Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study.

OBJECTIVES: To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. METHODS: We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. RESULTS: Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). CONCLUSIONS FOR PRACTICE: Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Measuring Female Veterans' Prepregnancy Wellness Using Department of Veterans Affairs' Health Record Data.

OBJECTIVE: To estimate the feasibility of using measures developed by the Clinical Workgroup of the National Preconception Health and Health Care Initiative to assess women's prepregnancy wellness in a large health care system. METHODS: We examined Department of Veterans Affairs' (VA) national administrative data, including inpatient, outpatient, fee-basis, laboratory, pharmacy, and screening data for female veterans aged 18-45 who had at least one pregnancy outcome (ectopic pregnancy, spontaneous abortion, stillbirth, and live birth) during fiscal years 2010-2015 and a VA primary care visit within 1 year before last menstrual period (LMP). LMP was estimated from gestational age at the time of pregnancy outcome, then used as a reference point to assess eight prepregnancy indicators from the Workgroup consensus measures (eg, 3 or 12 months before LMP). RESULTS: We identified 19,839 pregnancy outcomes from 16,034 female veterans. Most (74.9%) pregnancies ended in live birth; 22.6% resulted in spontaneous abortion or ectopic pregnancy, and 0.5% in stillbirth. More than one third (39.2%) of pregnancies had no documentation of prenatal care within 14 weeks of LMP. Nearly one third (31.2%) of pregnancies occurred in women with obesity. Among pregnancies with a recent relevant screening, 29.2% were positive for smoking and 28.4% for depression. More than half (57.4%) of pregnancies in women with preexisting diabetes did not have documentation of optimal glycemic control. Absence of sexually transmitted infection screening in the year before or within 3 months of LMP was high. Documentation of prenatal folic acid use was also high. Exposure in the same timeframe to six classes of teratogenic medications was low. CONCLUSION: Despite limitations of administrative data, monitoring measures of prepregnancy wellness can provide benchmarks for improving women's health across health care systems and communities. Areas for intervention to improve female veterans' prepregnancy wellness include healthy weight, optimizing control of diabetes before pregnancy, and improved use and documentation of key prepregnancy health screenings.

Infertility Services for Veterans: Policies, Challenges, and Opportunities.

Infertility prevalence and care needs among male and female Veterans are understudied topics. The Veterans Health Administration (VHA) medical benefits package covers full infertility evaluation and many infertility treatments for Veterans but not, by law, for their spouses. In vitro fertilization (IVF) is also specifically excluded from this medical benefits package by regulation. Congress passed a law in 2016 that allowed VHA to provide IVF to Veterans and their legal spouses, and broader infertility benefits to the legal spouse, if the Veteran has a service-connected condition associated with his or her infertility, with some limitations. As the Veteran population becomes increasingly female, research efforts in reproductive health, including infertility, are expanding and evolving. This includes a nationwide study currently underway examining infertility among male and female Veterans and associations with military-related trauma, such as injury, posttraumatic stress disorder, military sexual trauma, and toxin exposure. In this review, we describe the state of the science and policy on infertility care in the VHA along with challenges and opportunities that exist within the VHA system.

Women Veterans' Experiences with Department of Veterans Affairs Maternity Care: Current Successes and Targets for Improvement.

INTRODUCTION: Little is known about women veterans' experiences accessing and using Department of Veterans Affairs (VA) maternity care, which is nearly all purchased from non-VA providers. OBJECTIVE: To understand women veterans' experiences, preferences, and challenges using VA maternity care. METHODS: We conducted 27 semistructured interviews with women veterans who used VA maternity care during fiscal year 2016. To capture a wide variety of experiences, we randomly sampled veterans from urban and rural VA facilities with higher and lower volumes of VA paid deliveries. All interviews were recorded and transcribed verbatim. Transcripts were analyzed using inductive and deductive content analysis. RESULTS: Themes included experiences initiating prenatal care, obtaining prenatal and lactation classes, the role of maternity care coordinators, mental health care, and satisfaction with care. Women described challenges obtaining authorization for care and establishing care with non-VA providers. First-time mothers appreciated the availability of prenatal and lactation classes. VA maternity care coordinators helped women veterans to navigate the challenges related to VA maternity care, ranging from finding non-VA providers to billing. The majority of participants were engaged with mental health care before pregnancy and continued this care during pregnancy. Women's satisfaction with VA maternity care was impacted by access to supportive, knowledgeable providers; care coordinators; woman-centered labor and delivery experiences; and billing issues. CONCLUSIONS: Our findings provide a portrait of the current state of VA maternity care from the perspectives of women veterans and highlight areas, such as care coordination and woman-centered models for labor and delivery, that can improve satisfaction with care.

Preconception Health Risk Factors in Women with and without a History of Military Service.

INTRODUCTION: Given the increasing number of women service members and veterans of childbearing age, it is important to understand the preconception risks in this potentially vulnerable population. This study compared the prevalence of modifiable preconception risk factors among women with and without a history of service. METHODS: Analyses included data from the 2013 and 2014 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Preconception risk factors included health behaviors, chronic conditions, and mental health among women of childbearing age. Multivariate logistic regressions were used to compare the adjusted prevalence of each outcome among women with and without a history of service. Interaction terms assessed variation by age and history of service. RESULTS: Compared with women without a history of service, women with a history of service reported higher prevalence of insufficient sleep (49.6% vs. 36.3%; p < .001) and diagnosed depression (26.5% vs. 21.6%; p < .01). Women with a history of service were overall less likely to have obesity (19.8% vs. 26.5%; p < .001). Age-stratified results suggested that, compared with women without a history of service, women with a history of service were more likely to smoke in the 25 to 34 age group and reported comparable levels of obesity in the 35 to 44 age group. CONCLUSIONS: Women with a history of service demonstrated a preconception health profile that differs from women without a history of service. It is critical that providers are aware of their patients' military status and potential associated risks.

Care coordination for pregnant veterans: VA's Maternity Care Coordinator Telephone Care Program.

Coordinating care between Veterans Health Administration (VA) and community providers is essential for providing high-quality comprehensive maternity care to women veterans, particularly those with chronic medical or mental health issues. We iteratively developed and assessed feasibility, as well as facilitators and barriers, of implementing the VA Maternity Care Coordinator Telephone Care Program, and identified specific health needs of pregnant women Veterans served by the program. We used three Plan-Do-Study-Act cycles. The final program consisted of materials supporting seven structured phone calls spanning initiation of pregnancy care through six weeks postpartum. We used logs to measure veteran uptake and surveys and field notes to capture care-coordinator perceptions about potential program value and facilitators and barriers to implementing it. We conducted a medical record review assessing pregnant veterans' need for coordination of services for physical and mental health problems and health behaviors. Veterans' uptake was 60%. Implementation facilitators included conducting training sessions for program coordinators and tailoring materials to address differences across VA facilities. Implementation barriers included limited information and communication technology tools to support the program and lack of coordinator time for delivering the telephone care. Among 244 pregnant veterans, 41% had pre-pregnancy chronic physical problem(s); 34% mental health problem(s); 18% actively or recently smoked. Implementation of a telephone-based care coordination program for pregnant veterans was feasible. Effective program spread required tailoring for local variations in resources and processes, investing in information and communication technology tools and allocating coordinator time to deliver care. Pregnant women veterans have a substantial burden of physical health, mental health, and risky health behaviors needing care coordination.

Preconception Care in the Veterans Health Administration.

Preconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.

Coordinating Care Across Health Care Systems for Veterans With Gynecologic Malignancies: A Qualitative Analysis.

BACKGROUND: Veterans concurrently using both Veterans Affairs (VA) and community providers and facilities have increased coordination needs related to bridging their care across health care settings. Women Veterans commonly require a combination of VA and community care if they have women-specific specialty care needs, such as gynecologic malignancies. OBJECTIVES: We assessed VA women's health providers' and administrators' perceptions of coordination challenges for Veterans' gynecologic cancer care, and potential approaches for addressing these challenges. RESEARCH DESIGN AND PARTICIPANTS: We carried out semistructured qualitative interviews with field-based key informants (VA gynecologists, women's health medical directors, and other staff directly involved in women's health care coordination) at 15 VA facilities. Transcripts were summarized in a template to capture key points. Themes were identified and iteratively revised (inductively/deductively) via a collaborative decision-making process utilizing matrices to compare content across interviews. RESULTS: Key informants (n=23) noted that services for patients with gynecologic cancers are provided through a combination of VA and community care with wide variation in care arrangements by facility. Care coordination challenges included care fragmentation, lack of role clarity and care tracking, and difficulties associated with VA and community provider communication, patient communication, patient records exchange, and authorizations. Care coordination roles suggested for addressing challenges included: care tracker, provider point-of-contact, patient liaison, and records administrator. CONCLUSIONS: Experiences in coordinating care for women Veterans with gynecologic malignancies receiving concurrent VA and community cancer care reveal challenges inherent in delivering care across health care systems, as well as potential approaches for addressing them.

Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study.

BACKGROUND: Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system. OBJECTIVE: To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months. MAIN MEASURES: Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG). KEY RESULTS: Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended. CONCLUSIONS: While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans.

BACKGROUND: Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. OBJECTIVES: To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. DESIGN: Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. PARTICIPANTS: Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). MAIN MEASURES: We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. KEY RESULTS: Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). CONCLUSIONS: Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Reproductive Health Management for the Care of Women Veterans.

There are more than 2 million women veterans living in the United States. Many women do not identify themselves as veterans. As women's health care providers, it is important to understand and recognize the potentially complex health and social needs of women veterans and the role of military service on their lives. The reproductive health needs of women veterans may be shaped by their military experiences and coexisting medical or mental health conditions. Military sexual trauma and combat exposure are common causes of posttraumatic stress disorder and can affect overall health and well-being. Screening for military service is important in all women, and inclusion of this as a key demographic variable in research and clinical encounters can further inform health care considerations. The following key topics are addressed: who are women veterans, health and social risk factors associated with a history of military service, reproductive health across the life course, military sexual trauma and reproductive health of women veterans, how to take a military history, and the essential role of women's health providers, including obstetrician-gynecologists, in enhancing health systems and providing high-quality care to veterans.

Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort.

INTRODUCTION: Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans. PURPOSE OF THE STUDY: To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans. DESIGN AND METHODS: We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment). RESULTS: The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans. IMPLICATIONS: Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

Vasomotor Symptoms and Quality of Life Among Veteran and Non-Veteran Postmenopausal Women.

INTRODUCTION: Vasomotor symptoms (VMS), including hot flashes and night sweats, are common among postmenopausal women and are associated with reduced health related quality of life (HRQOL). PURPOSE OF THE STUDY: To determine whether Veterans are more likely to report VMS than non-Veterans, and whether the association of VMS with HRQOL varies by Veteran status. DESIGN AND METHODS: We used data from the Women's Health Initiative Observational Study, including self-reported baseline VMS presence and severity, and HRQOL at follow-up Year 3 (RAND Short Form 36-Item Health Survey). Employing generalized linear models we estimated whether Veteran status was associated with any VMS. We estimated the association between any VMS and HRQOL using linear regression, stratified by Veteran status. Interaction terms were added separately to determine whether the association varied by baseline depression, obesity, or smoking status. RESULTS: The final analyses included 77,153 postmenopausal women (2,004 Veterans). After adjustment, Veterans were no more likely than non-Veterans to report any VMS at baseline (relative risk [RR] 0.97, 95% confidence interval [CI] 0.90-1.04) or moderate to severe VMS (RR 1.03, 95% CI 0.89-1.18). Any VMS was associated with decreased HRQOL at Year 3, particularly among Veterans (mean difference range: Veterans -2.7 to -4.6, p-values < .001; non-Veterans -2.2 to -2.6, 95% CI -0.13 to -0.09, p values < .001). Baseline depression and obesity, but not smoking, amplified the negative association between VMS and HRQOL. IMPLICATIONS: Multicondition care models for postmenopausal Veteran and non-Veteran women are needed that incorporate management strategies for VMS, weight, and depression.

Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care.

OBJECTIVE: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. STUDY DESIGN: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ2 tests with Rao-Scott adjustment. All analyses used sampling weights. RESULTS: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p=.03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p=.02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p=.02]; PTSD, 52.5% vs. 14.8% [p=.02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p<.001). CONCLUSION: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.

Reproductive health diagnoses of women veterans using department of Veterans Affairs health care.

BACKGROUND: Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care. OBJECTIVE: To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses. RESEARCH DESIGN: This study is a cross-sectional analysis of VA administrative and clinical data. SUBJECTS: The study included women Veterans using VA health care in FY10. MEASURES: Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, ≥65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis. RESULTS: The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged ≥65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001). CONCLUSIONS: Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.

Gynecologists in the VA: do they enhance availability of sex-specific services and policies in the emergency department?

OBJECTIVES: To examine the association between on-site gynecology and availability of sex-specific services and policies in Department of Veterans Affairs (VA) emergency departments (EDs). RESEARCH DESIGN: Cross-sectional analysis using data from a VA national inventory of emergency services for women and gynecologist staffing information from the VA Office of Productivity, Efficiency, and Staffing. SUBJECTS: ED directors from all VA medical centers (N=120). MEASURES: We used logistic regression to evaluate the association between on-site gynecologist full-time equivalents (FTEs, <0.5 and ≥0.5), and availability of sex-specific ED services, such as consult and follow-up within VA by a gynecologist, emergency contraception, rho (D) immunoglobulin, pelvic ultrasound, and transfer policies for obstetric and gynecologic emergencies. All analyses were adjusted for number of ED encounters by women. RESULTS: Greater gynecologist FTE (≥0.5 vs. <0.5) was associated with increased odds of on-site availability of a gynecology consultation in the ED [odds ratio (OR)=10.9; 95% confidence interval (CI): 3.2, 36.6] and gynecologist follow-up within VA after an ED encounter (OR=2.5; 95% CI: 1.0, 6.2). A positive trend was seen in availability of rho (D) immunoglobulin (OR=1.4; 95% CI: 0.6, 3.5) and presence of transfer policies for obstetric (OR=1.7; 95% CI: 0.7, 4.5) and gynecologic emergencies (OR=1.6; 95% CI: 0.6, 4.2). Half of the facilities with <0.5 FTE did not have transfer policies in place or under development. CONCLUSIONS: On-site gynecologist FTE is associated with improved availability of sex-specific care in EDs. Development of transfer processes for obstetric and gynecologic emergencies in settings with limited on-site gynecology is needed.

Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications.

PURPOSE OF REVIEW: As the number of women serving in the US military has grown, so too has the number of women using the US Department of Veterans Affairs Healthcare System (VA). This poses tremendous opportunity to integrate reproductive health services across a national healthcare system. This review summarizes the approaches used to assess, rapidly design, and integrate VA's first National Reproductive Health Program. RECENT FINDINGS: Compared with the civilian population, women Veterans have poorer health status including increased likelihood of medical comorbidities and mental health conditions. Given these complex health needs, a health systems approach that integrates reproductive health with other needs is essential in this vulnerable population. SUMMARY: Delivery of high-quality reproductive healthcare must incorporate a systems perspective. Promoting major organizational and cultural change in a national system has required use of an evidence-based strategic framework, which has relied on several key tenets including the following: understanding the population of women Veterans served, developing research-clinical partnerships, building interdisciplinary initiatives for system-wide integration of reproductive healthcare, and developing innovative tools for enhancing care delivery. This approach can serve as a model for other healthcare systems committed to developing an integrated system of reproductive healthcare and addressing reproductive health conditions in women with complex needs.

Credentialing based on surgical volume, physician workforce challenges, and patient access.

Advances within the medical profession have resulted in an increase in available medical therapeutic options and minimally invasive surgical techniques for common gynecologic conditions. In many circumstances, this has led to a reduction in surgical volume for many common conditions in benign gynecology. There is also some evidence that a threshold number of cases may exist, below which surgical competence may be affected. Although the practice of medicine continues to evolve, there is broad recognition of a projected workforce shortage of physicians. If credentialing or privileging bodies establish criteria based solely on the number of procedures performed by an individual physician, patient access may be greatly affected. From a public health perspective, these issues cannot be considered in isolation. Thoughtful analysis of existing data and recognition of patient access issues should be carefully weighed before any dramatic changes in hospital privileging or hiring practices. Consideration for ongoing maintenance of credentialing should be carefully balanced and strategies for ongoing assurance of competency may require creative alternatives to simple numerical documentation. Differential approaches to regions with different densities of physicians may also be necessary.