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Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare. KEYWORDS: cancer n cardiovascular disease n diabetes n HIV n pain n veterans n women
Women are entering the military at very high rates (>20% of recruits are women), reshaping the veteran population. Women veterans (WVs) account for nearly 8% of the US veteran population now and an estimated 10% within 5 years [1,101]. The number of WVs using the Veteran Affairs (VA) healthcare system has doubled in the past decade [102]. The number of women 65 years and older can be expected to steadily increase each year for the next 20 years [102], which is driven in part by the large cohort of aging WVs from the Korean and Vietnam wars [102]. Given these projections, more attention is needed on chronic conditions that have major impacts on health and healthcare of WVs [2]. In 2004, the VA Office of Research and Development pursued the development of the first VA women’s health (WH) research conference [3]. The Office of Research and Development-wide planning group oversaw assessment of the prevalence of WVs’ health conditions, a critical appraisal of VA’s WH research portfolio and an assessment of WH research barriers among VA investigators. This work led to a systematic review on WVs research literature through 2004 by Goldzweig et al. [4]. Another important outcome of this meeting was a strong push for the VA to develop a VA WH practice-based research network (PBRN) to facilitate multisite research among WVs [5]. One rationale for creating a WH PBRN was to enable researchers to recruit enough WVs to conduct comparative effectiveness research (CER). In 2010, the VA convened a second WH research conference focusing on health services research. The conference included nearly 100 researchers from 45 VA facilities in 27 states and attendees generated a VA Women’s Health Services Research and Development (HSR&D) agenda [1]. At this conference, a second WVs systematic review was presented, updating the prior review with studies published between 2004 and 2008 [6]. Based on the systematic reviews and an assessment of WVs socio-demographics and health conditions, special priority areas were identified
10.2217/CER.14.4
3(2), 155–166 (2014)
Mark P Bielawski1, Karen M Goldstein2,3, Kristin M Mattocks4,5, Bevanne Bean-Mayberry6, Elizabeth M Yano6,7 & Lori A Bastian*8,9 Center of Excellence, VA Connecticut Healthcare System, Newington, CT, USA 2 Center for Health Services Research in Primary Care, Durham VAMC, Durham, NC, USA 3 Duke University, Durham, NC, USA 4 VA Central Western Massachusetts, Leeds, MA, USA 5 Department of Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA, USA 6 VA Greater Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Sepulveda, CA, USA 7 UCLA Fielding School of Public Health, Los Angeles, CA, USA 8 VA Connecticut Healthcare System, Newington, CT, USA 9 Division of General Internal Medicine, University of Connecticut, Farmington, CT, USA *Author for correspondence: Tel.: +1 860 667 6853 Fax: +1 860 667 6764 [email protected] 1
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at the agenda-setting conference, including the need to research chronic conditions among WVs [1]. The following areas were identified as important to improve the care of chronic conditions among WVs: evaluate and develop interventions for pain and musculoskeletal conditions adapted to WVs needs; improve care for chronic conditions related to lifestyle factors such as obesity and diabetes; assess gender differences in presentation and outcomes of cardiovascular disease and related risk factors such as tobacco use and hyperlipidemia; understand the unique needs of WVs with HIV and focus on gender disparities in care delivery; and examine the quality of cancer prevention, diagnosis and treatment among WVs. The purpose of this article is to review the state of the literature for the previously identified five targeted chronic conditions among WVs to identify opportunities for CER to improve health and healthcare for WVs. We review the relevant articles on chronic conditions in prior systematic reviews and we describe the literature published since the last systematic review was completed. We focused this review on studies that compared men and women or pertained specifically to WVs. Chronic pain
Chronic pain is the most frequent complaint of soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom, and it affects more than 50% of male primary care patients in the VA. Although one study reported that up to 78% of WVs suffer from ongoing pain [7], the systematic review by Goldzweig et al. only found one study that looked at pain among WVs and it was considered in relation to post-traumatic stress disorder (PTSD) [4]. In the systematic review conducted by BeanMayberry et al., there were five studies that looked specifically at pain [6]. Significant findings from these studies included that mastalgia (breast pain) was associated with PTSD and psychiatric illnesses such as major depression, alcohol abuse and eating disorders [8], and that WVs with pain were more likely to have psychiatric conditions such as PTSD and depression, and may need additional resources to adequately manage chronic pain conditions [9]. The other studies characterized pain in WVs and found that pain occurred most commonly in the lower extremities, low back and shoulders [7]. After adjusting for multiple pain sites,
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psychiatric diagnoses, age and comorbidities, WVs had a 27% higher rate of outpatient visits than men [10]. The final study in this group showed that veterans with chronic pain or cancer used complementary and alternative therapies and were interested in these modalities if they were offered by the VA [11]. Overall, the two systematic reviews demonstrated that – despite the high prevalence of pain in WVs – there had been relatively little research in this area. Much of the pain literature during this time reflects the research emphasis on mental health, specifically PTSD, but some attempts have been made to quantify and characterize WVs who suffer from chronic pain. We identified 14 new studies directly pertaining specifically to WVs with pain since 2008 (see Table 1). Generally, the topics of these articles were diverse; all but one of the studies was descriptive in nature. One study focusing on a sample of 1004 WVs found that 71% of participants reported chronic pain and that chronic pain was associated with significantly lower physical health status [12]. Among WVs referred for treatment of MST, 66% reported chronic pain [13]. With regards to gender-specific pain syndromes, Weitlauf et al. found that pain associated with pelvic examination was highest for women with prior sexual violence and PTSD [14], and Cohen et al. found more gender-specific pain syndromes among WVs with any mental health diagnosis [15]. In an ethnography of chronic pain among WVs, participants describe their experiences with pain during military service [16]. Several studies have examined gender differences in the prevalence of pain among veterans. In a national study of Iraq and Afghanistan veterans, WVs were less likely to report any pain [17]. Among those with any pain, WVs were more likely to report moderate–severe pain compared with male veterans [17]. In another study among Connecticut (USA) war veterans of Iraq and Afghanistan, there were no significant gender difference in pain scores [18]. However, WVs were more likely to screen positive for military sexual trauma and depression and less likely to screen positive for PTSD compared with male veterans [18]. In a study examining sex differences in noncancer chronic pain, WVs were more likely to be diagnosed with two or more pain conditions and less likely to receive chronic opioid therapy [19,20]. Carlson et al. found that headache diagnoses were 1.6-times more prevalent among
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WVs compared with men [21]. Among Iraq and Afghanistan veterans, WVs were more likely to endorse back pain and headaches [22]. Overall, WVs were more likely than men to have back problems, musculoskeletal problems and joint problems WVs with chronic low back pain had greater depression and may benefit more from yoga compared with men [23]. A study of rural WVs found a telemedicine pain intervention feasible and acceptable [24]. One study that looked at pain-related outcomes between veterans with major depressive disorder treated with duloxetine versus other antidepressants found that subjects treated with duloxetine had lower risks of substance abuse and opioid use and lower healthcare utilization compared with those treated with other antidepressants [25]. The overlap of pain and substance use found in this study was also highlighted in a recently published review on substance use among WVs [26]. Diabetes
Diabetes affects more than 10% of women in the USA. [103]. Obesity, a major risk factor for diabetes, affects up to 37% of WVs compared with nearly 34% of male veterans [104]. Goldzweig et al. only identified two studies concerning ‘endocrinology’, and they did not note any studies specifically focusing on diabetes [4]. Bean-Mayberry et al. found two studies on diabetes [6]. One study looked at gender differences in diabetes care [27] and the other study examined diabetes care among WVs with disabilities [28]. These studies found that WVs were less likely to have low-density lipoprotein (LDL) less than 130 mg/dl compared with men. In the literature review for this special report, we identified a relatively large number of new studies on diabetes among veterans. Most studies were secondary analyses of large national databases or small interventions studies that only included 2–5% WVs and did not analyze for possible gender differences. We identified four studies that pertained to WVs (see Table 1). Banerjea et al. looked at the prevalence of substance use disorders and mental illness in a large sample of 16,368 WVs with diabetes. These authors found that 45% of this population had a mental illness, a substance use disorder or both conditions [29]. Another study examined gender differences in lipid-lowering treatments among veterans with diabetes [30]. They found WVs received less aggressive use of lipid therapy
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compared with men, especially among younger age groups. In this large national database, the authors oversampled WVs and matched women to men in a 1:4 ratio on age and VA facility. In a more recent study, among veterans with diabetes aged 50–75 years, Vimalananda and her colleagues explored gender differences in lipid management [31]. They found WVs among the highest-risk group (those with ischemic heart disease) were less likely to meet lipid goals. Finally O’Toole et al. used a pre–post study design to examine the impact of a populationspecific medical home on healthcare utilization and found that WVs receiving primary care in a population-specific medical home increased primary care utilization and chronic disease monitoring compared with WVs assigned to a general internal medicine clinic [32]. Cardiovascular disease risk
In the USA, one in three women dies from cardiovascular disease (CVD), and this condition is the leading cause of mortality in WVs [105]. Risk factors for CVD include smoking, high cholesterol (hyperlipidemia), obesity (discussed in the section ‘Diabetes’) and high blood pressure (hypertension) [106,107]. In Goldzweig et al. there were only two descriptive studies on heart disease and its risks factors [4], including one study that described at-risk WVs’ limited concerns about and knowledge of coronary artery disease [33] and one that looked at smoking characteristics, such as nicotine dependence, in female veterans [34]. Bean-Mayberry et al. identified a total of ten descriptive studies concerning CVD and its risk factors, demonstrating a significant increase in the body of literature on this topic when compared with Goldzweig et al. [4,6]. There were two studies on cardiac risk, including one linking a history of military sexual assault to the presence of risk factors for CVD and one that analyzed all-cause and cause-specific mortality in Vietnam-era WVs (including circulatory system diseases such as CVD) [35,36]. Of the four studies on smoking, two looked at designing a smokingcessation program for WVs [37,38]; one looked at noncigarette tobacco (cigars, smokeless tobacco and so on) use in young military recruits [39]; and the last study looked at gender differences in smoking-cessation services received among veterans [40]. Bean-Mayberry et al. found two studies focusing on lipid screening. The first study is also
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans†. Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
Pain/chronic pain Weitlauf et al. (2008)
67
100
Patient survey
Pain associated with pelvic examination was highest for women with prior sexual violence and PTSD
[14]
Haskell et al. (2009)
153,212
12
National VA database
WV were less likely to report any pain compared with men. Among those veterans with any pain, WV were more likely to report moderate–severe pain and less likely to report persistent pain
[17]
Haskell et al. (2010)
1129
17
VA medical record review
There were no significant gender differences in pain but WV were more likely to screen positive for MST, depression and PTSD
[18]
Kelly et al. (2011)
135
100
Patient survey and VA medical record review
Among WV referred for MST treatment, 95% reported at least one trauma in addition to MST. 66% of WV with trauma history reported chronic pain
[13]
Shi et al. (2012)
878
28
Veterans with depression
Looked at pain-related outcomes between veterans with major depressive disorder treated with duloxetine versus other antidepressants, finding that subjects treated with duloxetine had lower risks of substance abuse and opioid use, and lower healthcare utilization compared with those treated with other antidepressants
[25]
Groessl et al. (2012)
53
24
Veterans with back WV with chronic low back pain had greater depression and pain pain attending may benefit more from yoga compared with men yoga program
[23]
Haskell et al. (2012)
450,329
12
National VA database
The prevalence of painful musculoskeletal conditions increased each year after deployment. After adjustment for significant demographic differences, WV were more likely than men to have back problems, musculoskeletal problems and joint problems
[20]
Booth et al. (2012)
1004
100
Patient telephone interviews
71% of WV reported history of chronic pain and pain was associated with history rape in military and current PTSD
[12]
Cohen et al. (2012)
71,504
100
National VA database
44% of WV using VA healthcare received at least one mental health diagnosis. WV with any mental health diagnosis had significantly higher prevalence of gynecologic pain syndromes
[15]
Runnals et al. (2013)
1614
21
Clinical interview and survey
Highest rate of pain complaints was observed in veterans with comorbid PTSD and depression. WV were more likely to endorse back pain and headaches
[22]
Tan et al. (2013)
34
100
Veterans with pain and comorbid depression and/or PTSD
WV living in rural areas with chronic pain and comorbid depression and/or PTSD found a telemedicine group therapy intervention plus biofeedback acceptable and improved pain and mental health symptoms
[24]
Carlson et al. (2013)
470,215
13
National VA database
Headache diagnosis 1.61-times more prevalent among WV (18%) compared with men (11%)
[21]
Denke and Barnes (2013)
15
100
WV with pain
WV describe their experiences with pain during their military duty and after discharge or retirement
[16]
Weimer et al. (2013)
17,583
11
National VA database
In a cohort of veterans with moderate–severe pain, WV were more likely to be diagnosed with two or more pain conditions and had lower odds of being prescribed chronic opioid treatment compared with men, especially among younger veterans
[19]
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans† (cont.). Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
Banerjea et al. (2009)
16,368
100
National VA database
45% of WV with diabetes had a mental illness, substance use disorder or both
[29]
O’Toole et al. (2011)
457
32
WV VA users at one site
Increase in primary care use, monitoring of blood pressure/ cholesterol and decrease in hemoglobin A1C among WV receiving care in a population specific-medical home versus a general internal medicine clinic
[32]
Vimalananda et al. (2011)
111,906
20
National VA database
WV with both diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men
[30]
Vimalananda et al. (2013)
668,209
3
National VA database
WV were less likely to have LDL 130 compared with men (27 vs 17%). One-third of the gender difference could be explained by individual characteristics such as age
[47]
Steinman et al. 2,002,693 1.9 (2012)
VA and Medicare databases
Hypertension, hyperlipidemia and arthritis were the most frequent three-way combination of illnesses when considering 23 common conditions in WV, affecting 25% of this population
[53]
Vimalananda et al. (2013)
2,527,496 10
Diabetes Epidemiologic Cohort (DEpiC)
Diabetes, HTN and hyperlipidemia were common among all veterans
[50]
Rose et al. (2013)
3611
100
Patient telephone survey
Black WV were more likely to report a diagnosis of diabetes or hypertension and to be obese than white WV
[51]
8300
3
Veterans Aging Cohort study
Compared to men, WV experienced less improvement in overall burden of disease after 1 year of HIV treatment
[55]
Sambamoorthi 527,568 et al. (2012)
HIV Blackstock et al. (2013)
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans† (cont.). Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
48%
Medical record review
Autonomic neuropathy in HIV-infected veterans of both sexes was underdiagnosed and associated with a higher burden of illness and a higher predicted mortality risk
[56]
HIV (cont.) Robinson-Papp 102 and Sharma (2013) Cancer Griffin et al. (2009)
345
37
Medical record review
Male veterans were more likely than WV to falsely report having a screening sigmoidoscopy or colonoscopy. Rates of over-report for FOBT and barium enema were similar between the sexes
[76]
Leong et al. (2009)
82
100
Local VA database
Breast reconstruction rates among WV with breast cancer were 42% after mastectomy and 22% overall
[74]
Lairson et al. (2011)
5500
100
National sample of The tailored intervention was dominated (more costly and less WV >52 years in effective) by the targeted intervention a mammography intervention
[70]
Yee et al. (2011)
606
100
Local VA database
WV with mental illness were less likely to adhere to breast cancer screening recommendations
[72]
Gellad et al. (2011)
1,112,645 2.8
National VA database
WVs were more likely than men to have adequate colorectal cancer screening with FOBT alone or FOBT and sigmoidoscopy, colonoscopy or barium enema. Adherence to repeat FOBT was low and similar between genders
[75]
Yoon et al. (2012)
423,283
100
National VA database
Gender-specific conditions, cancer, musculoskeletal disease and mental health/substance abuse illnesses accounted for a greater share of overall costs during the study periods of 2000 and 2008
[2]
Luther et al. (2013)
1161
100
National VA database
Breast conserving surgery rates were similar in WV to the nonveteran population after accounting for surgeries paid for by VA and performed in outside facilities
[73]
Weitlauf et al. (2013)
34,213
100
National VA database
PTSD or depression did not have an effect on receipt of cervical cancer screening
[71]
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
mentioned in the ‘HIV’ section and looked at lipid screening rates in HIV-infected veterans [41], and the second one also focused on a specific subpopulation, calculating the rate of cholesterol testing among veterans with mental illness [42]. The two diabetes studies in Bean-Mayberry et al. also considered lipid testing among WVs [27,28]. In the first study by Tseng and colleagues, women were more likely to have LDL 65 years), women were less likely to
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receive adequate hypertension control compared with men in VA [43]. Despite the importance of hypertension as a risk factor for CVD in women, there were no other studies in either review that looked at this condition directly. We identified several new studies that examined risk factors for CVD since the last systematic review (see Table 1). In a cross-sectional study conducted from 2004 to 2006, 67% of participating WVs were categorized as moderate-to-high risk for CVD [44]. Smoking prevalence among WVs was highest (44%) among those born between 1985 and 1989 [45]. Wheeler et al. examined the adherence to guideline-based therapy for acute myocardial infarction in VA hospitals and found that WVs received a similar
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level of care (i.e., cardiac catheterization) to men [46]. One study focused on gender differences in LDL levels [47] and another study examined determinants of response to statin medications [48]. These authors found the gender difference in poor lipid control was mostly explained by age, physical illnesses, lower use of lipid lowering medications and depression [47,48]. Given the prior emphasis on mental health research among WVs, Shen et al. found a 27% rate of depressive disorders among WVs with diabetes, heart disease and hypertension [49]. In a recent Journal of General Internal Medicine supplement on WVs research, two studies focused on CVD risk. Vimalananda et al. reported results of a cross-sectional study from the Diabetes Epidemiologic Cohorts, a national longitudinal data set of patients in the VA system and found that both male and female veterans have high rates of CVD risk factors [50]. Rose et al. go further to explore racial and ethnic differences in CVD risk factors in the 2008–2009 National Survey of Women Veterans [51]. In this study, black WVs were more likely to report a diagnosis of diabetes or hypertension and to be obese than white WVs [51]. We also identified studies on other topics linking WVs and CVD. Virani et al. found that WVs with CVD and a LDL level of >100 were less likely to receive treatment intensification with a cholesterol lowering drug than other subgroups, such as diabetics and hypertensive patients [52]. Finally, Steinman et al. found that hypertension, hyperlipidemia and arthritis was the most frequent three-way combination of illnesses when considering 23 common conditions in WVs, affecting 25% of this population [53]. HIV
The CDC estimates that approximately one quarter of those infected with HIV in the USA are women [108]. There were no studies in Goldzweig et al. that analyzed HIV-infected WVs, and there were only two descriptive studies in Bean-Mayberry et al. that analyzed infected veterans of both genders [4,6]. One study looked at lipid screening rates in veterans with HIV taking protease inhibitors [41], and the other compared the health-related quality of life between HIVinfected patients receiving care in the VA and their non-veteran counterparts receiving care in non-VA settings [54]. We identified two new articles in our literature review that pertained to HIV and WVs (see Table 1). Blackstock et al. addressed whether sex
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differences in disease burden exist among a cohort of HIV-infected veterans after 1 year of antiretroviral therapy and found that WVs experienced less improvement in disease burden after treatment compared with men [55]. In a small study, Robinson-Papp and Sharma found that autonomic neuropathy in patients with HIV was underdiagnosed and associated with a higher burden of illness and a higher predicted mortality risk [56]. Cancer
Cancer is the second leading cause of death in US women [109], and breast, lung and colorectal cancer are the three most common malignancies and causes of cancer death [110]. Among the chronicdisease categories considered in this article, breast cancer represented the largest amount of literature in the combined reviews [4,6]. In Goldzweig et al., there were four studies about breast cancer screening [57–60], one study about women’s perception of breast cancer risk [61] and one study about breast cancer surgery trends and outcomes [62]. In Bean-Mayberry et al. there were three studies about breast cancer screening (all on mammography) [63–65], one about WVs’ perceived susceptibility to breast cancer [66] and one about breast biopsy [67]. The study on breast cancer surgery trends mentioned in Goldzweig et al. was also included in this review [62]. Interestingly there were a similar number of studies about breast cancer in both systematic reviews, demonstrating a lack of a growth in the body of literature between Goldzweig et al. and Bean-Mayberry et al. [4,6]. It is important to note, however, that breast cancer screening was the target of one of the only randomized trials among WVs [63,64]. Unique to the review by Bean-Mayberry et al. were two studies on colorectal cancer screening – Goldzweig et al. had no articles on this topic [68,69]. These last two studies while not focused on women provided some insight to variations in screening for women and men. One found lower screening rates associated with female gender, black race and low income [68], while the other found gender-specific barriers to the colonoscopy preparation, as well as different fears and attitudes for women compared with men [69]. Although lung cancer is the second most common malignancy diagnosed in women and the number one cause of cancer death in women [109,110], neither review contained an article about the subject [4,6]. In our literature review, we identified eight new studies addressing cancer among WVs (see Table 1). Three studies focused on screening for
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gender-specific cancers such as breast and cervical cancer [70–72]. Two studies described treatment for breast cancer in the VA including a study examining the use of breast-conserving surgery [73] and access to breast reconstruction surgery after mastectomy [74]. And one study on WVs looked at the rates and attributable costs of all cancers and of many chronic conditions including diabetes, congestive heart failure and HIV/AIDS, finding that gender-specific conditions, cancer, musculoskeletal disease and mental health/substance abuse illnesses accounted for a greater share of overall costs during the study periods of 2000 and 2008. These disproportionate costs largely stemmed from higher rates of diagnosed conditions and, for several conditions, higher treatment costs [2]. Although we identified over 30 new articles that examined gastroenterology cancers in veterans, only two studies analyzed their data for gender differences. Over a 5-year period, Gellad et al. found that WVs were more likely than men (43.6 vs 41.1%) to have adequate colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) alone or FOBT and sigmoidoscopy, colonoscopy or barium enema. Adherence to repeat FOBT was low and similar between genders; less than 15% of both groups received exclusive FOBT annually for at least 4 years, which was the amount of testing considered to be adequate for screening [75]. In another study looking at gender differences in CRC screening, Griffin et al. concluded that male veterans were more likely than WVs to falsely report having a screening sigmoidoscopy or colonoscopy. Rates of over-report for FOBT and barium enema were similar between the sexes [76]. We did not identify studies that examined gender differences for lung cancer despite the call from Dr Patricia Hayes, Director of Women’s Health Services for the Department of Veterans Affairs, to examine this important topic [77].
Yet despite the fact that CVD and cancer are two leading causes of death in women, there were fewer studies published on these topics from 2008 to the present when compared with the amount of literature found in the prior systematic reviews. There were also no studies in the systematic reviews and in our updated search that focused on lung cancer. Finally, we found no growth in the amount of studies on HIV in WVs. The updated literature search highlights the need for more research on CVD, cancer and HIV in WVs, and reaffirms that significant gaps remain in achievement of the VA WH research agenda, especially in the area of chronic conditions [1]. Moreover, the majority of published literature is observational and clinical trials are needed. Although WVs comprise 8% of the veteran population and up to 10% in 5 years, very few VA studies have focused on WVs specifically: the majority of research on chronic conditions among veterans incorporated a small percentage of WVs (1–5%) and did not provide gender-specific analyses. There is evidence that analyzing data by gender is critical to improving heathcare. Studies such as Vimalananda et al.’s in veterans with diabetes demonstrate that there are important gender differences in chronic disease treatment and response to care [30,31]. These disparities necessitate studies that compare gender-based outcomes and studies that focus on interventions specifically for WVs. Such research may help guide treatment in ways that maximize quality of life and survival and reduce healthcare costs for all veterans. In the future, we encourage investigators to systematically assess gender differences in prevention/screening, risk reduction and disease management outcomes. This approach moves beyond including gender as a covariate in analyses and includes analyses stratified by gender. Conclusion
Discussion
Prior systematic reviews on WVs have informed the VA WH research agenda [1]. Since 2008, the volume of research studies and published literature on the health and healthcare of WVs has grown modestly in some areas. From 2008 to the present, we identified an increase in the number of studies concerning chronic diseases such as diabetes and chronic pain when compared with the amount of literature identified in Goldzweig et al. and Bean-Mayberry et al., which included all research on WVs up to 2008.
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The noticeable lack in CER creates specific challenges in caring for WVs. It can be difficult to apply study outcomes from a civilian population to veterans; standards of care in the general population may not work well in veterans causing inefficiency, worse outcomes and increased costs. In the future, this paucity of CER could be addressed by using the Women’s Health Practice Based Research Network (WHRN/PBRN). The WHRN/PBRN was started in 2010 to support multisite research within the VA, allowing for the recruitment of larger populations of WVs.
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The WHRN/PBRN now includes 37 US sites that see a high percentage of WVs with certain chronic diseases [5] and is well suited for inclusion of WVs in RCTs – including CER. We encourage investigators to capitalize on the PBRN infrastructure that facilitates multisite research to ensure adequate numbers of women in future chronic disease research and to ensure that all veterans benefit from the knowledge that can be discovered through CER. Future perspective
The goal over the next 5–10 years is to systematically accomplish the VA WH research agenda’s recommendations and accelerate the development and conduct of intervention studies and dissemination of research that addresses chronic conditions among WVs and ultimately improve health and healthcare for all veterans. There is a need to conduct CER on common clinical topics such as CVD, cancer and HIV among WVs.
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Disclaimer The contents do not represent the views of the Department of Veterans Affairs or the United States Government.
Financial & competing interests disclosure This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, HSR&D (CRE 12-008 and SDR 10-012). EM Yano’s effort was funded through a VA HSR&D Senior Research Career Scientist Award (RCS 05-195). M Bielawski is a trainee supported by the Department of Veterans Affairs, Office of Academic Affiliations, Center of Excellence in Primary Care Education at VA Connecticut Healthcare System. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Executive summary Background ■■ Few studies have focused on chronic conditions among women veterans (WVs) such as chronic pain, diabetes, HIV, cardiovascular disease risk and cancer. ■■ Even fewer studies have examined these conditions for gender differences or included enough WVs in clinical trials to test for gender effects. Chronic pain ■■ Pain is a frequent complaint among WVs and studies are needed to understand the most effective treatments for pain conditions. Diabetes ■■ WVs with diabetes may benefit from more effective models of care to achieve better control of diabetes. Cardiovascular disease risk ■■ WVs frequently have co-occurring cardiovascular disease risk factors and interventions that manage multiple risk factors are needed. HIV ■■ WVs with HIV may be under-recognized compared with male veterans. Cancer ■■ Among the three most common cancers of women, no studies were found that addressed lung cancer in WVs.
References
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n n
1
n
Yano EM, Bastian LA, Bean-Mayberry B et al. Using research to transform care for women veterans: advancing the research agenda and enhancing research-clinical partnerships. Womens Health Issues 21(4 Suppl.), S73–S83 (2011). Reviews the most recent women veterans (WVs) research agenda for health services research.
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More than military sexual trauma: interpersonal violence, PTSD, and mental health in women veterans. Res. Nurs. Health 34(6), 457–467 (2011). 14 Weitlauf JC, Finney JW, Ruzek JI et al.
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Dobscha SK, Duckart JP, Morasco BJ. Sex differences in the medical care of VA patients with chronic non-cancer pain. Pain Med. 14(12), 1839–1847 (2013). 20 Haskell SG, Ning Y, Krebs E et al.
Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clin. J. Pain 28(2), 163–167 (2012). 21 Carlson KF, Taylor BC, Hagel EM, Cutting
A, Kerns R, Sayer NA. Headache diagnoses among Iraq and Afghanistan war Veterans enrolled in VA: a gender comparison. Headache 53(10), 1573–1582 (2013). 22 Runnals JJ, Van Voorhees E, Robbins AT
et al. Self-reported pain complaints among Afghanistan/Iraq men and women veterans with comorbid posttraumatic stress disorder and major depressive disorder. Pain Med. 14, 1529–1533 (2013). 23 Groessl EJ, Weingart KR, Johnson N, Baxi S.
The benefits of yoga for women veterans with chronic low back pain. J. Altern. Complement. Med. 18(9), 832–838 (2012). 24 Tan G, Teo I, Srivastava D et al. Improving
access to care for women veterans suffering from chronic pain and depression associated with trauma. Pain Med. 14(7), 1010–1020 (2013). 25 Shi L, Liu J, Zhao Y. Comparative
effectiveness in pain-related outcomes and health care utilizations between veterans with major depressive disorder treated with duloxetine and other antidepressants: a retrospective propensity score-matched comparison. Pain Pract. 12(5), 374–381 (2012). 26 Cucciare MA, Simpson T, Hoggatt KJ,
Gifford E, Timko C. Substance use among women veterans: epidemiology to evidencebased treatment. J. Addict. Dis. 32, 119–139 (2013). 27 Tseng CL, Sambamoorthi U, Rajan M et al.
Are there gender differences in diabetes care among veterans? J. Gen. Int. Med. 21(Suppl. 3), S47–S53 (2006).
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M, Findley P, Pogach L. Diabetes care among veteran women with disability. Womens Health Issues 16(6), 361–371 (2006). 29 Banerjea R, Pogach LM, Smelson D,
Sambamoorthi U. Mental illness and substance use disorders among women veterans with diabetes. Womens Health Issues 19(6), 446–456 (2009). 30 Vimalananda VG, Miller DR, Palnati M,
Christiansen CL, Fincke BG. Gender disparities in lipid-lowering therapy among veterans with diabetes. Womens Health Issues 21(4 Suppl.), S176–S181 (2011). 31 Vimalananda VG, Miller DR, Hofer TP,
Holleman RG, Klamerus ML, Kerr EA. Accounting for clinical action reduces estimates of gender disparities in lipid management for diabetic veterans. J. Gen. Intern. Med. (Suppl. 2), S529–S535 (2013). 32 O’Toole TP, Pirraglia PA, Dosa D et al.
Building care systems to improve access for high-risk and vulnerable veteran populations. J. Gen.Intern. Med. 26(Suppl. 2), 683–688 (2011). 33 Biswas MS, Calhoun PS, Bosworth HB,
Bastian LA. Are women worrying.about heart disease? Womens Health Issues 12, 204–211 (2002). 34 Whitlock EP, Ferry LH, Burchette RJ, Abbey
D. Smoking characteristics.of female veterans. Addict. Behav. 20, 409–426 (1995). 35 Frayne SM, Skinner KM, Sullivan LM,
Freund KM. Sexual assault while in the military: violence as a predictor of cardiac risk? Violence Victims 18(2), 219–225 (2003). 36 Cypel Y, Kang H. Mortality patterns among
women Vietnam-era veterans: results of a retrospective cohort study. Ann. Epidemiol. 18(3), 244–252 (2008). 37 Katzburg JR, Farmer MM, Poza IV, Sherman
SE. Listen to the consumer: designing a tailored smoking-cessation program for women. Subst. Use Misuse 43(8–9), 1240–1259 (2008). 38 Katzburg JR, Yano EM, Washington DL et al.
Combining women’s preferences and expert advice to design a tailored smoking cessation program. Subst. Use Misuse 44(14), 2114–2137 (2009). 39 Vander Weg MW, Peterson AL, Ebbert JO,
Debon M, Klesges RC, Haddock CK. Prevalence of alternative forms of tobacco use in a population of young adult military recruits. Addict. Behav. 33(1), 69–82 (2008). 40 Sherman SE, Fu SS, Joseph AM, Lanto AB,
Yano EM. Gender differences in smoking
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cessation services received among veterans. Womens Health Issues 15(3), 126–133 (2005). 41 Korthuis P T, Asch, SM, Anaya HD et al. Lipid
screening in HIV-infected veterans. J. Acquir. Immune Defic. Syndr. 35(3), 253–260 (2004). 42 Kaplowitz RA, Scranton RE, Gagnon DR et al.
Health care utilization and receipt of cholesterol testing by veterans with and those without mental illness. Gen. Hosp. Psych. 28(2), 137–144 (2006). 43 Jha AK, Perlin JB, Steinman MA, Peabody
JW, Ayanian JZ. Quality of ambulatory care for women and men in the Veterans Affairs Health Care System. J. Gen. Intern. Med. 20(8), 762–765 (2005). 44 Canter DL, Atkins MD, McNeal CJ, Bush
RL. Risk factor treatment in veteran women at risk for cardiovascular disease. J. Surg. Res. 157(2), 175–180 (2009). 45 Brown DW. Smoking prevalence among US
veterans. J. Gen. Intern. Med. 25(2), 147–149 (2010). 46 Wheeler S, Bowen JD, Maynard C et al.
Women veterans and outcomes after acute myocardial infarction. J. Womens Health 18(5), 613–618 (2009). 47 Sambamoorthi U, Mitra S, Findley PA,
Pogach LM. Decomposing gender differences in low-density lipoprotein cholesterol among veterans with or at risk for cardiovascular illness. Womens Health Issues 22(2), e201–e208 (2012). 48 Cone C, Murata G, Myers O. Demographic
determinants of response to statin medications. Am. J. Health Syst. Pharm. 68(6), 511–517 (2011). 49 Shen C, Findley P, Banerjea R,
Sambamoorthi U. Depressive disorders among cohorts of women veterans with diabetes, heart disease, and hypertension. J. Womens Health 19(8), 1475–1486 (2010). 50 Vimalananda VG, Miller DR, Christiansen
CL, Wang W, Tremblay P, Fincke BG. Cardiovascular disease risk factors among women veterans at VA medical facilities. J. Gen. Intern. Med. Suppl. 2, S517–S523 (2013). 51 Rose DE, Farmer M, Yano EM, Washington
DL. Racial-ethnic differences in cardiovascular risk factors among women veterans. J. Gen. Intern. Med. 28(Suppl. 2), S524–S528 (2013). 52 Virani SS, Woodard LD, Chitwood SS et al.
Frequency and correlates of treatment intensification for elevated cholesterol levels in patients with cardiovascular disease. Am. Heart J. 162, 725–732.e1 (2011). 53 Steinman MA, Lee SJ, Boscardin WJ et al.
Patterns of multimorbidity in elderly
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veterans. J. Am. Geriat. Soc. 60, 1872–1880 (2012). 54 Mrus JM, Leonard AC, Yi MS et al. Health-
related quality of life in veterans and nonveterans with HIV/ AIDS. J. Gen. Intern. Med. 21(Suppl. 5), S39–S47 (2006). 55 Blackstock OJ, Tate JP, Akgün KM et al. Are
there sex differences in overall burden of disease among HIV-infected individuals in the Veterans Affairs healthcare system? J. Gen. Intern. Med. Suppl. 2, S577–S582 (2013). 56 Robinson-Papp J, Sharma SK. Autonomic
neuropathy in HIV is unrecognized and associated with medical morbidity. Clin. Epidemiol. Res. 27(10), 539–543 (2013). 57 Dalessandri KM, Cooper M, Rucker T. Effect
of mammography outreach in women veterans. West J. Med. 169, 150–152 (1998). 58 Hynes DM, Bastian LA, Rimer BK, Sloane R,
Feussner JR. Predictors of mammography use among women veterans. J. Womens Health 7, 239–247 (1998). 59 Goldzweig CL, Parkerton PH, Washington
DL, Lanto AB, Yano EM. Primary care practice and facility quality orientation: influence on breast and cervical cancer screening rates. Am. J. Manag. Care 10, 265–272 (2004). 60 Schwartz LM,Woloshin S, Black WC, Welch
HG. The role of numeracy in understanding the benefit of screening mammography. Ann. Intern. Med. 127, 966–972 (1997). 61 Woloshin S, Schwartz LM, Black WC,Welch
HG.Women’s perceptions of breast cancer risk: how you ask matters. Med. Decis. Making 19, 221–229 (1999). 62 Hynes DM, Weaver F, Morrow M et al.
Breast cancer surgery trends and outcomes: results from a National Department of Veterans Affairs study. J. Am. Coll. Surg. 198, 707–716 (2004). 63 Vernon SW, del Junco DJ, Tiro JA et al.
Promoting regular mammography screening II: Results from a randomized controlled trial in US women veterans. J. Natl Cancer Inst. 100, 347–358 (2008). 64 del Junco DJ, Vernon SW, Coan SP et al.
Promoting regular mammography screening I. A systematic assessment of validity in a randomized trial. J. Natl Cancer Inst. 100(5), 333–346 (2008). 65 Lairson DR, Chan W, Newmark GR.
Determinants of the demand for breast cancer screening among women veterans in the United States. Soc. Sci. Med. 61(7), 1608–1617 (2005). 66 McQueen A, Swank PR, Bastian LA, Vernon
SW. Predictors of perceived susceptibility of
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breast cancer and changes over time: a mixed modeling approach. Health Psychol. 27(1), 68–77 (2008). 67 Hatmaker AR, Donahue RM, Tarpley JL,
Pearson AS. Cost-effective use of breast biopsy techniques in a Veterans health care system. Am. J. Surg. 192(5), e37–e41 (2006). 68 Etzioni DA, Yano EM, Rubenstein LV et al.
Measuring the quality of colorectal cancer screening: the importance of follow-up. Dis. Colon Rectum 49(7), 1002–1010 (2006). 69 Friedemann-Sánchez G, Griffin JM, Partin
MR. Gender differences in colorectal cancer screening barriers and information needs. Health Expect. 10(2), 148–160 (2007). 70 Lairson DR, Chan W, Chang YC, del Junco
DJ, Vernon SW. Cost–effectiveness of targeted versus tailored interventions to promote mammography screening among women military veterans in the United States. Eval. Program Plann. 34(2), 97–104 (2011). 71 Weitlauf JC, Jones S, Xu X et al. Receipt of
cervical cancer screening in female veterans: impact of posttraumatic stress disorder and depression. Womens Health Issues 23(3), e153–e159 (2013). 72 Yee EF, White R, Lee SJ et al. Mental illness:
is there an association with cancer screening among women veterans? Womens Health Issues 21(4 Suppl.), S195–S202 (2011). 73 Luther SL, Neumayer L, Henderson WG
et al. The use of breast-conserving surgery for women treated for breast cancer in the Department of Veterans Affairs. Am. J. Surg. 206(1), 72–79 (2013). 74 Leong M, Chike-Obi CJ, Basu CB, Lee EI,
Albo D, Netscher DT. Effective breast reconstruction in female veterans. Am. J. Surg. 198(5), 658–663 (2009). 75 Gellad ZF, Stechuchak KM, Fisher DA et al.
Longitudinal adherence to fecal occult blood testing impacts colorectal cancer screening quality. Am. J. Gastroenterol. 106, 1125–1134 (2011). 76 Griffin JM, Burgess D, Vernon SW et al. Are
gender differences in colorectal cancer screening rates due to differences in selfreporting? Prevent. Med. 49, 436–441 (2009). 77 Hayes PM. Improving health of veterans
through research collaborations. J. Gen. Intern. Med. 28(Suppl. 2), S495–S497 (2013).
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Veterans. Health Administration. Volume 1. Sociodemographic Characteristics and Utilization of VHA Care (2010). Women’s Health Evaluation Initiative, Women’s Health Services,Veterans Health Administration, Department of Veterans Affairs, Washington, DC, USA. www.va.gov/vhapublications/ ViewPublication.asp?pub_ID=2455 102 Frayne S, Phibbs C, Friedman S et al.
Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2. Sociodemographics and Use of VHA and Non-VA Care(Fee) (2012). Women’s Health Evaluation Initiative, Women’s Health Services,Veterans Health Administration, Department of Veterans Affairs, Washington, DC, USA. www.womenshealth.va.gov/womenshealth/ docs/SourcebookVol2_508c_final.pdf
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Care. Women’s HealthServices, Veterans Health Administration, Department of Veterans Affairs. www.womenshealth.va.gov/womenshealth/ diabetes.asp 104 David Halpern, MD, Chris Ruser, MD, HCS,
William Yancey, MD. Weight Management Program for Veterans VA National Center for Health Promotion and Disease Prevention, Department of Veterans Affairs. www.move.va.gov/download/ moveReferenceManual/01_ EvidenceOfNeedForMOVE.pdf 105 Department of Veterans Affairs. VA Fights to
Prevent Heart Disease in Women Vets. Veterans Health Administration. www.va.gov/health/NewsFeatures/ 20121210a.asp
106 NIH, Department of Health and Human
Services. The heart truth-lower heart disease risk. What are the risk factors for heart disease? www.nhlbi.nih.gov/educational/hearttruth/ lower-risk/risk-factors.htm 107 National Heart, Lung, and Blood Institute.
High blood cholesterol: what you need to know. www.nhlbi.nih.gov/health/public/heart/chol/ wyntk.htm. 108 Department of Veterans Affairs. Veterans
with HIV/AIDS. www.hiv.va.gov/provider/state-of-care/ veterans.asp 109 CDC. Leading Causes of Death in Females
USA, 2009. www.cdc.gov/women/lcod/2009/index.htm 110 CDC. Cancer among women.
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Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare. KEYWORDS: cancer n cardiovascular disease n diabetes n HIV n pain n veterans n women
Women are entering the military at very high rates (>20% of recruits are women), reshaping the veteran population. Women veterans (WVs) account for nearly 8% of the US veteran population now and an estimated 10% within 5 years [1,101]. The number of WVs using the Veteran Affairs (VA) healthcare system has doubled in the past decade [102]. The number of women 65 years and older can be expected to steadily increase each year for the next 20 years [102], which is driven in part by the large cohort of aging WVs from the Korean and Vietnam wars [102]. Given these projections, more attention is needed on chronic conditions that have major impacts on health and healthcare of WVs [2]. In 2004, the VA Office of Research and Development pursued the development of the first VA women’s health (WH) research conference [3]. The Office of Research and Development-wide planning group oversaw assessment of the prevalence of WVs’ health conditions, a critical appraisal of VA’s WH research portfolio and an assessment of WH research barriers among VA investigators. This work led to a systematic review on WVs research literature through 2004 by Goldzweig et al. [4]. Another important outcome of this meeting was a strong push for the VA to develop a VA WH practice-based research network (PBRN) to facilitate multisite research among WVs [5]. One rationale for creating a WH PBRN was to enable researchers to recruit enough WVs to conduct comparative effectiveness research (CER). In 2010, the VA convened a second WH research conference focusing on health services research. The conference included nearly 100 researchers from 45 VA facilities in 27 states and attendees generated a VA Women’s Health Services Research and Development (HSR&D) agenda [1]. At this conference, a second WVs systematic review was presented, updating the prior review with studies published between 2004 and 2008 [6]. Based on the systematic reviews and an assessment of WVs socio-demographics and health conditions, special priority areas were identified
10.2217/CER.14.4
3(2), 155–166 (2014)
Mark P Bielawski1, Karen M Goldstein2,3, Kristin M Mattocks4,5, Bevanne Bean-Mayberry6, Elizabeth M Yano6,7 & Lori A Bastian*8,9 Center of Excellence, VA Connecticut Healthcare System, Newington, CT, USA 2 Center for Health Services Research in Primary Care, Durham VAMC, Durham, NC, USA 3 Duke University, Durham, NC, USA 4 VA Central Western Massachusetts, Leeds, MA, USA 5 Department of Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA, USA 6 VA Greater Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Sepulveda, CA, USA 7 UCLA Fielding School of Public Health, Los Angeles, CA, USA 8 VA Connecticut Healthcare System, Newington, CT, USA 9 Division of General Internal Medicine, University of Connecticut, Farmington, CT, USA *Author for correspondence: Tel.: +1 860 667 6853 Fax: +1 860 667 6764 [email protected] 1
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at the agenda-setting conference, including the need to research chronic conditions among WVs [1]. The following areas were identified as important to improve the care of chronic conditions among WVs: evaluate and develop interventions for pain and musculoskeletal conditions adapted to WVs needs; improve care for chronic conditions related to lifestyle factors such as obesity and diabetes; assess gender differences in presentation and outcomes of cardiovascular disease and related risk factors such as tobacco use and hyperlipidemia; understand the unique needs of WVs with HIV and focus on gender disparities in care delivery; and examine the quality of cancer prevention, diagnosis and treatment among WVs. The purpose of this article is to review the state of the literature for the previously identified five targeted chronic conditions among WVs to identify opportunities for CER to improve health and healthcare for WVs. We review the relevant articles on chronic conditions in prior systematic reviews and we describe the literature published since the last systematic review was completed. We focused this review on studies that compared men and women or pertained specifically to WVs. Chronic pain
Chronic pain is the most frequent complaint of soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom, and it affects more than 50% of male primary care patients in the VA. Although one study reported that up to 78% of WVs suffer from ongoing pain [7], the systematic review by Goldzweig et al. only found one study that looked at pain among WVs and it was considered in relation to post-traumatic stress disorder (PTSD) [4]. In the systematic review conducted by BeanMayberry et al., there were five studies that looked specifically at pain [6]. Significant findings from these studies included that mastalgia (breast pain) was associated with PTSD and psychiatric illnesses such as major depression, alcohol abuse and eating disorders [8], and that WVs with pain were more likely to have psychiatric conditions such as PTSD and depression, and may need additional resources to adequately manage chronic pain conditions [9]. The other studies characterized pain in WVs and found that pain occurred most commonly in the lower extremities, low back and shoulders [7]. After adjusting for multiple pain sites,
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psychiatric diagnoses, age and comorbidities, WVs had a 27% higher rate of outpatient visits than men [10]. The final study in this group showed that veterans with chronic pain or cancer used complementary and alternative therapies and were interested in these modalities if they were offered by the VA [11]. Overall, the two systematic reviews demonstrated that – despite the high prevalence of pain in WVs – there had been relatively little research in this area. Much of the pain literature during this time reflects the research emphasis on mental health, specifically PTSD, but some attempts have been made to quantify and characterize WVs who suffer from chronic pain. We identified 14 new studies directly pertaining specifically to WVs with pain since 2008 (see Table 1). Generally, the topics of these articles were diverse; all but one of the studies was descriptive in nature. One study focusing on a sample of 1004 WVs found that 71% of participants reported chronic pain and that chronic pain was associated with significantly lower physical health status [12]. Among WVs referred for treatment of MST, 66% reported chronic pain [13]. With regards to gender-specific pain syndromes, Weitlauf et al. found that pain associated with pelvic examination was highest for women with prior sexual violence and PTSD [14], and Cohen et al. found more gender-specific pain syndromes among WVs with any mental health diagnosis [15]. In an ethnography of chronic pain among WVs, participants describe their experiences with pain during military service [16]. Several studies have examined gender differences in the prevalence of pain among veterans. In a national study of Iraq and Afghanistan veterans, WVs were less likely to report any pain [17]. Among those with any pain, WVs were more likely to report moderate–severe pain compared with male veterans [17]. In another study among Connecticut (USA) war veterans of Iraq and Afghanistan, there were no significant gender difference in pain scores [18]. However, WVs were more likely to screen positive for military sexual trauma and depression and less likely to screen positive for PTSD compared with male veterans [18]. In a study examining sex differences in noncancer chronic pain, WVs were more likely to be diagnosed with two or more pain conditions and less likely to receive chronic opioid therapy [19,20]. Carlson et al. found that headache diagnoses were 1.6-times more prevalent among
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WVs compared with men [21]. Among Iraq and Afghanistan veterans, WVs were more likely to endorse back pain and headaches [22]. Overall, WVs were more likely than men to have back problems, musculoskeletal problems and joint problems WVs with chronic low back pain had greater depression and may benefit more from yoga compared with men [23]. A study of rural WVs found a telemedicine pain intervention feasible and acceptable [24]. One study that looked at pain-related outcomes between veterans with major depressive disorder treated with duloxetine versus other antidepressants found that subjects treated with duloxetine had lower risks of substance abuse and opioid use and lower healthcare utilization compared with those treated with other antidepressants [25]. The overlap of pain and substance use found in this study was also highlighted in a recently published review on substance use among WVs [26]. Diabetes
Diabetes affects more than 10% of women in the USA. [103]. Obesity, a major risk factor for diabetes, affects up to 37% of WVs compared with nearly 34% of male veterans [104]. Goldzweig et al. only identified two studies concerning ‘endocrinology’, and they did not note any studies specifically focusing on diabetes [4]. Bean-Mayberry et al. found two studies on diabetes [6]. One study looked at gender differences in diabetes care [27] and the other study examined diabetes care among WVs with disabilities [28]. These studies found that WVs were less likely to have low-density lipoprotein (LDL) less than 130 mg/dl compared with men. In the literature review for this special report, we identified a relatively large number of new studies on diabetes among veterans. Most studies were secondary analyses of large national databases or small interventions studies that only included 2–5% WVs and did not analyze for possible gender differences. We identified four studies that pertained to WVs (see Table 1). Banerjea et al. looked at the prevalence of substance use disorders and mental illness in a large sample of 16,368 WVs with diabetes. These authors found that 45% of this population had a mental illness, a substance use disorder or both conditions [29]. Another study examined gender differences in lipid-lowering treatments among veterans with diabetes [30]. They found WVs received less aggressive use of lipid therapy
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compared with men, especially among younger age groups. In this large national database, the authors oversampled WVs and matched women to men in a 1:4 ratio on age and VA facility. In a more recent study, among veterans with diabetes aged 50–75 years, Vimalananda and her colleagues explored gender differences in lipid management [31]. They found WVs among the highest-risk group (those with ischemic heart disease) were less likely to meet lipid goals. Finally O’Toole et al. used a pre–post study design to examine the impact of a populationspecific medical home on healthcare utilization and found that WVs receiving primary care in a population-specific medical home increased primary care utilization and chronic disease monitoring compared with WVs assigned to a general internal medicine clinic [32]. Cardiovascular disease risk
In the USA, one in three women dies from cardiovascular disease (CVD), and this condition is the leading cause of mortality in WVs [105]. Risk factors for CVD include smoking, high cholesterol (hyperlipidemia), obesity (discussed in the section ‘Diabetes’) and high blood pressure (hypertension) [106,107]. In Goldzweig et al. there were only two descriptive studies on heart disease and its risks factors [4], including one study that described at-risk WVs’ limited concerns about and knowledge of coronary artery disease [33] and one that looked at smoking characteristics, such as nicotine dependence, in female veterans [34]. Bean-Mayberry et al. identified a total of ten descriptive studies concerning CVD and its risk factors, demonstrating a significant increase in the body of literature on this topic when compared with Goldzweig et al. [4,6]. There were two studies on cardiac risk, including one linking a history of military sexual assault to the presence of risk factors for CVD and one that analyzed all-cause and cause-specific mortality in Vietnam-era WVs (including circulatory system diseases such as CVD) [35,36]. Of the four studies on smoking, two looked at designing a smokingcessation program for WVs [37,38]; one looked at noncigarette tobacco (cigars, smokeless tobacco and so on) use in young military recruits [39]; and the last study looked at gender differences in smoking-cessation services received among veterans [40]. Bean-Mayberry et al. found two studies focusing on lipid screening. The first study is also
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans†. Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
Pain/chronic pain Weitlauf et al. (2008)
67
100
Patient survey
Pain associated with pelvic examination was highest for women with prior sexual violence and PTSD
[14]
Haskell et al. (2009)
153,212
12
National VA database
WV were less likely to report any pain compared with men. Among those veterans with any pain, WV were more likely to report moderate–severe pain and less likely to report persistent pain
[17]
Haskell et al. (2010)
1129
17
VA medical record review
There were no significant gender differences in pain but WV were more likely to screen positive for MST, depression and PTSD
[18]
Kelly et al. (2011)
135
100
Patient survey and VA medical record review
Among WV referred for MST treatment, 95% reported at least one trauma in addition to MST. 66% of WV with trauma history reported chronic pain
[13]
Shi et al. (2012)
878
28
Veterans with depression
Looked at pain-related outcomes between veterans with major depressive disorder treated with duloxetine versus other antidepressants, finding that subjects treated with duloxetine had lower risks of substance abuse and opioid use, and lower healthcare utilization compared with those treated with other antidepressants
[25]
Groessl et al. (2012)
53
24
Veterans with back WV with chronic low back pain had greater depression and pain pain attending may benefit more from yoga compared with men yoga program
[23]
Haskell et al. (2012)
450,329
12
National VA database
The prevalence of painful musculoskeletal conditions increased each year after deployment. After adjustment for significant demographic differences, WV were more likely than men to have back problems, musculoskeletal problems and joint problems
[20]
Booth et al. (2012)
1004
100
Patient telephone interviews
71% of WV reported history of chronic pain and pain was associated with history rape in military and current PTSD
[12]
Cohen et al. (2012)
71,504
100
National VA database
44% of WV using VA healthcare received at least one mental health diagnosis. WV with any mental health diagnosis had significantly higher prevalence of gynecologic pain syndromes
[15]
Runnals et al. (2013)
1614
21
Clinical interview and survey
Highest rate of pain complaints was observed in veterans with comorbid PTSD and depression. WV were more likely to endorse back pain and headaches
[22]
Tan et al. (2013)
34
100
Veterans with pain and comorbid depression and/or PTSD
WV living in rural areas with chronic pain and comorbid depression and/or PTSD found a telemedicine group therapy intervention plus biofeedback acceptable and improved pain and mental health symptoms
[24]
Carlson et al. (2013)
470,215
13
National VA database
Headache diagnosis 1.61-times more prevalent among WV (18%) compared with men (11%)
[21]
Denke and Barnes (2013)
15
100
WV with pain
WV describe their experiences with pain during their military duty and after discharge or retirement
[16]
Weimer et al. (2013)
17,583
11
National VA database
In a cohort of veterans with moderate–severe pain, WV were more likely to be diagnosed with two or more pain conditions and had lower odds of being prescribed chronic opioid treatment compared with men, especially among younger veterans
[19]
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans† (cont.). Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
Banerjea et al. (2009)
16,368
100
National VA database
45% of WV with diabetes had a mental illness, substance use disorder or both
[29]
O’Toole et al. (2011)
457
32
WV VA users at one site
Increase in primary care use, monitoring of blood pressure/ cholesterol and decrease in hemoglobin A1C among WV receiving care in a population specific-medical home versus a general internal medicine clinic
[32]
Vimalananda et al. (2011)
111,906
20
National VA database
WV with both diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men
[30]
Vimalananda et al. (2013)
668,209
3
National VA database
WV were less likely to have LDL 130 compared with men (27 vs 17%). One-third of the gender difference could be explained by individual characteristics such as age
[47]
Steinman et al. 2,002,693 1.9 (2012)
VA and Medicare databases
Hypertension, hyperlipidemia and arthritis were the most frequent three-way combination of illnesses when considering 23 common conditions in WV, affecting 25% of this population
[53]
Vimalananda et al. (2013)
2,527,496 10
Diabetes Epidemiologic Cohort (DEpiC)
Diabetes, HTN and hyperlipidemia were common among all veterans
[50]
Rose et al. (2013)
3611
100
Patient telephone survey
Black WV were more likely to report a diagnosis of diabetes or hypertension and to be obese than white WV
[51]
8300
3
Veterans Aging Cohort study
Compared to men, WV experienced less improvement in overall burden of disease after 1 year of HIV treatment
[55]
Sambamoorthi 527,568 et al. (2012)
HIV Blackstock et al. (2013)
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
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Table 1. Summary of the literature identified on the five chronic disease topics pertaining specifically to women veterans or comparing men and women veterans† (cont.). Study (year)
Overall sample
Women Data sources veterans (%)
Selected findings
Ref.
48%
Medical record review
Autonomic neuropathy in HIV-infected veterans of both sexes was underdiagnosed and associated with a higher burden of illness and a higher predicted mortality risk
[56]
HIV (cont.) Robinson-Papp 102 and Sharma (2013) Cancer Griffin et al. (2009)
345
37
Medical record review
Male veterans were more likely than WV to falsely report having a screening sigmoidoscopy or colonoscopy. Rates of over-report for FOBT and barium enema were similar between the sexes
[76]
Leong et al. (2009)
82
100
Local VA database
Breast reconstruction rates among WV with breast cancer were 42% after mastectomy and 22% overall
[74]
Lairson et al. (2011)
5500
100
National sample of The tailored intervention was dominated (more costly and less WV >52 years in effective) by the targeted intervention a mammography intervention
[70]
Yee et al. (2011)
606
100
Local VA database
WV with mental illness were less likely to adhere to breast cancer screening recommendations
[72]
Gellad et al. (2011)
1,112,645 2.8
National VA database
WVs were more likely than men to have adequate colorectal cancer screening with FOBT alone or FOBT and sigmoidoscopy, colonoscopy or barium enema. Adherence to repeat FOBT was low and similar between genders
[75]
Yoon et al. (2012)
423,283
100
National VA database
Gender-specific conditions, cancer, musculoskeletal disease and mental health/substance abuse illnesses accounted for a greater share of overall costs during the study periods of 2000 and 2008
[2]
Luther et al. (2013)
1161
100
National VA database
Breast conserving surgery rates were similar in WV to the nonveteran population after accounting for surgeries paid for by VA and performed in outside facilities
[73]
Weitlauf et al. (2013)
34,213
100
National VA database
PTSD or depression did not have an effect on receipt of cervical cancer screening
[71]
Studies identified since the last systematic review was completed [6]. FOBT: Fecal occult blood testing; HTN: Hypertension; LDL: Low-density lipoprotein; MST: Military sexual trauma; PTSD: Post-traumatic stress disorder; VA: Veterans Affairs; WV: Women veterans. †
mentioned in the ‘HIV’ section and looked at lipid screening rates in HIV-infected veterans [41], and the second one also focused on a specific subpopulation, calculating the rate of cholesterol testing among veterans with mental illness [42]. The two diabetes studies in Bean-Mayberry et al. also considered lipid testing among WVs [27,28]. In the first study by Tseng and colleagues, women were more likely to have LDL 65 years), women were less likely to
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receive adequate hypertension control compared with men in VA [43]. Despite the importance of hypertension as a risk factor for CVD in women, there were no other studies in either review that looked at this condition directly. We identified several new studies that examined risk factors for CVD since the last systematic review (see Table 1). In a cross-sectional study conducted from 2004 to 2006, 67% of participating WVs were categorized as moderate-to-high risk for CVD [44]. Smoking prevalence among WVs was highest (44%) among those born between 1985 and 1989 [45]. Wheeler et al. examined the adherence to guideline-based therapy for acute myocardial infarction in VA hospitals and found that WVs received a similar
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level of care (i.e., cardiac catheterization) to men [46]. One study focused on gender differences in LDL levels [47] and another study examined determinants of response to statin medications [48]. These authors found the gender difference in poor lipid control was mostly explained by age, physical illnesses, lower use of lipid lowering medications and depression [47,48]. Given the prior emphasis on mental health research among WVs, Shen et al. found a 27% rate of depressive disorders among WVs with diabetes, heart disease and hypertension [49]. In a recent Journal of General Internal Medicine supplement on WVs research, two studies focused on CVD risk. Vimalananda et al. reported results of a cross-sectional study from the Diabetes Epidemiologic Cohorts, a national longitudinal data set of patients in the VA system and found that both male and female veterans have high rates of CVD risk factors [50]. Rose et al. go further to explore racial and ethnic differences in CVD risk factors in the 2008–2009 National Survey of Women Veterans [51]. In this study, black WVs were more likely to report a diagnosis of diabetes or hypertension and to be obese than white WVs [51]. We also identified studies on other topics linking WVs and CVD. Virani et al. found that WVs with CVD and a LDL level of >100 were less likely to receive treatment intensification with a cholesterol lowering drug than other subgroups, such as diabetics and hypertensive patients [52]. Finally, Steinman et al. found that hypertension, hyperlipidemia and arthritis was the most frequent three-way combination of illnesses when considering 23 common conditions in WVs, affecting 25% of this population [53]. HIV
The CDC estimates that approximately one quarter of those infected with HIV in the USA are women [108]. There were no studies in Goldzweig et al. that analyzed HIV-infected WVs, and there were only two descriptive studies in Bean-Mayberry et al. that analyzed infected veterans of both genders [4,6]. One study looked at lipid screening rates in veterans with HIV taking protease inhibitors [41], and the other compared the health-related quality of life between HIVinfected patients receiving care in the VA and their non-veteran counterparts receiving care in non-VA settings [54]. We identified two new articles in our literature review that pertained to HIV and WVs (see Table 1). Blackstock et al. addressed whether sex
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differences in disease burden exist among a cohort of HIV-infected veterans after 1 year of antiretroviral therapy and found that WVs experienced less improvement in disease burden after treatment compared with men [55]. In a small study, Robinson-Papp and Sharma found that autonomic neuropathy in patients with HIV was underdiagnosed and associated with a higher burden of illness and a higher predicted mortality risk [56]. Cancer
Cancer is the second leading cause of death in US women [109], and breast, lung and colorectal cancer are the three most common malignancies and causes of cancer death [110]. Among the chronicdisease categories considered in this article, breast cancer represented the largest amount of literature in the combined reviews [4,6]. In Goldzweig et al., there were four studies about breast cancer screening [57–60], one study about women’s perception of breast cancer risk [61] and one study about breast cancer surgery trends and outcomes [62]. In Bean-Mayberry et al. there were three studies about breast cancer screening (all on mammography) [63–65], one about WVs’ perceived susceptibility to breast cancer [66] and one about breast biopsy [67]. The study on breast cancer surgery trends mentioned in Goldzweig et al. was also included in this review [62]. Interestingly there were a similar number of studies about breast cancer in both systematic reviews, demonstrating a lack of a growth in the body of literature between Goldzweig et al. and Bean-Mayberry et al. [4,6]. It is important to note, however, that breast cancer screening was the target of one of the only randomized trials among WVs [63,64]. Unique to the review by Bean-Mayberry et al. were two studies on colorectal cancer screening – Goldzweig et al. had no articles on this topic [68,69]. These last two studies while not focused on women provided some insight to variations in screening for women and men. One found lower screening rates associated with female gender, black race and low income [68], while the other found gender-specific barriers to the colonoscopy preparation, as well as different fears and attitudes for women compared with men [69]. Although lung cancer is the second most common malignancy diagnosed in women and the number one cause of cancer death in women [109,110], neither review contained an article about the subject [4,6]. In our literature review, we identified eight new studies addressing cancer among WVs (see Table 1). Three studies focused on screening for
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gender-specific cancers such as breast and cervical cancer [70–72]. Two studies described treatment for breast cancer in the VA including a study examining the use of breast-conserving surgery [73] and access to breast reconstruction surgery after mastectomy [74]. And one study on WVs looked at the rates and attributable costs of all cancers and of many chronic conditions including diabetes, congestive heart failure and HIV/AIDS, finding that gender-specific conditions, cancer, musculoskeletal disease and mental health/substance abuse illnesses accounted for a greater share of overall costs during the study periods of 2000 and 2008. These disproportionate costs largely stemmed from higher rates of diagnosed conditions and, for several conditions, higher treatment costs [2]. Although we identified over 30 new articles that examined gastroenterology cancers in veterans, only two studies analyzed their data for gender differences. Over a 5-year period, Gellad et al. found that WVs were more likely than men (43.6 vs 41.1%) to have adequate colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) alone or FOBT and sigmoidoscopy, colonoscopy or barium enema. Adherence to repeat FOBT was low and similar between genders; less than 15% of both groups received exclusive FOBT annually for at least 4 years, which was the amount of testing considered to be adequate for screening [75]. In another study looking at gender differences in CRC screening, Griffin et al. concluded that male veterans were more likely than WVs to falsely report having a screening sigmoidoscopy or colonoscopy. Rates of over-report for FOBT and barium enema were similar between the sexes [76]. We did not identify studies that examined gender differences for lung cancer despite the call from Dr Patricia Hayes, Director of Women’s Health Services for the Department of Veterans Affairs, to examine this important topic [77].
Yet despite the fact that CVD and cancer are two leading causes of death in women, there were fewer studies published on these topics from 2008 to the present when compared with the amount of literature found in the prior systematic reviews. There were also no studies in the systematic reviews and in our updated search that focused on lung cancer. Finally, we found no growth in the amount of studies on HIV in WVs. The updated literature search highlights the need for more research on CVD, cancer and HIV in WVs, and reaffirms that significant gaps remain in achievement of the VA WH research agenda, especially in the area of chronic conditions [1]. Moreover, the majority of published literature is observational and clinical trials are needed. Although WVs comprise 8% of the veteran population and up to 10% in 5 years, very few VA studies have focused on WVs specifically: the majority of research on chronic conditions among veterans incorporated a small percentage of WVs (1–5%) and did not provide gender-specific analyses. There is evidence that analyzing data by gender is critical to improving heathcare. Studies such as Vimalananda et al.’s in veterans with diabetes demonstrate that there are important gender differences in chronic disease treatment and response to care [30,31]. These disparities necessitate studies that compare gender-based outcomes and studies that focus on interventions specifically for WVs. Such research may help guide treatment in ways that maximize quality of life and survival and reduce healthcare costs for all veterans. In the future, we encourage investigators to systematically assess gender differences in prevention/screening, risk reduction and disease management outcomes. This approach moves beyond including gender as a covariate in analyses and includes analyses stratified by gender. Conclusion
Discussion
Prior systematic reviews on WVs have informed the VA WH research agenda [1]. Since 2008, the volume of research studies and published literature on the health and healthcare of WVs has grown modestly in some areas. From 2008 to the present, we identified an increase in the number of studies concerning chronic diseases such as diabetes and chronic pain when compared with the amount of literature identified in Goldzweig et al. and Bean-Mayberry et al., which included all research on WVs up to 2008.
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The noticeable lack in CER creates specific challenges in caring for WVs. It can be difficult to apply study outcomes from a civilian population to veterans; standards of care in the general population may not work well in veterans causing inefficiency, worse outcomes and increased costs. In the future, this paucity of CER could be addressed by using the Women’s Health Practice Based Research Network (WHRN/PBRN). The WHRN/PBRN was started in 2010 to support multisite research within the VA, allowing for the recruitment of larger populations of WVs.
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The WHRN/PBRN now includes 37 US sites that see a high percentage of WVs with certain chronic diseases [5] and is well suited for inclusion of WVs in RCTs – including CER. We encourage investigators to capitalize on the PBRN infrastructure that facilitates multisite research to ensure adequate numbers of women in future chronic disease research and to ensure that all veterans benefit from the knowledge that can be discovered through CER. Future perspective
The goal over the next 5–10 years is to systematically accomplish the VA WH research agenda’s recommendations and accelerate the development and conduct of intervention studies and dissemination of research that addresses chronic conditions among WVs and ultimately improve health and healthcare for all veterans. There is a need to conduct CER on common clinical topics such as CVD, cancer and HIV among WVs.
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Disclaimer The contents do not represent the views of the Department of Veterans Affairs or the United States Government.
Financial & competing interests disclosure This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, HSR&D (CRE 12-008 and SDR 10-012). EM Yano’s effort was funded through a VA HSR&D Senior Research Career Scientist Award (RCS 05-195). M Bielawski is a trainee supported by the Department of Veterans Affairs, Office of Academic Affiliations, Center of Excellence in Primary Care Education at VA Connecticut Healthcare System. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Executive summary Background ■■ Few studies have focused on chronic conditions among women veterans (WVs) such as chronic pain, diabetes, HIV, cardiovascular disease risk and cancer. ■■ Even fewer studies have examined these conditions for gender differences or included enough WVs in clinical trials to test for gender effects. Chronic pain ■■ Pain is a frequent complaint among WVs and studies are needed to understand the most effective treatments for pain conditions. Diabetes ■■ WVs with diabetes may benefit from more effective models of care to achieve better control of diabetes. Cardiovascular disease risk ■■ WVs frequently have co-occurring cardiovascular disease risk factors and interventions that manage multiple risk factors are needed. HIV ■■ WVs with HIV may be under-recognized compared with male veterans. Cancer ■■ Among the three most common cancers of women, no studies were found that addressed lung cancer in WVs.
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