI-therapy experienced increased odds
of receiving both types of care. Females in QI-therapy were
already receiving higher levels of medication than men at
baseline; QI-therapy brought men up to equivalent levels.
Implications for Policy, Delivery, or Practice: Although the
interventions studied here were not designed to serve men
and women differently, they shed light on an unexpected
opportunity to improve men’s quality of care for depression by
facilitating their access to mental health specialty care.
Strengthening QI interventions for both men and women is a
priority for future studies; our findings may afford some clues
as to what features may be useful in achieving these aims.
Primary Funding Source: NIMH
●What Women Want: Understanding Obesity and
Preferences for Primary Care Weight Reduction
Interventions among African American and Caucasian
Women
Carol Blixen, Ph.D., Anisha Singh, M.D., Holly Thacker, M.D.,
Meng Xu, MS, Edward Mascha, Ph.D.
Presented By: Carol Blixen, Ph.D., Associate Staff,
Biostatistics and Epidemiology-Wb-4, The Cleveland Clinic
Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; Tel:
(216) 444-6254; Fax: (216) 445-7659; Email: blixenc@ccf.org
Research Objective: Although African American (AA) women
have been shown to have similar weight loss practices as
Caucasian (C) women, C women have been more successful
than AA women in controlling their weight. However, no
studies have been conducted that compare preferences for
weight management interventions between AA and C women.
The objectives of this study were to explore attitudes and
perceptions of obesity, and identify the actual preferences for
weight management interventions by AA and C women in the
primary care setting.
Study Design: From the content areas identified from
separate focus groups of AA and C women with a BMI>30, we
developed and pre-tested an 18-item questionnaire. We then
used the multiple mailing method to send the questionnaires
to the study population. Descriptive statistics, including
means and standard deviations, medians, quartiles, percents,
and relevant confidence intervals, were used to describe the
variables. T-tests, or Wilcoxin rank sum tests, or Chi square
tests, were used to compare groups on outcomes, using a
significance level of 0.05.
Population Studied: 464 female patients 18 years and older,
with a diagnosis of obesity (ICD–9 code-278.00/278.01) who
were being followed in the General Internal Medicine
outpatient clinics of the Cleveland Clinic Foundation.
Principal Findings: The majority of the women 256 (55%)
who returned their questionnaires were primarily (138) AA and
C (91). AA women were more likely to be unmarried (65%.7%
vs 46.7%, P=0.003) than C women, and have a lower
socioeconomic status (P<0.001). Although AA women
weighed significantly more than C women (M=245.4; SD=58.6
vs 225.3; SD=51.8, P=0.008), C women expressed having a
lower self-esteem because of their weight than did AA women
((80.9% vs 65.7%, P=0.013). C women felt that past weight
loss efforts were helped by weight loss programs significantly
more than AA women (P< .001), but AA women were more
likely to feel that their cultural background contributed to their
weight gain than did C women (P=0.001 ). AA women
expressed a higher need for one-on-one counseling with their
physician (<0.001) as well as team meetings with the
dietician, physician, and other women (0.004) than did C
women. AA women also felt it was more important for weight
loss programs to have information on food common to their
culture than did C women (P<0.001).
Conclusions: Weight loss programs may be geared towards
the needs and preferences of the dominant society and,
therefore, may be less attractive or successful with those who
are not members of the majority
Implications for Policy, Delivery, or Practice: Differences in
cultural background and preferences about weight loss
interventions have important policy implications for how the
U.S. health system provides care to an ever increasing
multicultural population with a national epidemic such as
obesity. Primary care physicians should recognize that people
use the categories and rules of their specific cultures and
ethnic groups to frame what they consider to be acceptable
and preferable foods and use this information to develop
culturally appropriate weight loss menus. In addition, AA
women may benefit from shared medical visits with other AA
women, that focus on weight loss interventions in a group
setting.
Primary Funding Source: Cleveland Clinic Foundation
●Women Veterans’ Satisfaction with VA Hospitalization
Carron Cherrie, Ph.D., Skai Schwartz, Ph.D., Leigh Mathias,
MPH, Margaret Mikelonis, MS, Toni Lawrie, MS
Presented By: Carron Cherrie, Ph.D., Project Manager,
Nursing Research, VHA, 11605 North Nebraska Avenue,
Tampa, FL 33612; Tel: (813) 903-2416; Fax: (813) 558-3994;
Email: Carron.cherrie@med.va.gov
Research Objective: Background: As women make up just
6.5% of the VA population, few studies have examined their
satisfaction with hospitalization. This study examines
correlates of women’s satisfaction with VA hospitalization.
Study Design: Design: A cross sectional mailed survey.
Participants: All women hospitalized during a four-month
period in 2003 and 2004 in six VA medical centers were
included. Measures: Overall satisfaction was comprised of
three questions from the Women Veterans Inpatient
Satisfaction Survey pertaining to overall rating of quality of
care, complaints and their choice to return for care.
Methods: ANOVA models were used to determine the
association of each of 42 potential reasons for dissatisfaction
with the overall satisfaction score. A step-wise selection
procedure was used after adjustment for age group,
education, self-rated health and hospital unit.
Population Studied: All women discharged from inpatient
units of six facilities between February 1, 2003 and August 31,
2003 [N=634] or between February 2, 2004 and June 2, 2004
[N=566] were included.
Principal Findings: Results: Forty-nine percent of women
had the highest possible score on overall satisfaction.
Analysis of baseline and hospital characteristics indicated that
younger women, women with graduate degrees, women in
poorer health and women in psychiatric units tended to be
less satisfied with hospital care. After adjusting for these
characteristics 39 of the 41 questions related to specific
reasons for dissatisfaction were strongly associated (p<0.001
for each) with the overall satisfaction score. Questions
remaining highly significant after stepwise selection included
not having one doctor, providers contradicting each other,
feeling like a second class citizen and poor courtesy of nurses.
Conclusions: Most women are satisfied with hospital care;
possible areas for improvement may include identification of
one doctor in charge, better provider communication and
more respect for the patients.
Implications for Policy, Delivery, or Practice: The VISN 8
women veterans’ workgroup submits recommendations for
changes in policy to the Executive Leadership Board Health
Systems Committee. This streamlined communication
process has facilitated approval of changes needed in
women’s health care. The annual satisfaction survey has
provided a quality assurance tool that evaluates both
strengths and weaknesses in service provision, provides time
trending and promotes customer participation in shaping
service delivery. Nursing care on inpatient units has
improved as a result. One example of positive change
resulting from implementation of survey recommendations is
sensitivity training for nursing staff to improve courtesy and
respect for patients. Subsequent to the nurse sensitivity
training patient satisfaction ratings for these indicators
improved.
Primary Funding Source: VISN 8
●Rurality, Gender and Disparities in Mental Health
Treatment
Emily Hauenstein, Ph.D., LCP, APRN, BC, Stephen Petterson,
Ph.D., Douglas Wagner, Ph.D., Virginia Rovnyak, Ph.D.,
Elizabeth Merwin, Ph.D., MSN, Barbara Heise, MSN, NP
Presented By: Emily Hauenstein, Ph.D., LCP, APRN, BC,
Associate Professor, School of Nursing, University of Virginia,
Box 800782, Charlottesville, VA 22908; Tel: (434)924-0093;
Fax: 434-982-1809; Email: ejh7m@virginia.edu
Research Objective: To assess urban-rural and gender
differences in mental health treatment rates and pathways to
care among non-elderly adults using a refined measure of
rurality.
Study Design: We use data from the Medical Expenditure
Panel Survey (MEPS) to examine the relationship between
rurality, gender, and mental health treatment. Three calendar
year measures of mental health treatment are examined: any
medical visit related to a mental health condition, the number
of those visits and any specialized mental health care visit. We
use the Urban-Rural Continuum as an ordinal measure of
rurality, which classifies metropolitan counties on the basis of
the size of the metropolitan area and nonmetropolitan
counties on the basis of their urbanization and their adjacency
to metropolitan areas. We also assess the sensitivity of core
findings to confounding by a number of explanatory factors
using logistic and linear regression. The explanatory factors
include self-perceived mental health status and physical health
status, income-to-needs, insurance status, region, age, race,
ethnicity and marital status.
Population Studied: The sample consists of adults aged 18 to
64 in the first four panels MEPS, covering a period from 1996
to 2000. The MEPS is a large nationally representative panel
survey of households designed to provide estimates of the use
of health services, medical expenditures and sources of
payment. The sample size is 33,090. Of these respondents,
approximately 3% reside in the two most rural types of
counties on the urban-rural continuum.
Principal Findings: Rural men and women report poorer
mental health than do urban dwellers. Despite this, they
receive less treatment than do urban men and women. Only
6.2% of rural women received mental health visits while 5.4%
of rural men received mental health visits. Urban women are
more likely to receive a mental health visit (10.3%) than urban
men (5.9%). Marital disruption is a particular salient
determinant of mental health treatment for rural women.
Among rural men, higher income is strongly associated with
mental health treatment.
Conclusions: Rural men and women receive substantially less
mental health care than urban women, despite greater needs.
Implications for Policy, Delivery, or Practice: Both men and
women living in rural counties may have unique problems that
put them at greater risk for mental health problems.
Inadequate services and mental health delivery mechanisms
may heighten that risk by reducing overall access to treatment.
Primary Funding Source: National Institute of Mental Health
●Are Women's Pregnancy Intentions Associated With
Health Care Access?
Marianne Hillemeier, Ph.D., MPH, Carol S. Weisman, Ph.D.
Presented By: Marianne Hillemeier, Ph.D., MPH, Assistant
Professor, Health Policy and Administration, The Pennsylvania
State University, 116 Henderson, University Park, PA 16802;
Tel: (814)863-0873; Fax: (814)863-2905; Email:
mmh18@psu.edu
Research Objective: Women’s health status prior to
pregnancy is likely to influence their subsequent risk of
experiencing pregnancy complications and adverse birth
outcomes including preterm birth and low birthweight.
Because high quality health care can play a key role in
promoting optimal health and well-being, the degree to which
preconceptional women have access to such services is of
considerable interest. The objective of this study is to
determine whether women who intend to become pregnant
differ from those who do not in their access to health care.
Study Design: A telephone survey using random-digit dialing
was administered to a representative sample of 2,000
reproductive aged women ages 18-45. The survey asked about
the following reproduction-related and health care access
information: 1) pregnancy history; 2) contraceptive use; 3)
intent to become pregnant within the next year, at some other
time in the future, or not at all; 4) whether respondent had a
usual source of care and type of provider; 5) health insurance
status; 6) visits to provider and health services received in
previous 12 months; and 7) perceived obstacles to obtaining
health care. Information was also collected related to
socioeconomic status and county of residence, which allowed
linkage to county-level information about the availability of
health care providers and facilities.
Population Studied: The study population includes women
living in a 28 county region of central Pennsylvania. This
region includes a large and predominantly white rural
population, and includes 15 counties that are primarily or
entirely rural. There are also several metropolitan areas in the
region, in which sizable African American and Latina
populations reside. The study region is relatively
disadvantaged in terms of health care resources, with only 8
counties having hospitals that offer both obstetric and
neonatal intensive care services, and 6 rural counties in the
region lacking hospitals with either type of service.
Principal Findings: About one in five reproductive-aged
women in our sample reported being uninsured at some time
during the previous year, and 6% lacked a usual source of
health care. Access to care measures varied among groups of
women with different pregnancy intention. The most favorable
access measures were seen among women not planning to
become pregnant who were, for example, least likely to have
been uninsured and more likely to have a usual source of care.
In contrast, women who were planning to become pregnant
either in the next year or at some other time in the future were
at higher risk of being uninsured and lacking a usual source of
care.
Conclusions: Women who plan to become pregnant have
disproportionately poorer access to health care than other
reproductive-aged women.
Implications for Policy, Delivery, or Practice: Because poor
preconceptional health status may precipitate adverse
pregnancy and birth outcomes, increasing access to health
care for reproductive-aged women at risk for pregnancy should
be a priority.
Primary Funding Source: Pennsylvania Deptartment of
Health
●Maternal Morbidity Rates in a Managed Care Population
Mark C. Hornbrook, Ph.D., Cynthia Berg, M.D., MPH, Evelyn
Whitlock, M.D., MPH, William Callaghan, M.D., MPH, Carol
Bruce, MPH, Patricia Dietz, DrPH, MPH, Rachel Gold, Ph.D.,
MPH
Presented By: Mark C. Hornbrook, Ph.D., Chief Scientist,
Center for Health Research, Kaiser Permanente Northwest,
3800 North Interstate Avenue, Portland, OR 97227-1110; Tel:
(503) 335-6746; Fax: (503) 335-2228; Email:
mark.c.hornbrook@kpchr.org
Research Objective: To assess the prevalence of pregnancyrelated morbidity in a large community-based population of
pregnant women enrolled in an integrated health care delivery
system. Most research on maternal and child health has
focused on the health of fetuses and newborns, while few
researchers have studied the health of pregnant women.
Study Design: To ascertain pregnancies in automated
encounter and clinical data systems, we developed a
computerized episode algorithm to identify pregnancy begin
and end dates, pregnancy outcome, duration of gestation, and
number of fetuses. Compared to medical records, the
algorithm identifies 96 percent of pregnancy episodes. We
used ICD-9-CM codes to develop a list of 46 major disease
classes that encompass complications directly and indirectly
related to pregnancy. The denominator for pregnancy-related
morbidity prevalence rates is the number of pregnancies
among women of childbearing age in our study population.
Population Studied: Among members of Kaiser Permanente
Northwest, a prepaid group practice HMO with about 455,000
members, the algorithm searched for evidence of pregnancy
episodes for all women of childbearing age, 12 to 55 years old,
who were KPNW members for at least 42 continuous days at
any time during the study period, January 1, 1998, through
December 31, 2001. We included only those episodes fully
contained within the study period and the mother’s health
plan eligibility period.
Principal Findings: Prevalence rates of maternal morbidity
ranged from 9 percent for anemia and urinary tract infection
to less than 1 percent for tuberculosis. The six most common
maternal health problems are anemia, 9.3 percent; urinary
tract infections, 9.0 percent; mental health conditions, 9.0
percent; pelvic and/or perineal complications, 7.0 percent;
postpartum hemorrhage, 3.8 percent; and asthma, 3.8 percent.
Other health problems with less clear relationships to
pregnancy included upper respiratory infections, 19.0 percent,
and back disorders, 9.8 percent. Out of 24,680 pregnancies,
17 percent ended in therapeutic abortions and 12.5 percent in
spontaneous abortions. Over 67.0 percent of pregnancies
ended in live births. Ectopic pregnancies accounted for 1.3
percent of episodes, stillbirths accounted for 0.4 percent, and
trophoblastic disease accounted for 0.1 percent.
Conclusions: Pregnant women experience a variety of mild to
severe health problems. Assuring early diagnosis and high
quality intervention for pregnancy-related health problems
should lead to better outcomes for both mothers and babies.
Implications for Policy, Delivery, or Practice: Using
computerized administrative and clinical data to
retrospectively identify the beginning and end of pregnancy
regardless of pregnancy outcome allows for defining a window
to explore maternal pregnancy complications. Understanding
these complications may facilitate design and improvement of
obstetrical care in health care systems. While more than six
million women in the US become pregnant each year, efforts
to assess the extent and nature of morbidities experienced
during pregnancy have been limited to analyzing
hospitalization data. These shortcomings are salient because
recent changes in medical practice have resulted in increased
treatment and better outcomes for maternal complications in
outpatient settings. A pregnancy episode framework is
needed to measure morbidity profiles in the prepartum,
intrapartum, and postpartum phases.
Primary Funding Source: CDC
●Predictors of Breast Cancer Screening in African
American and White Women
Amal Khoury, Ph.D., MPH, Nedra Lisovicz, Ph.D., MPH,
Amanda Avis, MPH
Presented By: Amal Khoury, Ph.D., MPH, Associate
Professor, Health Services Research, Management & Policy,
University of Florida, PO Box 100195, Gainesville, FL 32610;
Tel: (352)273-6079; Email: akhoury@phhp.ufl.edu
Research Objective: Breast cancer is a leading cause of death
for American women. Breast cancer mortality rates have
decreased in recent years for the population overall. However,
disparities exist among subgroups of women. Specifically,
African American women are more likely to die from breast
cancer than White women, in part because they have lower
screening rates and therefore later stage at diagnosis. The
objective of this study is to examine factors associated with
mammography screening among African American and
White, non-Hispanic women in the south.
Study Design: We conducted a cross-sectional telephone
survey of a representative sample of households in the state of
Mississippi with at least one woman 40 years of age and
older. Computer-assisted telephone interviewing (CATI) was
used. The survey was developed and then pilot tested with a
sample of 30 women. An extensive literature review
established face validity of the questionnaire. Content validity
was established by breast cancer experts. Social cognitive
theory was used to guide the analysis. The outcome variable
was the proportion of women who reported getting a
screening mammogram within one year preceding the survey
(for women 50+) and withing the past two years (for women
40 to 49 years of age). Explanatory variables included
personal factors (knowledge, attitudes, self-efficacy,
perceptions of screening and treatment) and environmental
factors (having a usual source of care, perceptions of the
healthcare system, social norm). Sociodemographic
characteristics were controlled for. Two regression models,
one for African American and one for White women, were
developed.
Population Studied: African American and White, nonHispanic women 40 years of age and older in the state of
Mississippi. The final sample included 299 African American
and 728 White women for a total sample of $1,027 women.
The response rate exceeded 60 percent.
Principal Findings: Among women 50+, 68 percent reported
getting a screening mammogram in the year preceding the
survey. White women appeared more knowledgeable about
risk factors and signs and symptoms of the disease. Overall,
no differences between the two groups emerged in their
awareness of the benefits of screening. Many respondents had
negative perceptions of the healthcare system: 62% believed
that rich people received better medical care than poor people,
and 77% believed that health insurance affected the kind of
care that a person received. Also, 44% agreed that hospitals
sometimes do not tell patients the truth. Perceptions of
racism in healthcare delviery were also assessed and varied by
group. The regression analyses are underway to determine to
factors associated with screening behavior at the multivariate
level.
Conclusions: A significant proportion of Mississippian
women are not receving screening mammograms according
to the national guidelines. Both personal and environmental
factors contribute to this problem.
Implications for Policy, Delivery, or Practice: Although
breast cancer screening rates have increased in recent years
and the disparity in screening rates between subgroups of
women has narrowed, there is room for further increasing the
rates overall and closing the gap between African American
and White women. This study results will provide useful
information for developing behavioral and healthcare system
interventions to achieve this goal.
Primary Funding Source: Susan G Komen Breast Cancer
Foundation
●Gender Differences in Healthcare Utilization and
Expenditures Associated With Chronic Conditions
Kristen Kjerulff, Ph.D., Carol S. Weisman, Ph.D., Kevin D.
Frick, Ph.D., Jeffrey A. Rhoades, Ph.D., Anne-Marie Dyer, MS
Presented By: Kristen Kjerulff, Ph.D., Associate Professor,
Health Evaluation Sciences, Penn State College of Medicine,
600 Centerview Drive, Hershey, PA 17033-0855; Tel: (717)5311258; Fax: (717)531-0839; Email: kkjerulf@hes.hmc.psu.edu
Research Objective: To investigate gender differences in
healthcare utilization and expenditures associated with the
presence of one or more chronic conditions among American
men and women and to assess the impact of health
insurance, income, age, race and health status on these
factors.
Study Design: Estimates were derived from the 2001 Medical
Expenditure Panel Survey (MEPS), a representative national
survey of 33,556 non-institutionalized individuals. Weights
were used to estimate the number of men and women aged
20 and older who had 1 or more chronic conditions, the
number of ambulatory care visits, prescription medications
filled, emergency room visits and hospital stays associated
with these disorders; the associated expenditures for each type
of utilization and overall. We used multiple and logistic
regression equations to estimate the effects of health
insurance, income, race and health status on these factors,
controlling for age and sex-specific conditions (such as
prostate cancer or breast cancer).
Population Studied: This study included all males (n =
10,573) and females (n = 12,105) aged 20 and older who
participated in the 2001 MEPS.
Principal Findings: 60.7% of females and 48.1% of males
aged 20 and older had one or more chronic conditions in
2001, and 25.11% of females and 4.24% of males reported
having a sex-specific condition. The most common chronic
conditions for females were pulmonary diseases (25.5%),
hypertension (20.0%)and mental disorders (18.6%), while for
males the most common chronic conditions were pulmonary
diseases (16.8%), hypertension (16.4%) and joint disorders
(10.6%). Women had an average of 1.35 chronic conditions,
while men had an average of 0.94 chronic conditions. The
average overall medical expenditures among women with 1 or
more chronic conditions was $4,694.45, the largest
component of which was ambulatory care (30.4%). For men
with 1 or more chronic conditions, the average overall
expenditure was $4,707.52, the largest component of which
was in-patient care (35.19%). Multiple regression indicated
that even after controlling for age, race, number of chronic
conditions, sex-specific conditions, health insurance coverage
and health status, total medical expenditures were higher for
American women than men.
Conclusions: American women are more likely than American
men to report having both chronic and sex-specific conditions
and have higher rates of healthcare utilization and
expenditures associated with these conditions. However,
women with chronic conditions are more likely to use
ambulatory care and less likely to be hospitalized than men
with chronic conditions.
Implications for Policy, Delivery, or Practice: It's important
that projections of future patterns of healthcare utilization take
into account the higher rates of chronic as well as sex-specific
conditions among American women in comparison to men,
and higher rates of heathcare utilization, particularly in terms
of ambulatory care.
Primary Funding Source: AHRQ
●Depression & Diabetes: Sex Differences
Cheryl Laskowski, DNS, APRN-BC, Benjamin Littenberg, M.D.
Presented By: Cheryl Laskowski, DNS, APRN-BC, Assistant
Professor, Department of Nursing, University of Vermont,
Rowell Room 202, 106 Carrigan Drive, Burlington, VT 05401;
Tel: (802)656-0229; Fax: (802)656-8306; Email:
cheryl.laskowski@uvm.edu
Research Objective: To explore the association between
depression and glycemic control in patients with diabetes.
Study Design: Cross-sectional survey. Depression was
measured by the Patient Health Questionnaire-9 (PHQ), a
validated measure of the presence and severity of depression
in primary care. Diabetic control was measured by serum A1C.
We used linear regression to control for age, education,
marital status, duration of diabetes, and antidepressant use.
Population Studied: 333 adults (182 women and 151 men)
enrolled in the Vermont Diabetes Information System. All
subjects were receiving outpatient services in Primary Care
settings in Vermont or adjoining states and had been
diagnosed with diabetes by their Primary Care Provider.
Principal Findings: The mean A1C was 7.23% (median 7; IQR
6.3, 7.9). The mean PHQ score was 3.8 (median 2; InterQuartile Range 0, 5). 68% of subjects had no or minimal
findings of depression (PHQ<5; mean A1C 7.15%) 22% were
mildly depressed (PHQ 5-9; A1C 7.29%). 11% were moderately
or severely depressed (PHQ>9; A1C 7.60%). Neither PHQ nor
A1C varied significantly by sex. PHQ was directly associated
with A1C by simple linear regression without adjustment
(coefficient = +0.036; 95% CI +0.006, +0.065; P=0.015).
Exploratory analyses revealed that sex was an important
modifier of this relationship. In linear regressions controlling
for age, education, marital status, duration of diabetes, and
antidepressant use, PHQ was independently associated with
A1C in men (0.059; CI +0.008, +0.109; P=0.023) but not
women (-0.010; CI -0.051, +0.031; P=0.62). The results were
similar using other markers of depression such as self-report.
Conclusions: In our study, a 5 point difference in PHQ scores
(about one severity category) was associated with a clinically
important 0.29% difference in A1C in men. No such
relationship was observed in women. Possible explanations
for these findings include differential measurement of
depression in men and women (instrument bias),
unmeasured confounders, or intrinsic psychological or
biologic sex differences. The causal direction of the
relationship between depression and diabetes, if any, is
unclear.
Implications for Policy, Delivery, or Practice: Depression is
common in people with diabetes. The degree of depression
appears to be related to glycemic control in men. Further
research is required to examine whether treatment of
depression alters glycemic control (or vice versa) in men or
women.
Primary Funding Source: NIDDK
●National Patterns of Medication Use during Pregnancy
Euni Lee, Pharm.D., Ph.D., Sheila R. Weiss, Ph.D., Leah Smith,
Mary Maneno, Anthony K. Wutoh, Ph.D., Ilene H. Zuckerman,
Pharm.D.
Presented By: Euni Lee, Pharm.D., Ph.D., Assistant Professor,
Clinical and Administrative Pharmacy Science, Howard
University, 2300 4th Street NW, Washington, DC 20059; Tel:
(202)806-4919; Fax: (202)806-4478; Email:
eunlee@howard.edu
Research Objective: To estimate and compare the national
prevalence of medication use during pregnancy in two
ambulatory care settings (i.e., office-based vs. hospital
outpatient department) and to describe the use by therapeutic
drug class, and the Food and Drug Administration (FDA)
pregnancy risk category.
Study Design: Cross-sectional analysis of the 1999 and 2000
National Ambulatory Medical Care Survey (NAMCS) and
National Hospital Ambulatory Medical Care Survey
(NHAMCS)
Population Studied: Visits to office-based physicians and
hospital ambulatory care clinics by pregnant women
Principal Findings: In 1999 and 2000, pregnant women
made a total of 54.5 million (95% CI 49.3-58.9) and 8.6 million
(95% CI 7.9-9.3 million) visits to private- and hospital-based
ambulatory clinics, respectively. The mean age was 27.7 (SD
10.4) years and 25.4 (SD 11.4) years and most visits were
made by women of white race (84% in private vs. 67% in
hospital setting). Paytypes varied by setting with public
insurance more prevalent in the hospital setting. In addition,
visits that were associated with complications of pregnancy
were more prevalent in the hospital setting. One half of all
pregnant visits were recorded with one or more medications.
The prevalence was higher in the hospital care setting (44%
vs. 54%). Other than vitamins or mineral supplements, top
drug classes were medications for anemia and blood glucose
regulators. However, antiasthmatics and diagnostic agents
were more prevalent in the hospital care setting and
antimicrobial agents were more prevalent in the private care
setting. When prescribed medications were classified by the
FDA pregnancy risk category according to drug information
references, approximately one half of all prescriptions were
from FDA class A (47.5% in private vs 54.2% in hospital
setting) followed by class C (22.2% in private vs 28.1% in
hospital setting). Of all the medications that were prescribed
to pregnant women, drugs classified as Class D/X accounted
for 5.0% of prescriptions in the private and 2.1% in the
hospital setting.(p<0.001) A list of the drugs from Class X
include estrogens, medroxyprogesterone, warfarin,
methotrexate, triazolam, and simvastatin. Logistic regression
analysis adjusted by other visit characteristics showed no
difference in patterns of prescribing drugs with pregnancy risk
of Class D/ X by the care setting.
Conclusions: Many pregnant women require drug therapy
because of pregnancy-induced, chronic, or acute conditions.
Our findings show that in one half of all visits made by
pregnant women one or more medications were prescribed.
Although visit characteristics and patterns of prevalent drug
forms were different between private- and hospital-based
ambulatory care settings, quality of care measured by
prescriptions with the FDA high risk drugs was not different
between these settings.
Implications for Policy, Delivery, or Practice: Drug use in
pregnancy has been an importance issue among health care
providers. Few data have been available to provide insight of
prevalence of medication use among pregnant women in
ambulatory care setting. Clear understanding regarding the
effects of those medications on fetal development is required
and appropriate team efforts are needed to choose
medications with less risk during pregnancy.
Primary Funding Source: Funds for Academic Excellence,
Howard University
●The Postpartum Health of Employed Mothers
Patricia McGovern, Ph.D., MPH, RN, Bryan Dowd, Ph.D.,
Dwenda Gjerdingen, M.D., MS, Cindy Gross, Ph.D., Todd
Rockwood, Ph.D., Sally Kenney, Ph.D., Laurie Ukestad, MS
Presented By: Patricia McGovern, Ph.D., MPH, RN, Associate
Professor, School of Public Health, University of MN, Mayo
Building, MMC 807, 420 Delaware Street SE, Minneapolis,
MN 55455; Tel: (612)625-7429; Fax: (612)626-4837; Email:
pmcg@umn.edu
Research Objective: To evaluate the effects of personal,
family and employment factors on health at six weeks
postpartum.
Study Design: This study employs a hybrid model of health
and workforce participation and a prospective cohort design
to estimate a production function for maternal health. The
woman’s health is measured at six weeks after childbirth as a
function of personal, family and employment characteristics
and choice variables. Women were recruited into the study
while hospitalized for childbirth. Data were abstracted from
hospital records; women were interviewed in-person at
enrollment and by-telephone at six weeks postpartum. TwoStage Least Squares (2SLS) was used to estimate the effects
of explanatory variables on maternal postpartum health.
Women’s health outcomes were measured with the SF-12 to
assess general mental and physical health and with a
symptom list developed by the investigators.
Population Studied: The population included all women 18
years of age and older, residing in the Twin Cities, Minnesota
admitted to the hospital and giving birth in 2001. Women
were enrolled from three hospitals where the demographics of
the birth mothers were consistent with the population. Sample
selection criteria included: having had a live birth of a
singleton infant with no serious complications, being 18 years
or older, and employed before childbirth.
Principal Findings: At 6 weeks postpartum, 716 women (88%
of enrollees) were employed and completed an interview. On
average, women were 30 years old; 86% were Caucasian, 73%
were married, 47% were first time mothers, 7% had returned
to work, and 67% were breastfeeding. On the SF-12,
postpartum women scored 51.4 (SD:7.2)on the Physical
Component Summary (PCS) score (national
norm:52.7;SD:9.1), and 49.4 (SD:7.6)on the Mental
Component Summary (MCS) score (national norm:
47.2;SD:12.1). Postpartum women scored slightly lower on
physical health and slightly higher on mental health than
national (non-postpartum) norms with significant differences
on z-scores. On average, women reported 6 postpartum
symptoms (SD:3.5). The most frequent symptoms reported
were breast symptoms(69%), fatigue (64%), decreased desire
for sex (52%), headaches(50%)and back or neck pain (45%).
Outcomes measures of maternal health included general
physical health (PCS), general mental health (MCS) and the
number of postpartum symptoms. Multivariate analyses using
2SLS revealed factors associated with better postpartum
health on one or more of outcome measures including better
pre-pregnancy health, better prenatal moods, greater
perceived control, a blue collar/service occupation (vs.
professional), more prenatal workplace support, vaginal (vs.
C-section) delivery, increased social support, having a girl
baby, and not breastfeeding.
Conclusions: These mothers continue to experience several
childbirth-related symptoms at six weeks after delivery
indicating a need for ongoing rest and recovery. Issues for
health care providers to consider include counseling women
on expected symptoms, functional limitations and appropriate
length of Family and Medical Leave in association with
delivery type and breastfeeding status and teaching women to
ask for support.
Implications for Policy, Delivery, or Practice: Women
experiencing a greater number of symptoms or poorer
postpartum health may need physician authorization for use
of intermittent rather than straight-time leave from work under
the federal Family and Medical Leave Act.
Primary Funding Source: National Institute for Occupational
Health and Safety
●Women in the Veterans Health Administration: Medical
Conditions, Utilization and Costs of Care
Ciaran Phibbs, Ph.D., Susan Frayne, M.D., MPH, Wei Yu,
Ph.D., Elizabeth Yano, PhD, Lakshmi Ananth, MS, Samina
Iqbal, M.D., Ann Thrailkill, RPN, MSN, CNS
Presented By: Ciaran Phibbs, Ph.D., Health Economist,
Health Economics Resource Center (152), VA Palo Alto Health
Care System, 795 Willow Road, Menlo Park, CA 94025; Tel:
(650) 493-5000 x22813; Fax: (650) 617-2639; Email:
cphibbs@stanford.edu
Research Objective: Historically, men have constituted the
vast majority of Veterans Health Administration (VA) patients.
With growing numbers of women veterans receiving care in
VA, a systematic assessment of their medical profile was
needed to guide innovations in VA’s approach to women’s
health care. This study examined disease burden, utilization
and costs of VA care differ in women veterans, compared to
male veteran VA patients.
Study Design: Cross-sectional study using fiscal year 2002
centralized VA administrative and clinical files. Patients with
missing gender, age, veterans status, or costs of care were
excluded. A modified version of AHRQ’s Clinical
Classifications Software was used to describe the clinical
conditions of patients. Descriptive statistics were used to
compare patients by gender and veterans status. Logistic
regressions were used to estimate the age-adjusted odds
ratios (OR) of the clinical conditions in women veterans
versus male veterans. Mean health care utilization and costs
were compared by gender and the presence and absence of
medical and mental health conditions. Linear regression was
used to compare differences in utilization and costs by
gender, controlling for age and clinical conditions.
Population Studied: All (N=4,444,577) users of VA care in FY
2002. The main analyses focused on the 178,463 women
veterans and 3,940,148 male veterans who used VA care. We
also characterized the non-veteran women (N=185,040).
Principal Findings: Half of the women who received VA care
were not veterans, compared to only 3% of males. Among
veterans, women were younger, less likely to be married, and
more likely to have a service-connected disability. Chronic
conditions were common in both men and women veterans
with some differences in prevalence. Several conditions were
more common in women than in men, most notably
osteoporosis (age-adjusted OR 13.6). Mean total annual
outpatient encounters per patient was 16.9 for veteran women
and 15.1 for veteran men. Mean total annual inpatient days
per patient was 1.9 days for women veterans and 2.5 days for
male veterans. Mean total annual cost per patient was $3,941
for veteran women and $4,446 for veteran men. Adjusting
for age and medical conditions, women veterans had 1% more
outpatient encounters, 11% fewer inpatient days, and 3% less
total cost. Among veterans with both medical and mental
health conditions, women used outpatient services more
heavily.
Conclusions: There are substantial gender differences in the
patients receiving VA care. But, after accounting for
differences in age and clinical conditions, the VA costs and
utilization are similar across genders. Researchers using VA
data need to be careful about non-veterans in the data,
especially among women.
Implications for Policy, Delivery, or Practice: VA’s efforts to
build capacity for the growing women veteran population
must account for the spectrum of medical conditions seen in
this special population, which cross the life span and include
both gender-specific and gender-neutral diseases. To meet
the needs of the subset of women veterans with comorbid
medical and mental health conditions, who represent high
intensity users of outpatient services, delivery systems
integrating ambulatory medical and mental health care
deserve attention.
Primary Funding Source: VA
●Veteran and Non-Veteran Health Care System Use and
Diabetes Care Among Women Veterans
Usha Sambamoorthi, Ph.D., Patricia Findley, DrPH, MSW,
Wenhui Wei, Ph.D.
Presented By: Usha Sambamoorthi, Ph.D., Health Scientist,
Health Care Knowledge and Management, Veteran Affairs NJ
Health Care System, 385 Tremont Avenue, East Orange, NJ
07018; Tel: (973)676-1000 x1512; Fax: (973) 395-7111; Email:
ushasambamoorthi@gmail.com
Research Objective: This paper describes women who use
Veteran Health Administration (VHA) services and compares
them to those who use other health systems, examining the
impact of VHA system use on utilization of services for
diabetes care among veteran women with diabetes.
Study Design: Cross-sectional data from the 2003 Behavioral
Risk Factor Surveillance Survey were used. Women veterans
were identified through a self-reported question on veteran
status. We measured quality of care by the total number of
completed diabetes process of care measures. Chi-square
techniques and mutivariate regressions were used.
Population Studied: Veteran women aged 21 and over and
not in active military duty (n = 2,494) were included.
Principal Findings: Overall, 17% veteran women received
either all or some of their health care from VHA facilities.
Women who were full VHA users were less likely to be college
educated, insured, or healthy. Nearly 7% (n = 194) of veteran
women reported physician-diagnosed diabetes. Despite the
fact that disadvantaged women were more likely to use VHA
services, of those with diabetes, we found those who received
all of their health care from the VHA had similar quality of
diabetes care and women who sometimes use the VHA were
had higher quality of diabetes care, even after adjusting for
relevant covariates.
Conclusions: Our study highlights underutilization of the
VHA by women veterans. Despite the fact that the more
vulnerable subgroup of veteran women must rely on the VHA,
women veterans get a similar or higher quality of care than the
veteran women who do not use VHA care.
Implications for Policy, Delivery, or Practice: Known for its
overlapping medical, educational, and social missions, the VA
is able to provide comprehensive and integrated services.
Women who had poor access defined by having a cost barrier
to care need special attention to improve their completed
diabetes care measures.
Primary Funding Source: No Funding Source
●Gender Discrepancies in Level of Disease Progression for
Diabetic Patients
Jay Shen, Ph.D, Elmer L. Washington, M.D., MPH
Presented By: Jay Shen, Ph.D., University Professor, Health
Administration, Governors State University, One University
Parkway, University Park, IL 60423; Tel: (708)235-2131; Fax:
(708) 534-8041; Email: j-shen@govst.edu
Research Objective: To assess gender differences in level of
progression of diabetes at the point of hospitalization.
Study Design: We categorized causes of hospitalization into
three tiers. Tier 1 represented those causes being unrelated to
diabetes and would be expected to be present in equivalent
frequencies among diabetics and non-diabetics. Tier 2
represented those causes (e.g., heart disease, ischemic stroke,
pneumonia) of hospitalization for which diabetes is a
significant risk factor, and if controlled, would be expected to
lower the risk of hospitalization associated with the condition.
Tier 3 represented those causes (e.g., diabetic ketoacidosis,
diabetic retinopathy, gangrene due to peripheral vascular
disease, nonketotic coma, and renal failure caused by
Kimmelstein-Wilson related glomerulosclerosis) of
hospitalization that never occur in the absence of diabetes.
Covariates such as age, race, insurance status, income level,
region of residence, and hospital characteristics were
controlled in multivariate analyses.
Population Studied: 650,735 adults (54% females and 46%
males) with type 2 diabetes as principle or secondary
diagnosis identified from the 2001 National Inpatient Sample.
Principal Findings: 58.3% of females and 52.1% of males
belonged to Tier 1, 26.3% of females and 31.7% of males
belonged to Tier 2, and 4.2% of females and 5.0% of males
belonged to Tier 3. All differences were statistically significant.
As compared to females, males were less likely to be admitted
as Tier 1 patients (odds ratio (OR), 0.77, [95% confidence
interval (CI)], [0.76, 0.78]), but more likely to be admitted as
either Tier 2 patients (OR [CI], 1.27 [1.26, 1.29]) or Tier 3
patients (OR [CI], 1.24 [1.21, 1.28]).
Conclusions: Male patients with diabetes were more likely to
be admitted with clinical conditions consistent with a long
term history of poor control. This is consistent with well
established differences in care seeking behavior by gender.
Implications for Policy, Delivery, or Practice: Historical,
social, and behavioral factors contributing to relatively lower
levels of care seeking behavior among males need to be
addressed in order to improve diabetes control and reduce
risk of related diseases and complications among the male
diabetic population.
Primary Funding Source: GSU Fund
●Social Support as an Explanation for Differential Effects
of a Quality Improvement Program for Men and Women
Cathy Sherbourne, Ph.D., Chloe Bird, Ph.D., Robert Weiss,
Ph.D., Naihua Duan, Ph.D.
Presented By: Cathy Sherbourne, Ph.D., Senior Health Policy
Analyst, Health, RAND, 1776 Main St. PO Box 2138, Santa
Monica, CA 90407-2138; Tel: (310) 393-0411 ext. 7216; Fax:
(310) 260-8150; Email: Cathy_Sherbourne@rand.org
Research Objective: Gender differences in the impact of
primary care quality improvement (QI) programs have been
infrequently studied. We found that two gender-neutral QI
programs, one that facilitated access to medication
management (QI-Meds) and the other that facilitated access
to effective psychotherapy for depression (QI-Therapy), help
narrow the gender gap that leaves a greater proportion of
depressed men untreated compared with women. While QI
was effective for both genders, men showed more
improvement than women on some outcomes under QITherapy. Here, we explore one potential reason for the
beneficial effect of a psychotherapy-oriented intervention for
men. Because inadequate social support plays an important
role in poor mental health and support is often lower among
men, we hypothesized that men with low social support might
benefit particularly from an intervention that involved a
counseling component.
Study Design: Partners in Care (PIC) assigned 46 primary
care practices across different sites in the US to either their
usual care (UC) for depression or to programs that provided
education for providers and patients about depression
treatments. PIC provided resources to make it easier to get
either medication or cognitive-behavioral psychotherapy if
necessary. Analyses were stratified by gender. We compared
the trajectory of mental health-related quality-of-life, as
measured by the MCS12, for patients with initially low versus
high levels of social support within each intervention arm.
Interactions between intervention, time and social support
were tested.
Population Studied: This analysis focused on 1299 primary
care patients who screened positive for depression and
completed at least one questionnaire over 24 months of
follow-up
Principal Findings: At baseline men and women had
comparable levels of social support; those with higher levels of
social support had better mcs12 in each intervention arm than
those with low levels of support. There was a significant main
effect for social support (t=4.61, p<.0001 for men and t=7.26,
p<.0001) but not for interactions between social support and
either intervention or intervention*time. For women, the
baseline pattern of lower MCS12 for patients with lower social
support remained constant over time in each intervention
arm. For men with low social support, the QI-Therapy
intervention brought mental health scores up to those of men
with high levels of social support in the QI-Meds and UC
arms. This pattern was maintained over 12-18 months.
Conclusions: QI interventions are effective for men and
women with low and high levels of social support, but the
mental health of women with low support remains lower that
those with high support. QI-therapy appeared particularly
beneficial to men with low initial social support. Moreover,
the benefits relative to usual care or QI-Meds persisted over
time.
Implications for Policy, Delivery, or Practice: Data on illness
trajectories provide information to inform clinical care. For
depressed men with low levels of social support a QI program
that facilitates access to effective psychotherapy is beneficial.
However, QI programs for depressed women with low levels
of social support may need to be enhanced further to bring
their levels of mental health up to those with high levels of
social support.
Primary Funding Source: NIMH
●Gender and Diabetes Care
Chin-Lin Tseng, DrPH, Susan Frayne, M.D., MPH, Usha
Sambamoorthi, Ph.D., Anjali Tiwari, M.D., MS, Mangala
Rajan, MBA, Leonard Pogach, M.D., MBA
Presented By: Chin-Lin Tseng, DrPH, Health Research
Scientist; Assistant Professor, Ceter of Healthcare Lnowledge
Management;, New Jersey Health Care System-East Orange
VA Medical Center; University of Medicine and Dentistry, 385
Tremont Avenue; #129, East Orange, NJ 07078; Tel: (973)6761000x2028; Fax: (973)395-7114; Email: tseng@njneuromed.org
Research Objective: Gender disparities in care have been well
documented for a number of conditions. However, gender
disparities in diabetes care have not been examined
extensively. The study was to assess whether women and men
veterans clinical users had similar diabetes care.
Study Design: This was a retrospective longitudinal cohort
study. The outcome diabetes care variables (fiscal year (FY)
2000) included lab tests (A1c, low-density lipoproteins(LDL),
blood pressure(BP), and creatinine), whether these lab values
exceeding certain thresholds, as well as indication of eye care
visits, foot care visits, and visits to an endocrinologist.
Independent variables (FY 1999) were age, race, marital
status, comorbid illness burden (physical and mental),
number of face to face visits, Veteran priority status, and
Medicare enrollment reasons. Multiple logistic regression
models were used to study the gender effect on diabetes care
measures while controlling for other covariates. The results
reported below were all significant at Type I error rate 0.01.
Population Studied: We used the Diabetes Epidemiology
Cohort dataset from our prior work to identify 235,361 veteran
clinical users with diabetes who were aged 65 years or older
and were dually enrolled in Medicare fee-for service in FYs
1999 and 2000 alive at the end of FY2000. 3227 (1.4%) were
women; 232,134 (98.6%) were men.
Principal Findings: Compared to men with diabetes, women
with diabetes were older (74.5+-5.2 vs. 72.7+-5.1), more likely to
be white (89.5% vs. 82.9%), less likely to be married (27.2%
vs. 69.9%). They had fewer physical health conditions (4.8+2.8 vs. 4.9+-2.8), but more likely to have any of the six more
prevalent mental health conditions included in this study.
Women also had more frequent face-to-face visits then their
men counterparts (12.47+-8.6 vs. 11.5+-7.8).
No gender differences existed on any of the A1c and creatinine
measures. However, women were less likely to have LDL
tested (66.4% vs. 68.95), blood pressure taken (68.0% vs.
74%), and more likely to have LDL exceeding 130 (10.7% vs.
8.9%), and blood pressure exceeding thresholds of 130
(34.6% vs. 31.4%) and of 140 (26.2% vs. 22.75). We continued
to observe women doing poorly than men on variables that
combined absence of tests with bad control of these process
measures for LDL and BP. Women had more frequent visits to
specialists such as podiatrists (43.3% vs. 36.8%) and
endocrinologists (16.2% vs. 13.9%), although there were no
gender differences on eye care. These gender differences
remained after adjusting for other covariates except for
presence of LDL tests, combined measures of absence of tests
and bad control of LDL (both 100 and 130 thresholds) and BP
measures (the 130 threshold).
Conclusions: There were no gender differences on measures
of A1c, creatinine, and eye care. Gender differences existed on
LDL, BP, and visits to specialists.
Implications for Policy, Delivery, or Practice: Our data
suggest gender differences only existed on some aspects of
diabetes care. It may be due to differential emphasis on
various aspects of diabetes care at VHA and requires further
investigation. Similar studies may be extended to the civilian
population.
Primary Funding Source: VA
●Causes and Effects of a Changed Gender Ratio in the
Health Professions
Leo van der Reis, M.D.
Presented By: Leo van der Reis, M.D., Adjunct Professor in
Health Care Management; Clinical Professor of Community &
Rural Medicine, University of Alabama-Quincy Foundation, 70
San Pablo Avenue, San Francisco, CA 94127; Tel: (415)661
8865; Fax: (415)566 0110; Email: lvdr@comcast.net
Research Objective: To determine the short and long term
effects of the changes that have taken place in the gender
ratio in the health professions since World War II. To describe
remedies to offset undesirable aspects of the change in
gender ratio.
Study Design: Continued monitoring of the scientific and lay
press and interviews with students and graduates from
professional schools in medicine, dentistry, pharmacy and
veterinary medicine.
A form has been developed which assesses and tabulates a
broad spectrum of opinions and attitudes.
Population Studied: Students, matriculants, faculty and
administrators of health care professional schools primarily in
the United States, but also including Switzerland, the United
Kingdom, Australia, New Zealand, Israel and The Netherlands.
The foreign data provide valuable comparative information.
Principal Findings: A) Persistent " traditional" discrimination
against women; B) Little recourse on the part of
complainants; C) Persistent skewing of female faculty
compensation; D)A lower percentage of opportunities for
professional women when viewed against the number of
women in the health care professions.
Conclusions: In spite of legislative actions, traditional bias
against women in the health professions persists. Measures
must be taken to remedy the unfortunate and undesirable
effects in order to prevent deterioration in the health care
services in the United States and world wide.
Implications for Policy, Delivery, or Practice: In spite of the
increased number of women, the overall number of health
care professionals is declining. This phenomenon is related to
the impact of the changed gender ratio. Policy makers must
consider the related issues in order to prevent deterioration of
health care services.
Primary Funding Source: Other Foundation
●Enrollment in Medicare HMO by Elderly Women
Veterans
Iris Wei, DrPH,Dolly John, Jessica Davila, Margaret Byrne,
Laura Petersen, Nora Osemene, Raji Sundaravaradan, Robert
Morgan
Presented By: Iris Wei, DrPH, Michael E. DeBakey VA
Medical Center (152), 2002 Holcombe Boulevard, Houston,
TX 77030; Tel: (713) 794-8648; Email: wei.iris@med.va.gov
Research Objective: Although the Veterans’ Health
Administration, VHA, expanded women-specific services in
1992, studies investigating women veterans’ healthcare use
are limited. Researches on women veterans’ enrollment in
Medicare Health Maintenance Organizations, HMOs, are
especially scarce. The present study examines how the
availability of Medicare HMO health plans affects women
veterans’ decisions to enroll in Medicare HMO, and how this
effect varies by health plan or personal characteristics of VHAusing women veterans.
Study Design: We pooled VHA user datasets including fiscal
years 1996-2001 to create a VHA-user cohort for calendar year,
CY2000. We merged the cohort with: CY2000 Medicare
denominator data which provided age, sex, race, and state
buy-in status; Group Health Plan data which provided
enrollees’ Medicare contracts; and Benefits Information Form
data, BIF, for contract plan benefits and plan service areas.
We identified all BIF contracts, N=261, and the counties where
they were active in CY2000, N=817. Enrollment status was
defined by having a BIF contract at any time during CY2000.
We used logistic regressions to examine the likelihood of
enrolling in Medicare HMO by VHA-using women veterans
aged >=65, N=24,354, adjusting for age, race, income, VHA
priority code, distance to VHA healthcare facilities, metro/nonmetro status of residence, and separately, three county-level
plan benefit indicators. The benefit indicators signified
whether each county offered a basic plan with $0 monthly
premium, prescription drug coverage, or generous benefit
package.
Population Studied: Medicare-enrolled women veterans aged
>=65 who used VHA healthcare between 10/1/1996 and
12/31/2000.
Principal Findings: Our data showed 24% Medicare HMO
enrollment. The availability of plans with generous benefits,
prescription drug coverage, or a $0 monthly premium was
positively related to higher HMO enrollment, ORs ranged 1.44
to 1.80 with 95%CI ranged 1.32 to 2.13. Additionally, the
availability of >1 plan, farther distance from residence to the
VHA inpatient facility, vs. <15 miles, lower service priority, 5 or
7 vs. 1-4 and 6, and Hispanics were associated with higher
HMO enrollment, ORs ranged from 1.16 to 1.97 with 95%CI
ranged 1.04 to 2.22. In contrast, age >75 years, lower income,
<=20K, use of VHA in CY2000, state buy-in, non-metropolitan
residence, or farther distance to a VHA outpatient facility were
associated with lower HMO enrollment, ORs ranged 0.70 to
0.90 with 95%CI ranged 0.59 to 0.99.
Conclusions: Medicare HMO plans with more generous
benefits, prescription coverage, or a $0 monthly premium
attracted higher enrollment. Conversely, older age, lower
income, living farther away from VHA health facilities, and
living in non-metropolitan counties were associated with a
lower likelihood of HMO enrollment among Medicareenrolled, VHA-using women veterans.
Implications for Policy, Delivery, or Practice: Elderly women
veterans’ enrollment in Medicare HMO plans can be
constrained by person level characteristics such as age,
income, where they live, as well as by system level
characteristics like number of active HMO plans in county of
residence, and the scope of plan benefits. Future studies need
to delineate whether service availability or quality of care at the
VHA drive women veterans to seek non-VHA care. Such
information can better guide VHA's committed efforts to
deliver comprehensive healthcare to women veterans.
Primary Funding Source: VA
●The Utility of Intimate Partner Violence: Impact on
Health Related Quality of Life
Eve Wittenberg, Ph.D., MPP, Erika L. Lichter, Sc.D., Michael L.
Ganz, Ph.D., Laura A. McCloskey, Ph.D.
Presented By: Eve Wittenberg, Ph.D., MPP, Senior Scientist,
Institute for Technology Assessment, Massachusetts General
Hospital, 101 Merrimac Street 10th floor, Boston, MA 02114;
Tel: (617)724-4481; Email: eve@mgh-ita.org
Research Objective: To estimate the utility of health states
associated with intimate partner violence (IPV) and the
independent effect of IPV on health related quality of life.
Study Design: In-person interviews were conducted with a
convenience sample of 231 abused and non-abused women
defined by scores on the Conflict Tactics Scale. Data were
collected on health status using the SF-12, which were
transformed to utilities using a published algorithm. Linear
regression modeling was used to estimate the association
between IPV and utility while controlling for other health and
demographic factors.
Population Studied: A convenience sample of women visiting
outpatient hospital departments (obstetrics/gynecology,
emergency, primary care, pediatrics and addiction recovery)
and freestanding clinics (gynecology) for random reasons in
greater Boston.
Principal Findings: Utilities estimated from 93 women
experiencing varying degrees of IPV showed a median value of
0.58 on a scale of 0 (dead) to 1.0 (perfect health), ranging
from 0.64 for less-severe IPV (lower scores on the conflict
tactics scale) to 0.53 for more-severe IPV (higher scores).
Current IPV was independently associated with lower health
related quality of life (HRQOL; as measured by utility), while
controlling for depression, comorbid conditions, past IPV,
level of education and employment status (n=217; parameter
estimate for IPV=-0.14, p=0.003; model adjusted rsquare=0.26). Of these other factors, depression was the
largest contributor to lower HRQOL (parameter estimate = -
0.12, p=0.001). The impact of IPV on HRQOL may be most
significant at moderate levels of abuse, and less so at lower
levels while tapering off at higher ones.
Conclusions: Women experiencing IPV have significantly
diminished health related quality of life compared with
unaffected women and other health conditions. While women
who experience IPV have co-existing characteristics and health
conditions that diminish health related quality of life, IPV
alone has a separate negative association with quality of life
that remains after controlling for these other effects.
Implications for Policy, Delivery, or Practice: These results
provide a previously unidentified comparison between partner
violence and other diseases and conditions that affect the
health related quality of life of women. The estimated utility
values for IPV-related health states can be used in economic
analyses of IPV prevention and intervention efforts to
determine their cost effectiveness relative to other public
health and medical programs. These results inform priorities
and resource allocation decisions for efforts to improve health
related quality of life.
Primary Funding Source: AHRQ