DESCRIPTION (provided by applicant): BACKGROUND/RATIONALE: Among women new to Veterans Health Administration (VHA) in 2006, 30% failed to return in the subsequent two years. With access to care for women Veterans among the top VHA priorities, this rate of attrition of women Veterans from VHA is of major concern. Any effort to assure that women new to the system have access to high-quality, comprehensive women's health (WH) care must account for the perspectives of those not won over by VHA's current delivery system. Therefore, we propose to assess whether and how patient experiences of VHA care contribute to attrition, recognize patient subgroups at risk for attrition, and identify promising, patient-centered remedies. This will set the stage for refinements to national implementation of comprehensive WH care delivery policy. To obtain a multifaceted understanding of the attrition phenomenon, we apply a mixed methods design guided by an innovative combination of Consumer Choice Theory and the Andersen Behavioral Model. OBJECTIVES: Among women Veterans new to VHA, our specific aims are: Aim 1: To identify predictors of attrition (patient experiences of VHA care, VHA organizational factors, community health care resources, patient factors) Aim 2: To determine whether the attrition rate is changing over time Aim 3: To understand perspectives of attritors regarding what aspects of the VHA delivery system led them to leave VHA, and perspectives of non-attritors regarding why they have stayed Aim 4: To explore plans for future VHA use among current VHA users METHODS: This is a mixed methods study. Aims 1 and 2 use quantitative methods with existing databases, including VHA's National Patient Care Database, Medicare data, Medicaid data, and national VHA organizational data. Aim 1 will examine predictors of attrition in a national cohort of ~50,000 women new to VHA in Fiscal Year 2011 (FY11). Aim 2 will examine attrition longitudinally in women new to VHA in FY03- FY11. Aims 3 and 4 use qualitative interview methods. Aim 3 will involve telephone interviews with a national stratified sample of ~125 women primary care patients new to VHA in FY10, composed of attritors and non- attritors from high and low attrition facilities. Aim 4 will involve focus group interviews with recent (FY15) new women Veteran VHA patients at two VHA facilities. IMPACT: Depending upon study findings, domains that could prove to be targets for intervention at practice or policy levels include organization of VHA gender-specific care, gender sensitivity of clinicians and staff, clinician expertise in women's health, service availability in community-based outpatient clinics, and availability of specialty women's health/mental health services in VHA versus through fee basis. Patient subgroups that may turn out to be important targets for future interventions include those with post-traumatic stress disorder, pregnant women using the fee basis system, rural women, dual users, and younger women. As VHA seeks to make its services welcoming and accessible to women Veterans and sensitive to their health care needs, those lost to the system represent a group requiring special targeting. Their experiences may provide clues about how to optimize VHA WH care.

Nearly one third of new women Veterans who recently used the VA did not return in the subsequent two years. Women Veterans are among the fastest growing segment of new Veterans Health Administration (VHA) patients, so it is critical to understand why a sizable proportion do not continue to use VHA on a long-term basis. This study will use existing databases and interviews with new women Veteran VHA patients to understand how patient experiences of VHA care influence their decisions about whether to leave VHA. This can help to inform systems improvements that will benefit all women in VHA. Sustained engagement of women in VHA care could promote preventive care to avert or reduce late-life diseases and their adverse effects on health care costs and quality of life. As VHA seeks to make its services welcoming and accessible to women Veterans and sensitive to their health care needs, those lost to the system represent a group that can fill a gap in our understanding of what will constitute optimal comprehensive health care for all women Veterans.