A clinical pharmacy specialist with the Department of Veterans Affairs (VA) described how the department is trying to address the needs of female veterans, including their reproductive health, as well as addressing disparities in chronic diseases.
Although their total overall numbers are still small compared with men, the explosive percentage growth of women in the military over the past 2 decades and their accompanying health needs has changed how the Department of Veterans Affairs (VA) is trying to deliver primary care to this group of veterans.
That was the message conveyed by a keynote speaker at the American Society of Health-System Pharmacists (ASHP) 2022 Midyear Clinical Meeting & Exposition. Chasitie Levesque, PharmD, is a clinical pharmacy specialist at the Jesse Brown Veteran Affairs Medical Center in Chicago, Illinois, and the Veterans Integrated Service Network women veteran program manager and clinical pharmacy program manager.
During the W. Mike Heath ASHP Federal Forum, she presented “Women’s Health: The Role of the Clinical Pharmacist Practitioner in Recognizing and Managing Health Disparities.”
“Women veterans are the fastest-growing population in [Veterans Health Administration],” said Levesque, who started one of the first Women’s Health Clinical Pharmacy services in 2005.
As such, they have gender-specific health needs that clinical pharmacists should be ready to serve, she said. Women account for 18% of the military, and there are more than 2 million female veterans.
About half of the female veterans (350,000) seeking care at the VA are of reproductive age, and the vast majority (72%) have a service connection, meaning their medical condition was directly caused by their service, of 30% or higher.
While the male population of veterans is older, peaking at about age 70, and is leveling off, the female demographic is younger, peaking at 2 age groups, 25 to 40 years and about 50 to 60 years. They are also more racially and ethnically diverse.
Women also have higher rates of service-connected disability, 52% compared with 39% of men.
Providing Reproductive Health Services to Veterans
Levesque briefly reviewed several policies that relate to reproductive health care, including emergency contraception, contraception, infertility, and access to abortion services.
According to Levesque, levonorgestrel, also known as Plan B One Step, must be available to all women veterans on the same day as their appointment. If a provider has requested to opt out from providing emergency contraception, claiming their conscience does not allow it, there must be a process in place so that the drug is still available on the same day.
In addition, the VA supports advanced provision of levonorgestrel for patients who are on high-risk teratogenic medications. There also needs to be teratogenic medication monitoring and discussions with patients about the fetal risks if they become pregnant.
“You will be surprised when you work with patients. I've had patients over the years tell me, ‘Well, I just thought I was taking so many toxic medications that there's no way I could become pregnant.' That's not the case,” Levesque said.
In addition, all veterans are eligible to receive infertility care. While the VA does not employ obstertricians, veterans can fill certain prescriptions they received outside the VA at VA pharmacies, including controlled ovarian stimulation and ovulation induction and injectable gonadotropin medications.
Until recently, in vitro fertilization (IVF) was not included. As a result of a legislative change a few years ago, IVF is now covered if the reason for it stems from a service-connected health issue.
Levesque also touched on the change the VA made about abortion in the wake of the Supreme Court’s decision in June overturning Roe v Wade. Interim final rule AR57, Reproductive Health Services, which went into effect in September, removed the exclusion on abortion counseling in its medical regulations. It also created exceptions to performing abortions, saying it would now do so in cases where the woman’s life is endangered or in cases of rape or incest.
She also noted the forthcoming implementation of a new law to reduce maternal mortality in the VA by following new mothers for 12 months postpartum. Last year, President Joe Biden signed the bipartisan Protecting Moms Who Served Act. Recent research indicates female veterans have higher rates of maternal mortality.
Addressing Gender Disparities
While it is not mandatory, the VA recommends that female veterans be cared for in a patient aligned care team (PACT), which consists of the primary care provider, the clinical pharmacy practitioner, a dietician/nutritionist, a military sexual trauma coordinator, mental health and social work specialists, and more.
The top 5 clinical pharmacy interventions seen in female veterans are for mental health, diabetes, pain, anticoagulation, and hypertension, Levesque said; 28% of interventions are for mental health.
Reducing the differences in prescriptions for statins and diabetes drugs between men and women is an area the VA is trying to address, she said.
In the youngest demographic, she said, “there may have been some hesitancy with reproductive health concerns.”
Percentages of patients with diabetes prescribed statins are similar. For individuals younger than 50 years, 59% of women are being prescribed a statin, compared with 71% of men. In patients between the ages of 50 and 64 years, 73.5% of women with diabetes are prescribed a statin, compared with 78% of men. For those 65 years and older, almost 75% of women are prescribed a statin, versus 80% of men.
To close these gaps, a new cardiovascular working group, in collaboration with other federal health offices, aims to collect evidence-based data to create dahsboards and pilots to improve care.
“The take-home message is, we're seeing that our women with cardiovascular disease are not being treated at the same levels as the male side,” Levesque said.