Comprehensive Women's Health Care Research Articles

Anticipated Impact of Dobbs v Jackson Women's Health Organization on Training of Residents in Obstetrics and Gynecology: A Qualitative Analysis.

On June 24, 2022, the Supreme Court of the United States in the case of Dobbs v Jackson Women's Health Organization ended constitutional protection for abortion, thus severely restricting access to reproductive health care for millions of individuals. Concerns have arisen about the potential impact on medical students, residents, and fellows training in restricted areas and the effect on gynecologic training and the future provision of competent comprehensive women's health care in the United States. To qualitatively explore the anticipated impacts of the Dobbs ruling on training in obstetrics and gynecology (OB/GYN). A participatory action research approach employing methods of qualitative analysis was used. Trainees and leaders in national OB/GYN professional and academic organizations with missions related to clinical care and training of medical students, residents, and fellows in OB/GYN participated. Two focus groups were held via Zoom in July 2022. Using an iterative process, transcripts underwent coding by 2 independent researchers to identify categories and common themes. Themes were organized into categories and subcategories. An additional reviewer resolved discrepancies. Twenty-six OB/GYN leaders/stakeholders representing 14 OB/GYN societies along with 4 trainees participated. Eight thematic categories were identified: competency, provision of reproductive health care, residency selection, inequity in training, alternative training, law-based vs evidence-based medicine, morality and ethics, and uncertainty about next steps. This qualitative study of leaders and learners in OB/GYN identified 8 themes of potential impacts of the Dobbs ruling on current and future training in OB/GYN.

Differential screening for non-viral sexually transmitted infections by type of vaginitis testing.

Data are lacking on adherence to Centers for Disease Control and Prevention testing guidelines among insured US women presenting with vaginal health complaints; thus, we quantified vaginitis testing frequency and assessed the co-testing rate for causes of vaginitis and Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). This was a retrospective analysis of de-identified data from a medical database. Information from women, ages 18-50 years, was obtained from the Truven MarketScan Commercial Database (2012-2017) using Current Procedural Technology codes; chi-square testing was applied to determine co-testing differences for CT/NG based on vaginitis test type. Odds ratios were calculated to determine the association with CT/NG screening across vaginitis testing categories. Approximately 48% of 1,359,289 women received a vaginitis diagnosis that involved a laboratory-based test. Of these women only 34% were co-tested for CT/NG. CT/NG co-testing was highest for those with nucleic acid amplification testing for vaginitis and lowest for those with no vaginitis testing Current Procedural Technology code (respectively, 71% vs 23%, P < 0.0001). The vaginitis nucleic acid amplification test, indicated by CPT code, was associated with statistically significant, higher CT/NG testing rates. Molecular diagnostics may support vaginitis testing in settings that have limited opportunities for microscopy and clinical exams and offer greater opportunity to offer comprehensive women's healthcare that includes testing for chlamydia and/or gonorrhea infections.

Challenges to Engaging Women Veterans in Quality Improvement From Patient Care to Policy: Women's Health Managers' Perspectives.

Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman etal.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration.

Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.

The Motherhood Penalty in Obstetrics and Gynecology Training.

Since 2017, the number of women enrolled in medical schools in the United States has increased steadily. For the average female graduate, residency training will coincide with peak childbearing years. Despite increasingly well-defined parental leave policies in other industries, there is no standardized approach across graduate medical education programs. Physician mothers, particularly those in surgical specialties, have also been shown to be at increased risk for major pregnancy complications and postpartum depression. In addition, despite excellent initiation rates, the majority of breastfeeding trainees struggle with low milk supply, and as few as 7% of physician mothers continue to breastfeed for 1 year. Although the medical field routinely advocates for the benefits of parental leave and breastfeeding for our patients, significant and comprehensive change is needed to ensure that graduate medical education trainees can follow physician-recommended postpartum guidelines without meaningful implications for their careers. In February 2020, the American Board of Obstetrics and Gynecology changed its leave policy, allowing residents to take up to 12 weeks of paid or unpaid leave in a single year for vacation, parenting, or medical issues without extending their training. This change represents an important first step, and, as comprehensive women's health care professionals, our specialty should be leaders in normalizing family building for physicians-in-training. A culture change toward an environment of support for pregnant and parenting trainees and access to affordable, extended-hour childcare are also critical to enabling physicians at all levels to be successful in their careers.

Screen, Notify, See, and Treat: Initial Results of Cervical Cancer Screening and Treatment in Rwanda.

PURPOSETo describe the first year results of Rwanda's Screen, Notify, See, and Treat cervical cancer screening program, including challenges encountered and revisions made to improve service delivery.METHODSThrough public radio broadcasts, meetings of local leaders, church networks, and local women's groups, public awareness of cervical cancer screening opportunities was increased and community health workers were enlisted to recruit and inform eligible women of the locations and dates on which services would be available. Screening was performed using human papillomavirus (HPV) DNA testing technology, followed by visual inspection with acetic acid (VIA), and cryotherapy, biopsy, and surgical treatment for those who tested HPV-positive. These services were provided by five district hospitals and 15 health centers to HIV-negative women of age 35-45 and HIV-positive women of age 30-50. Service utilization data were collected from the program's initiation in September 2013 to October 2014.RESULTSOf 7,520 cervical samples tested, 874 (11.6%) screened HPV-positive, leading 780 (89%) patients to undergo VIA. Cervical lesions were found in 204 patients (26.2%) during VIA; of these, 151 were treated with cryoablation and 15 were referred for biopsies. Eight patients underwent complete hysterectomy to treat advanced cervical cancer. Challenges to service delivery included recruitment of eligible patients, patient loss to follow-up, maintaining HIV status confidentiality, and efficient use of consumable resources.CONCLUSIONProviding cervical cancer screening services through public health facilities is a feasible and valuable component of comprehensive women's health care in resource-limited settings. Special caution is warranted in ensuring proper adherence to follow-up and maintaining patient confidentiality.

Trends in nonresident abortion rates in New York City from 2005 to 2015: a time series analysis

ObjectivesTo examine trends and utilization patterns of NYC abortion services by nonresidents since growing abortion restrictions across many states could drive women to seek care in less restrictive jurisdictions including NYC. Study designWe used data from Induced Termination of Pregnancy certificates filed with the NYC Department of Health and Mental Hygiene in 2005–2015. An autoregressive integrated moving average (ARIMA) model was fit to the monthly nonresident abortion rate time series. Pearson's χ2 tests determined associations between women's residence and other variables. ResultsDuring 2005–2015, 885,816 abortions were reported in NYC, with 76,990 (8.7%) among nonresidents; 50,211 (65.2%) nonresidents lived in other New York State counties. The NYC abortion rate declined from 49.4 per 1000 women 15–44 in 2005 to 32.7 in 2015, while the nonresident rate showed minimal change from 0.12 per 1000 US women 15–44 in 2005 to 0.10 in 2015. ARIMA(0,1,1)(0,0,1) [12] fit the time series indicating minimal monthly changes in nonresident rates reflecting seasonal patterns and shorter-term dependencies between successive observations. Nonresidents differed from residents in all investigated variables including terminating at 20+ weeks (9.0% vs. 2.5%, p<.001) and having procedural methods (87.2% vs. 82.2%, p<.001). ConclusionsNonresidents constituted few abortion patients in NYC with minimal change in nonresident rates in 2005–2015. Nonresidents more often sought later-term abortions and more complicated procedures posing greater associated costs/risks. Monitoring nonresident abortion trends and utilization patterns is valuable for planning local service delivery particularly in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions. ImplicationsWhile we found limited change in nonresident abortion rates in NYC in 2005–2015, other jurisdictions bordering more restrictive states could show different results and should consider conducting similar research. Such analyses are important in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions in the future.

Primary Care Providers with More Experience and Stronger Self-Efficacy Beliefs Regarding Women Veterans Screen More Frequently for Interpersonal Violence

BackgroundMilitary sexual trauma (MST) and/or intimate partner violence (IPV) are common experiences in the growing group of women veterans using the Veterans Health Administration health care system. And even though MST screening is closely monitored at the facility level, little is known about individual primary care provider (PCP) behavior with regard to screening women for MST and IPV. ObjectivesTo understand how PCP experiences and beliefs regarding women's health care influence PCP-reported screening for MST and IPV. Research Design and ParticipantsWe administered a cross-sectional online survey from September 2014 through April 2015 (supplemented by a mailed survey between April and May 2015) to 281 PCPs in 12 Veterans Health Administration medical centers. Measures and AnalysisSurveys measured PCP-reported screening frequency for MST and IPV, experience with women veterans, self-efficacy, gender-sensitive beliefs, and perceived barriers to providing comprehensive care for women. We used multivariable ordered logistic regression analysis to identify correlates of screening, weighted for nonresponse and adjusted for clustering. ResultsNinety-four PCPs (34%) completed the survey. Being a designated women's health provider (p < .05) and stronger self-efficacy beliefs about screening women for MST (p < .001) were associated with reporting more frequent screening for MST. Being a designated women's health provider (p < .01), seeing women patients at least once per week (p < .001), and self-efficacy beliefs about screening women for IPV (p < .001) were associated with reporting more frequent screening for IPV. ConclusionsVeterans Health Administration initiatives to enhance PCP opportunities to screen women veterans for trauma and to strengthen self-efficacy beliefs about comprehensive women's health care may increase screening of women veterans for MST and IPV.

Drug abuse and eating disorders in women: symptoms of gender discomfort?

The article discusses drug abuse and eating disorders from the critical gender and healthcare perspectives, postulating that subjective suffering can be expressed in the body through psychosomatic illnesses. From this perspective, craving for drugs or superfluous consumer goods, just as illness from self-imposed hunger in pursuit of an ideal of slimness, as in anorexia and bulimia, can be symptoms that expose the woman's suffering. A review in the fields of public health and feminist theories highlights the magnitude of the phenomena of medicalization and commodification of health in the psychiatrization of female discomfort. In the gender transition in capitalist societies, social demands for the performance of old and new women's roles accentuate feelings of inadequacy, expressed as the gender discomfort permeating drug abuse and eating disorders, analyzed as diseases of protest. The study proposes to reclaim the ideals of the Program for Comprehensive Women's Healthcare to deal with such challenges.

Women's Preferred Sources for Primary and Mental Health Care: Implications for Reproductive Health Providers

PurposeTo describe women's preferences for reproductive health providers as sources of primary and mental health care. MethodsThis is secondary data analysis of the Women's Health Care Experiences and Preferences Study, an Internet survey conducted in September 2013 of 1,078 women aged 18 to 55 randomly sampled from a U.S. national probability panel. We estimated women's preferred and usual sources of care (reproductive health providers, generalists, other) for various primary care and mental health care services using weighted statistics and multiple logistic regression. Main FindingsAmong women using health care in the past 5 years (n = 981), 88% received primary and/or mental health care, including a routine medical checkup (78%), urgent/acute (48%), chronic disease (27%), depression/anxiety (21%), stress (16%), and intimate partner violence (2%) visits. Of those, reproductive health providers were the source of checkup (14%), urgent/acute (3%), chronic disease (6%), depression/anxiety (6%), stress (11%), and intimate partner violence (3%) services. Preference for specific reproductive health-provided primary/mental health care services ranged from 7% to 20%. Among women having used primary/mental health care services (N = 894), more women (1%–17%) preferred than had received primary/mental health care from reproductive health providers. Nearly one-quarter (22%) identified reproductive health providers as their single most preferred source of care. Contraceptive use was the strongest predictor of preference for reproductive health-provided primary/mental health care (odds ratios range, 2.11–3.30). ConclusionsReproductive health providers are the sole source of health care for a substantial proportion of reproductive-aged women—the same groups at risk for unmet primary and mental health care needs. Findings have implications for reproductive health providers' role in comprehensive women's health care provision and potentially for informing patient-centered, integrated models of care in current health systems.

Changes in the Practice of Obstetrics and Gynecology.

A projected shortage of obstetrician-gynecologists (OB-GYNs) is a result of both the increasing US population and the relatively static number of residency graduates. In addition, generational changes have contributed to increasing subspecialization, more desiring part-time employment, and earlier retirement. This article reviews data regarding changes in the practice of obstetrics and gynecology. Residency education is focusing more on a core curriculum in general obstetrics and gynecology, while subspecialty fellowship training has grown in popularity. There are no recent data to describe whether OB-GYNs are working fewer hours, yet more are employed in larger practices at mostly metropolitan locations. A team-based care model that incorporates nonphysician clinicians and digital conversion of clinical data has been encouraged to increase accessibility, improve comprehensiveness, commit to more continuity of care, and reduce redundancy. Compared with other medical specialists, OB-GYNs retire slightly earlier, especially females who will represent the field more. The specialty is moving toward a more comprehensive women's health care practice model that is more patient-centered, efficient, cost controlling, team-based, and adaptable to the needs of a diverse population. Implications from these changes for our practices and improving patient care are currently unclear and await more reported experience.

Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative.

Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. To evaluate early implementation of this national policy. At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001). VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.

Social support to women after mastectomy: a review study

It is necessary to understand how social support can contribute to minimize the impact of the diagnosis and treatment of mammary tumors in order to underpin the actions of comprehensive women's health care. This study seeks to analyze the contribution of the national and international literature regarding the perceived social support by women diagnosed with breast cancer. Twelve studies were selected from the MedLine, Lilacs and PsycINFO databases over a 10-year period (2000-2010) with pre-defined criteria for inclusion. The results were organized into thematic categories: the perception of family support; perceived social support; the perception of educational support; the need to improve the research and the assistance given to women after mastectomy and their families. The studies dedicated to the subjective dimension of social support are still incipient. The available evidence suggests that the literature is limited to topics of interest to the traditional health professions, such as Nursing and Medicine, focusing on constructs that can be directly quantified. The concern with social support must be present from the time of diagnosis to psychosocial rehabilitation, as part of the process of tackling the situation.

Towards comprehensive women's healthcare in sub-Saharan Africa: addressing intersections between HIV, reproductive and maternal health.

:This themed supplement to JAIDS: Journal of Acquired Immune Deficiency Syndromes focuses on the critical intersections between HIV, reproductive, and maternal health services in the health systems of sub-Saharan Africa. The epidemiology of HIV among women of reproductive age on the sub-continent demands a holistic conceptualization and comprehensive approaches to ensure that HIV, reproductive, and maternal health are optimally addressed. Yet, in many instances, the national and global responses to these health issues remain siloed. Women's health needs and new global and national guidelines for HIV treatment raise important policy, programmatic, and operational questions regarding service integration, scale-up, and health systems functioning. In June 2013, the Maternal Health Task Force at the Harvard School of Public Health, the United States Agency for International Development, and the United States Centers for Disease Control and Prevention convened an international technical meeting of researchers, policymakers, and practitioners to discuss the existing evidence base about the interconnections between HIV, reproductive, and maternal health and identify the most important knowledge gaps and research priorities. The articles in this special issue deepen and expand on those discussions by (1) providing empirical evidence about challenges, (2) identifying how improving clinical care and models of service delivery, strengthening health systems, and addressing social dynamics can contribute to better outcomes, and (3) mapping future research directions. Together, these articles underscore that new policy frameworks and integrated approaches are necessary but not sufficient to address health system challenges. Addressing the multiple needs of women of reproductive age who are living with HIV or are at risk of acquiring HIV is a complex undertaking that requires improved access to, utilization and quality of comprehensive women's healthcare. Continued evaluation and knowledge generation are needed to ensure that potential health gains are actualized.

Association between Women Veterans' Experiences with VA Outpatient Health Care and Designation as a Women's Health Provider in Primary Care Clinics

BackgroundWomen veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. MethodsSecondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. FindingsOf the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. ConclusionsThe main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.

Still Piecing It Together: Women's Primary Care

The 20-year anniversary of Women’s Health Issues is an opportune time to consider whether the past two decades have seen substantial progress in improving primary care for American women. At least as early as 1992, when Clancy and Massion (1992) described women’s health care as ‘‘a patchwork quilt with gaps,’’ health services researchers and health care providers have been aware of the unique challenges to providing coordinated, comprehensive, high-quality primary care services to women. One of the major issues is how to integrate and coordinate routine reproductive health services with other components of women’s primary care in a seamless delivery system. This is not a trivial question, because reproductive caredincluding, for example, contraceptive services, pregnancy-related care, infertility services, gynecological care, and gender-specific cancer screeningdis needed by all women at some point in their lives. Despite the fact that women are the majority of health care consumers, this issue has not beenwidely recognized by those promoting ideal conceptions of ‘‘primary care’’ or the newer concept of a ‘‘patient-centered medical home.’’ Have we made any progress at all? Historical patterns of care delivery based on the specialty areas of physicians, as well as on the ways in which health services are funded or reimbursed, have resulted in fragmented primary care for women. Most women have directly experienced fragmentation. Any womanwho has visited her family physician for a regular checkup and then had tomake a separate visit (with another copay) for a routine Pap smear understands that her convenience and needs are not foremost in the design of basic health services. Anywomanwhose obstetrician-gynecologist has told her that she has to go elsewhere for a cholesterol test knows that a reproductive health specialist does not provide comprehensive care. Any womanwho reports symptoms of postpartum depression or consequences of intimate partner violence to her

Factors associated with the risk of progression to precursor lesions or cervical cancer in women with negative cytologic findings

Objective To evaluate factors associated with progression to cervical cancer or moderate to severe precursor lesions (cervical intraepithelial neoplasia grade 2 [CIN 2] or higher) in women with negative cervical screening results. Method A cohort of 1236 women from the state of Rio de Janeiro, Brazil, was followed up for 36 months. Hazards ratios (HR) and related 95% confidence intervals (CIs) were calculated, and the Cox proportional hazards model was used to evaluate factors associated with the development of lesions grade CIN 2 or higher. Results After adjusting for age, education level, number of sexual partners, and parity, the presence of CIN 2 or more advanced lesions was associated with HPV infection (HR, 39.0; 95% CI, 9.8–156.0), smoking (HR, 7.7; 95% CI, 2.0–29.6), and early age at first sexual intercourse (HR, 4.1; 95% CI, 1.1–15.1). Conclusion These findings suggest that women at increased risk for cervical cancer be screened for HPV at the time of cervical screening, particularly in areas where access to health services is difficult. Antismoking strategies especially targeting young women should be a priority in a comprehensive women's health care program.

Diffusion of innovation in women’s health care delivery: The Department of Veterans Affairs’ adoption of women’s health clinics

In response to concerns about the availability and quality of women's health services in Department of Veterans Affairs (VA) medical centers in the early 1990s, Congress approved landmark legislation earmarking funds to enhance women's health services. A portion of the appropriation was used to launch Comprehensive Women's Health Centers as exemplars for the development of VA women's health care throughout the system. We report on the diffusion and characteristics of VA women's health clinics (WHCs) 10 years later. In 2001, we surveyed the senior women's health clinician at each VA medical center serving > or =400 women veterans (83% response rate) regarding their internal organizational characteristics in relation to factors associated with organizational innovation (centralization, complexity, formalization, interconnectedness, organizational slack, size). We evaluated the comparability of WHCs (n = 66) with characteristics of the original comprehensive women's health centers (CWHCs; n = 8). Gender-specific service availability in WHCs was comparable to that of CWHCs with important exceptions in mental health, mammography and osteoporosis management. WHCs were less likely to have same-gender providers (p < .05), women's health training programs (p < .01), separate women's mental health clinics (p < .001), separate space (p < .05), or adequate privacy (p < .05); however, they were less likely to have experienced educational program closures (p < .001) and staffing losses (p < .05) compared to CWHCs. Diffusion of comprehensive women's health care is as yet incomplete. More research is needed to examine the quality of care associated with these models and to establish the business case for managers faced with small female patient caseloads.

A comprehensive women's health care center: Are gynecologists offering primary care?

The purpose of this study was to compare patient characteristics and diagnoses in a comprehensive Women's Health Care Clinic between gynecologists and internal medicine physicians. This retrospective cohort study evaluated International Classification of Diseases, 9th Revision, codes that were recorded between January 1, 2001, and January 4, 2004, at the Women's Health Care Clinic. We compared demographics and prevalence of diagnosis codes for patients who were seen by obstetricians/gynecologists and internal medicine physicians and compared these data with national survey statistics. A sampling of charts was reviewed for coding verification. We analyzed 13,462 visits at the Women's Health Care Clinic. Patients who were seen by internists were older, had greater racial diversity, and had more gender-nonspecific medical disorders (hypertension, depression). Gynecologists saw more specific women's health problems (P < .05). The diagnoses of menstrual disorders, menopause, pelvic pain, and abnormal cytologic findings within the Women's Health Care Clinic follow closely with the national ambulatory survey data. Within this multispecialty Women's Health Care Clinic, internal medicine physicians are practicing primary care and obstetricians/gynecologists are providing specialty care.

Life span and repeated violence against women during military service: effects on health status and outpatient utilization.

To determine whether the type or frequency of intentional violence experiences among women during military service influences health status or healthcare utilization. Differences in utilization and health status were also examined while controlling for life span violence exposures and important patient characteristic confounders. A cross-sectional survey of women veterans was conducted using a random sample stratified by region and era of service. Women veterans who served in the Vietnam and subsequent eras (n = 520) were selected from comprehensive women's healthcare centers' registries at Department of Veterans medical centers in Boston, Durham, Tampa, Minneapolis, Chicago, and Los Angeles (n = 8693). Socioeconomic information, violence exposure history, outpatient healthcare utilization, and assessment of health status (measured by the Medical Outcomes Study Short-Form 36) were obtained by structured telephone interview. The type of violence women experienced was unrelated to differences in medical utilization. Women reporting repeated violence exposures during military service had significantly more outpatient visits in the year preceding the interview than singly or nontraumatized peers (16 vs. 9 and 8 visits, respectively, p < 0.05). Repeatedly assaulted women also had poorer health status (p < 0.05), and more often reported a history of childhood violence (p < 0.001) and postmilitary violence (p < 0.001). Repeated violence exposure is a relatively common experience among women in the military, and this has substantial implications for their health.