How research drives VA’s approach to women veterans health care

The Veterans Health Administration (VHA) has been steadily improving the way it delivers health care to a growing segment of the veteran population: Women. Research has unpinned many of the care initiatives. To learn more about what is behind much of that research, Federal Drive with Tom Temin spoke with someone deeply involved it, as well as a recipient of a special VA Secretary’s award. Based in Los Angeles, Elizabeth “Becky” Yano is Director and Co-Founder of the VA Women’s Health Research Network.

Interview Transcript: 

Tom Temin Let’s start with the here and now. A lot of the issues that VA had in treating women they have overcome over the past decade or decade and a half now. What are your current research priorities? What is of concern right now in the delivery of health care to women veterans?

Elizabeth Yano It’s a really important question because I think that we are continuing to make really important progress in high priority areas like post-traumatic stress disorder, military sexual trauma, post-deployment health, access to care, and a lot of new areas like reproductive health, rural health, primary care, and areas like depression and anxiety and serious mental illness. And then areas like long term care and healthy aging. When we started, there was not a single published article on older women veterans. It was like they didn’t age. It was just not on anyone’s radar. So we’ve done a lot of work in that area. For me, I think the most important areas are really about better understanding how VA women’s health care is organized. And really what it should look like. Also, thinking about gender tailoring care. Whenever we see gender disparities in quality or patient experience, the ideas really aren’t about trying to make care equal to that of men. It’s about making it fit for women veterans. So a lot of our work now is about transforming health care, about making sure we hear from women veterans not in our ivory towers, in academia, but really get in the trenches alongside the providers and the staff and the women so that we’re designing and testing interventions that work for them. That’s really what’s going to eliminate disparities.

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Tom Temin And if you really look at it, the word women is not really one thing either. There’s a variety of backgrounds and races and so forth within the rubric of women. So it’s really a lot of things you’ve got to look at.

Elizabeth Yano Absolutely. And in fact, while the Women’s Health Research Network, per se, does not span all gender identities in terms of men’s health and the like, the reality is, is we fostered a lot of work in an LGBTQ-plus research work group as well. To make sure we’re thinking about the range of gender identities and thinking about their experiences as well when they come to the VA for care.

Tom Temin And that idea of healthy aging, I guess is really important because in the greater population, women outlive men in general. So you have widows that might be aging all by themselves.

Elizabeth Yano And there’s social support among women veterans is a challenge and making sure that they have access to services and the supports they need in the community and in the VA. It’s really practically untapped research right now. So we’re working to reach out to some of the researchers who focus on geriatrics in healthy aging to make sure that they realize that we want them to include women in their studies and we want to make sure that they are thinking about the measures they need to include and the partnerships they have to have with women veterans to design care that is effective.

Tom Temin Yeah, So it sounds like if you add this all up, the real concern is not this medicine or that shot or this piece of surgery, but really the whole person and the context of that person seems to be what’s driving a lot of health care initiatives these days.

Elizabeth Yano I couldn’t have said it better myself. It really is thinking about tailoring services, understanding contexts. From a research perspective, we were trained to try and like statistically adjust away for individual characteristics. But you and I can’t adjust away our histories, our contexts, our families, our neighborhoods, our risk behaviors, and doctors and nurses and social workers and like shouldn’t be trying to do that either. Right? We have to work with veterans where they are. And our research needs to do the same.

Tom Temin We’re speaking with Becky Yano. She’s director and co-founder of the Women’s Health Research Network at the Veterans Health Administration. And let’s talk about methodologies for research. I mean, in some areas of medicine, you do research on cadavers or in clinical settings of people getting certain treatments. It sounds like there might be a lot of data driven and metadata driven types of studies that your work would entail.

Elizabeth Yano Yeah, I was thinking in one level, there’s not a research methodology I don’t like, but that’s not actually very true. I love the power of health services research. It’s whole people, as you said. It’s studying patients, their providers, their staff, the clinics, the hospitals, whole systems of care. My training is in epidemiology, which is like infectious disease, but most of my work is in chronic disease. And I think about in epidemiology, we were trained to think about being exposed to COVID, exposed to bad eating. I think of it as exposure to the health care system, exposure to your doctors. How do we improve what you’re exposed to in that environment from the moment you leave your house to coming back through the health care system and back home? So in that area, it’s really thinking about what are the key ingredients, if you will, in VA health care that make a recipe for good outcomes. The other key methodology that I work in is called implementation science. And basically, I don’t think most people know that it takes about 17 years on average for research evidence to make it into practice, which means, let’s say there’s some game changing cancer care that comes out. It may be a decade or more before you and I see that, but implementation science is actually about changing that timeline to make things happen faster. So it’s interesting, VA is a global leader actually in implementation science. We’re the largest integrated delivery system in the United States. That means we need to know how to implement evidence faster, better and scale it up more than others. So in this case, I’m randomizing whole medical centers, not just people, to get the whole medical center to do practice in a different way. So those are the kinds of methods that I like to use.

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Tom Temin Do you run into resistance of people that is that are operating the medical centers? Because that’s a whole other question. One of these days for the VA, the people running the medical centers is a challenge for VA often, and they just simply say, well, you’re not going to put me under that microscope.

Elizabeth Yano That’s a great question. The reason why implementation science is important is because it expects there to be different challenges, kind of entropy, people not wanting to change business as usual. And so the interventions we use in implementation science think about individual behavior, organizational behavior, and actually address those things explicitly. So I’ll do things like bring together the frontline doctor with the head of primary care, with the head of women’s health, with the medical center director, and even a VA network director on high, pull them together into a common meeting. And I have methods where basically I level the playing field so that everyone’s voices have equal weight. And then we work through had actually tackle some of those barriers.

Tom Temin Because if you look at implementation science in that 17 year research to clinical deployment cycle, I mean, if you postulate that in the long run we’re all dead. 17 years is a really long time and it’s probably much longer from the first implementation of the pioneers 17 years later till everybody is doing it, that could be another ten years.

Elizabeth Yano Exactly. I mean, one of my recent studies, and it’s what I love about what I am able to do in the VA is that we worked through what’s called an evidence based quality improvement approach to helping VA medical centers gender tailor their primary care models for women veterans needs. And during that study, we found that that improved how primary care teams work together. It improved physicians gender sensitivity. It actually lowered burnout all at the same time frontline providers were improving care in measurable ways. And all of those practices have continued five, six, seven years out to make these evidence based changes as we showed them how to use their own resources in the medical center to make a difference for the veterans they serve.

Tom Temin Sounds like a lot of the work you do could serve almost any type of program, even outside of medicine, that kind of research based feedback. I wanted to return to a couple things you mentioned earlier, and that was PTSD and sexual assault that occurs in the military. And this is a seemingly intractable problem for the military, despite what Congress does and the pronouncements of leadership. Do you ever want to take the military kind of collectively by the collar and say to them, look, this is not just an instance of a crime while under your watch, but the infliction of something that can harm someone for a lifetime, which means we’re going to inherit it as PTSD.

Elizabeth Yano We actually were asked to brief the Department of Defense Independent Review Commission on sexual assault in the military, and I was in the fortunate position to organize the leading experts in that area for women’s health. And during that briefing, we actually made many of those points that we do indeed inherit the misadventures and exposures that happened during military service and were able to communicate the long standing adverse impacts on health, family, home. And the recommendations that came out of that commission acknowledged those and in fact talked about increasing access to evidence based practices for those. But at the end of the day, we need prevention.

Tom Temin Sure. And when looking at the holistic whole person of women in the veterans system, have you had findings or discoveries that actually can translate back to improving care for men? That is to say, value to everybody in the veteran system.

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Elizabeth Yano Absolutely. Absolutely. When we’re thinking about gender tailoring, it is about thinking about what is needed for that veteran and making sure that we are being mindful of any kind of intervention that is going to improve their outcomes. So one example is right now we have someone who’s developing a new intervention to help men who’ve had histories of military sexual trauma. Most military sexual trauma care, and it’s not a condition, it’s exposure, but most care for the consequences of military sexual trauma may end up being in a women’s clinic. And so there has not been very much, if any, research on how do we develop a men’s clinic focused on people with those exposures. And so we are working with someone right now who’s testing an intervention at VA Greater Los Angeles and wanting to do that in a multi-site trial. And it builds on 25 years of work on military sexual trauma, research on women.

Tom Temin And in the course of all of this research, do you ever get a chance to walk down a hallway and talk to a female veteran and say, How’s it going? What can we do better?

Elizabeth Yano I do. I do. And in fact, that was what inspired my work in harassment reduction. And I make a point of always reaching out to a women veteran or a active duty service woman when I’m in the airport or anywhere that I can tell that she has provided service. I just say hello and I tell them what I do and I thank them for their service. And they’re always surprised that there’s research in the VA. They’re even more surprised there’s women’s health research in VA. But I think that one of the things that we learned early on from just these anecdotes in the hallways is that women were coming to the VA once and not necessarily coming back. And we started to talk to women and try and find out why. And one of the reasons was, I get harassed when I come to the VA. So it’s really hard to come see my doctor if I have to run the gauntlet. And so we included questions about that in one of my surveys and found that one in four women veterans were being harassed on their way to see their VA doctor and that that was associated with delayed and missed care. And what’s different in working in the VA as a researcher is I knew that was going to be bad news for people up the chain. We reported those results immediately and they immediately responded with, we need to better understand what works out there to combat harassment. They launched a national end harassment campaign, and then they funded us to actually do more work in that area. And it’s been a tremendous journey. In fact, the rates have gone down from about 25% to closer to 13% because of national initiatives based on talking to some women veterans in a hallway.

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