Integration of Women Veterans into VA Quality Improvement
Research Efforts: What Researchers Need to Know
Elizabeth M. Yano, PhD, MSPH1,2, Patricia Hayes, PhD3, Steven Wright, PhD4,
Paula P. Schnurr, PhD5,6, Linda Lipson, MA7, Bevanne Bean-Mayberry, MD, MSHS1,8,
and Donna L. Washington, MD, MPH1,8
1VA Greater Los Angeles HSR&D Center of Excellence, Sepulveda, CA, USA;2Department of Health Services, UCLA School of Public Health, Los
Angeles, CA, USA;3U.S. Department of Veterans Affairs, Women Veterans Health Strategic Health Care Group, Office of Public Health &
Environmental Hazards, Washington, DC, USA;4Office of Quality & Performance, Veterans Health Administration, Providence, RI, USA;5White River
Junction VA Medical Center, National Center for PTSD, White River Junction, VT, USA;6Dartmouth Medical School, Hanover, NH, USA;7VA HSR&D
Service, Office of Research & Development, Veterans Health Administration, Washington, DC, USA;8Department of Medicine, UCLA School of
Medicine, Los Angeles, CA, USA.
The Department of Veterans Affairs (VA) and other
federal agencies require funded researchers to include
women in their studies. Historically, many researchers
have indicated they will include women in proportion
to their VA representation or pointed to their numerical
minority as justification for exclusion. However,
women’s participation in the military—currently 14%
of active military—is rapidly changing veteran demo-
graphics, with women among the fastest growing
segments of new VA users. These changes will require
researchers to meet the challenge of finding ways to
adequately represent women veterans for meaningful
analysis. We describe women veterans’ health and
health-care use, note how VA care is organized to meet
their needs, report gender differences in quality,
highlight national plans for women veterans’ quality
improvement, and discuss VA women’s health re-
search. We then discuss challenges and potential
solutions for increasing representation of women
veterans in VA research, including steps for implemen-
KEY WORDS: quality improvement; disparities; implementation
research; women’s health; veterans.
J Gen Intern Med 25(Suppl 1):56–61
© Society of General Internal Medicine 2009
Ideally, research participants should represent the populations
for whom the resulting treatments or care improvements will be
implemented. For women, concerns about the harm that poten-
tial exposures could have on developing fetuses resulted in
exclusions of women of childbearing age until the early 1990s,
when federal agencies reversed their policies.1–3Federal agencies
now require their funded researchers to include women in their
research in sufficient numbers to enable valid analyses of
differences in intervention effects where pertinent.4Cost cannot
be used as justification for their exclusion, and programs for
effective outreach to recruit women into studies are required.
Research within the Veterans Health Administration has
similar requirements to include women veterans as subjects
whenever appropriate. Historically, many researchers have
either indicated they will include women in proportion to their
representation in VA settings or justified the exclusion of
women veterans based on their numerical minority. Among
researchers who include women, many find general sampling
strategies insufficient to enable subgroup analyses by gender.
However, women’s participation in the military—now 14% of
active military—is rapidly changing veteran demographics.
Women are among the fastest growing segments of new VA
users. Changes in gender mix affect clinical care arrangements
and the mix of services that many VA facilities provide, and
further increase the imperative for researchers to identify
strategies to ensure women veterans’ representation in suffi-
cient numbers to conduct meaningful analyses.
In this paper, we describe women veterans’ use of health care,
how VA care is currently organized, gender differences in quality,
national plans for quality improvement, and advances in VA
women’s health research. We then discuss challenges and poten-
tial solutions for increasing the representation of women veterans
in VA research, building on experiences from the VA’s only
cooperative trial among women veterans as well as other research.
Several VA Health Services Research and Development (HSR&D)
Service funded studies provided source information for this paper,
including Impact of Practice Structure on the Quality of Care for Women
Veterans (phase 1 project no. IIR-04-036 and phase 2 project no. IAE-
07-170), and the Women Veterans Ambulatory Care Use project phase
II (project no. IAE-06-083). Dr. Yano’s effort was funded by a VA
HSR&D Research Career Scientist Award (project no. 05-195), while
Dr. Bean-Mayberry’s effort was funded by a VA HSR&D Career
Development Transition Award (project no. RCD 02-039). We acknowl-
edge the VA Office of Quality and Performance for direct contribution of
results from internal reports on gender disparities in VA quality of care.
The issues summarized in this paper were presented at the National VA
Quality Enhancement Research Initiative (QUERI) Meeting, Phoenix, AZ,
December 12, 2008, and the VA HSR&D Meeting, Baltimore, MD,
February 12, 2009.
Women Veterans: What Do We Know About Them?
In 2008, US women veterans numbered 1.8 million, accounting
for 7.7% of the US veteran population. VA estimates indicate
that women will comprise 10.0% of the veteran population by
2018, and 14.3% by 2033. Younger, on average, than male
veterans (48 vs. 61 years), women veterans are less likely to use
VA health care than male veterans (15% versus 22% in 2007).
However, VA enrollment has reached twice the national level
(44.2%) among women discharged from military service in Iraq
and Afghanistan, and of those VA enrollees, 43.8% have already
made two or more visits. Despite this shift, most of today’s
women veterans obtain all or most of their medical care outside
the VA.5Barriers to VA use include lack of information about VA
eligibility, benefits, and available women’s health-care services,
and perceptions of poor VA quality.6–7
Among women veterans, VA users are more likely than VA
nonusers to have low income, no medical insurance, poor
health status and social support, and a military service-
connected disability.6Their mental health and chronic disease
burdens are comparable to male VA users; top diagnoses
include post-traumatic stress disorder (PTSD), hypertension,
depression, hyperlipidemia, and chronic low back pain.8,9
How is VA Women’s Health Care Organized?
As women veterans have entered the VA health-care system in
increasing numbers, VA managers and providers have strug-
gled with the challenge of organizing and delivering gender-
specific and gender-sensitive services in a system historically
focused on treating men. Currently, most women veterans who
use VA receive care at 1 of about 200 VA medical centers and
large community-based outpatient clinics. Nationally, these
facilities have adopted one of four basic models for delivering
primary care services to women: (1) a separate women’s
primary care (PC) clinic (39%), (2) general PC clinics that
preferentially assign women to designated providers (13%), (3)
a combination of (1) and (2), or (4) general PC clinics where
care for women is fully integrated with that of men (20%).10Of
the two-thirds that have a women’s PC clinic (combining the
39% with and 28% without designated providers), 44% provide
gender-specific exams only. In contrast, most women veterans
obtain their mental health care in fully integrated clinics, with
34% using designated providers and a few VAs creating
separate women’s mental health clinics. Fewer than half of
VAMCs have a gynecology clinic for provision of specialized
women’s health services (44%).11
Gender-specific care (e.g., reproductive health services) and
care for conditions of higher prevalence among women (e.g.,
osteoporosis) or with different clinical presentations (e.g.,
myocardial infarction) imposes considerable training and
experiential requirements on a VA workforce with limited
exposure to female patients. Researchers have described
health-care staff’s difficulty maintaining gender sensitivity, for
example, presuming that women in VA settings are a spouse.12
Lack of privacy due to physical plant and procedural problems
that result in women being denied access to needed specialized
service remain longstanding concerns (e.g., need for separate
inpatient rooms/wards for women).13,14The high prevalence of
military sexual trauma among women veterans also requires a
substantial degree of staff and provider sensitivity, as well as
accommodations in establishing safe and comfortable care
environments.15Understanding how VA care is organized for
women is therefore important for researchers interested in
engaging in women veterans’ research.
How Does Quality of Care Compare for Men
and Women Veterans in the VA
The VA Office of Quality and Performance (OQP) nationally
monitors prevention and chronic disease quality indicators
based on nationally accepted guidelines through externally
performed chart reviews of randomly selected patients at each
VA. OQP oversamples women as part of this assessment,
enabling direct comparisons by gender and providing useful
guidance for areas warranting attention. In 2007, OQP over-
sampled approximately 12,000 outpatient women veterans, age
50–65, to examine age-stratified gender differences in quality.
Overall, quality of care for women veteran VA users is quite
high and outperforms most HEDIS measures among commer-
cial, Medicare, or Medicaid populations.16–19However, signif-
icant and durable gaps in care exist when comparing quality
by gender in VA outpatient settings, including general preven-
tion measures (e.g., colorectal cancer screening, immunization
status, and depression screening) and management of women
veterans with cardiovascular risk [e.g., lower use of cholesterol
medications and poorer low-density lipoprotein (LDL)-choles-
terol control]. Among diabetics, women veterans are signifi-
cantly less likely to have LDL cholesterols lower than 100 (or
<130), testing for proteinuria, or timely retinal examinations.
More research is needed to determine whether these differ-
ences reflect patient characteristics (e.g., medication adher-
ence, differences in access/use),20provider issues (e.g.,
proficiency, attitudes), or organizational factors (e.g., how local
VA care for women is organized and coordinated).10,21
Women Veterans Health Strategic Health-Care
In recognition of the growth of women veterans using VA care,
as well as their unique health-care needs, VA elevated
oversight of women’s health care by creating the WVHSHG in
2007. The WVHSHG provides strategic direction and program-
matic support to address the health care needs of women
veterans and works to ensure that timely, equitable, high-
quality comprehensive health-care services are provided in a
sensitive and safe environment at VA health facilities nation-
wide. The VA also mandated that all VA facilities have a fulltime
Women Veterans Program Manager (WVPM). The WVHSHG
and WVPMs provide built-in partnerships for implementation
research that may directly inform policy and practice initia-
tives (Table 1).
VA Women’s Health Research
In view of the military’s changing demographics and anticipat-
ed impacts on the VA patient population, the VA Office of
Research and Development sponsored development of the
first-ever VA women’s health research agenda in 2004.9The
agenda was the product of a national consensus development
conference attended by representatives from the VA, academia,
and other federal agencies (e.g., NIH, AHRQ).22Conferees
Yano et al.: Inclusion of Women Veterans in VA Research
reviewed the VA’s research portfolio, data on the prevalence of
women veterans’ health conditions, results of a systematic
review of the published literature, and barriers to conducting
research on women veterans.9,23,24In parallel, the VA Cooper-
ative Studies Program funded the first multi-site trial of
treatment for PTSD among women veterans.25
The VA has also identified research priorities for women’s
health, represented by special research solicitations.26High
priority topics include assessments of quality, costs, access,
continuity, and coordination of care for women with different
health conditions (e.g., mental health, gender-specific ser-
vices), for different subpopulations (e.g., by era of service),
across the spectrum of care (e.g., preventive, chronic, acute,
rehabilitative, long-term, and end-of-life care).26The VA also
maintains interest in innovative models of care that facilitate
coordination across providers/settings, or otherwise reduce
gender-related gaps in care.
As a result, the VA’s portfolio has significantly expanded over
the past 5 years(Table 2). These studiesincluderesearchfocused
exclusively on women as well as projects that have made special
efforts to augment samples with women veterans to better
understand, for example, gender differences in post-deployment
re-integration. Current research examines the complex interac-
tions of physical and mental health, unique risks and outcomes
of military service, barriers to care, and patterns of access and
utilization. Reflecting the infusion of returning women veterans,
research is also directed at analyzing the needs and experiences
of the new generation of women from Operation Enduring
Freedom and Operation Iraqi Freedom, including women who
served in the National Guard and Reserves.
VA’s future research agenda will be guided by results from the
growing body of work already underway, in addition to results of
the recently completed National Survey of Women Veterans and
an updated evidence synthesis that will capture the surge in
relevant published literature in the past 5 years (both due out in
late 2009). These will provide a strong knowledge base regarding
women veterans’ health-care needs, access, and utilization, as
well as gaps in care. However, we believe there is an urgent need
for intervention research, to rapidly translate this base into pilot
and larger scale intervention studies. Priorities should include
Table 1. Women Veterans Health Strategic Health-Care Group Priorities: Building a Quality Improvement Research Agenda for Women
Strategic prioritiesQuality Improvement research opportunities
Redesign primary care delivery for women veterans
to integrate gender-specific services
• Evaluate variations in care
• Evaluate quality of care delivered under different care models
• Develop and test new care models
• Develop and test provider education interventions to advance their interest
and proficiency in women’s health
• Develop and evaluate computerized decision support interventions to support
integration of gender-specific care in routine primary care visits
• Develop and evaluate patient navigation and/or care management
interventions to support coordination across VA providers, between
• Evaluate determinants of gender disparities in quality (e.g., patient, provider,
• Identify predictors of quality in high vs. low performing VA networks
and/or facilities (outliers)
• Collect new primary data needed to characterize health or health care needs
not already captured by administrative or performance data (e.g.,
gender-sensitive patient satisfaction)
• Develop and evaluate new gender-specific performance measures (e.g.,
follow-up of abnormal Pap smears)
• Adapt and evaluate “best practice” interventions and other innovations from
private or other public sectors for use in VA
• Adapt interventions found to be effective among male veterans for use among
women veterans (e.g., in different clinic venues, with adapted study materials,
on related conditions)
• Assess health and health care needs among returning women veterans
• Evaluate determinants of post-deployment high utilization among women veterans
• Evaluate patterns of injury and illness, including possible exposures to toxic
substances, animal exposures, evaluation for depleted uranium exposure from
munitions and shielding
• Evaluate quality of care for menstrual disorders, contraceptive management
(consequences of continuous use), pregnancy, infertility, urinary tract infections
(anecdotal reports of high rates)
• Evaluate quality of care coordination for comorbid physical and mental health
• Evaluate transitions from active duty/guard/reserve to home (including role
impacts for mothers, such as attachment disruption and parenting issues, and as
• Develop and test quality improvement interventions based on identified quality
• Evaluate patterns of medication use among women veterans (including access/use
of medications with teratogenic properties as well as informed consent)
• Evaluate access to contraception when appropriate
• Develop and test interventions for reducing risk of medication prescribing
(errors, dosage problems, contraindications, adverse events)
Accurately represent and evaluate women veterans’ health
and health-care needs through data and analysis
Post-deployment health and readjustment issues
among women veterans
Implement risk reduction strategies in prescribing
Yano et al.: Inclusion of Women Veterans in VA Research
interventions toimprove (1)knowledge, awareness,andaccessto
VA care, (2) quality of women’s health care (both gender-neutral
and gender-specific), and (3) health professionals’ women’s
health proficiency (both clinical knowledge of women’s health
Initiative (QUERI) framework, VAwomen’s health research sits at
steps 2 (identify best practices) and 3 (define existing practice
patterns and outcomes across the VA and current variation from
best practices).27Moving to step 4 (identify and implement
of future initiatives. The systematic approach to developing VA’s
women’s health research agenda combined with the QUERI
framework provides a model for research development for other
under-represented groups or topics.
Challenges and Potential Solutions to Including
Women Veterans in VA Research
Many challenges remain to including women in VA research.
Historically, researchers havebeenhampered becausethere were
too few women veterans at most VA locations to effectively
integrate them into single-site studies. Small sample sizes result
in having not enough cases to analyze findings by gender
subgroups, which in turn wastes the data that are collected.
There are currently no explicit incentives to oversample women
veterans, though VA principal investigators may apply for sup-
plemental funding through standard project modification proce-
VA lacks an infrastructure to facilitate oversampling. Develop-
ment of a women veterans’ practice-based research network
women in relevant studies currently limited to men.28–29
Women veterans can also be difficult to recruit given that
they differ from non-VA users and men in their utilization
patterns, and that VA care for women is organized differently at
individual facilities (i.e., preferential assignment to and con-
centration within a women’s clinic or dispersed across PC
teams). Even among VAs with women’s clinics, some function
as comprehensive primary care centers, while others deliver
only gender-specific exams. Recruitment must therefore be
context-specific, requiring an understanding of variations in
local clinic structure and patterns of care. For example,
primary care-based interventions may be adapted to women’s
PC clinics by shifting to a different venue within the same
facility, while other interventions may need to be modified to
address additional gender-sensitive concerns (e.g., use of
same-gender interviewers or providers).
Working with facilities that have established women’s health
programs offers another approach to facilitating inclusion of
women in research. Identifying an interested local site princi-
pal investigator may be easier in such facilities, and they may
have established communication networks allowing research-
ers to capitalize on the strength of their local clinical programs
for women. Women Veterans Program Managers familiar with
the women veterans served at each facility offer additional
research-clinical partnership opportunities. The VA Office of
Academic Affiliations also funds Women’s Health Fellowship
sites, while the WVHSHG awards VA Women’s Health Clinical
Centers of Excellence, all of which extend the network of likely
partners for implementation research, in addition to the
growing consortium of VA- and university-based women’s
health researchers. However, some providers may be unwilling
to participate in research because of high caseloads. While
clinicians working with men may face similar time pressures,
our anecdotal experience suggests that pressures are greater
for clinicians who focus their practice on women, perhaps due
Table 2. Current VA Women’s Health Services Research Portfolio (Through FY08)*
General topic Funded research studies
Health-care needs, utilization, outcomes, and quality• Chronic physical and mental illness care in women veterans
• Assessment of preventive and chronic disease measures in women veterans
• Women veterans’ ambulatory care use project
• Improving VA access and quality of care for women
• Alcohol misuse and the risk of post-surgical complication and mortality
• The quality of locoregional breast cancer treatment for breast cancer in VA
• Study of women veterans in menopause
• Impact of practice structure on quality of care for women veterans
• Implementation and sustainability of VA women’s mental health clinics
• Sexual violence and women veterans gynecological health
• Physical and sexual assault in deployed women: risks, outcomes and services
• Evaluation of military sexual trauma screening and treatment
• Longitudinal study of MST effects on PTSD and health behavior among women Marines
• Detection of intimate partner violence: Implications for intervention
• Combat, sexual assault, and PTSD in OEF/OIF military women
• Gender and medical needs of OEF/OIF veterans with PTSD and comorbid substance abuse
• Examining the diagnostic and clinical utility of the PTSD checklist
• Barriers and facilitators to PTSD treatment seeking
• Re-engineering systems for the primary care treatment of PTSD
• Pilot study of PTSD-focused cognitive behavioral therapy for partner violence
• Women veterans cohort study
• Further development and validation of the DRRI
• Predicting post-deployment mental health, substance abuse, and service needs
• Community re-integration and service needs for women veteran mothers
Organization of health services to women veterans
Sexual trauma, military sexual trauma (MST),
intimate partner violence
Posttraumatic stress disorder (PTSD)
Post-deployment health and other related research
*This portfolio represents studies funded by VA HSR&D Service. Other VA Office of Research & Development Services and the Department of Defense also
fund research relevant to women veterans that are not captured by this portfolio review.38–39
OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom
Yano et al.: Inclusion of Women Veterans in VA Research
to more limited clinical backup and administrative support in
women’s programs. Protocols should take this into account by
offsetting the burden of participation through, for example,
offering free training, helping staff acquire new skills, and
providing supervision to facilitate implementation.
Women-specific programs are also undergoing changes, with
the dissolution of some programs in favor of integrated clinics.
Such changes can have negative consequences for study recruit-
ment and ongoing implementation studies that have capitalized
on the concentrated volume of women veterans in women’s
clinics to accomplish the goals of balanced recruitment.
Women veterans’ younger age distribution may present bar-
riers to research participation during usual VA hours of business
due to work and/or childcare obligations. Few facilities can
bias sample enrollment. Provision of childcare also runs counter
to the liability policies of many VA facilities, so in the absence of
onsite childcare programs, there would be no place for the
children of prospective research participants. It also remains
unclear whether research resources may be used to pay for
childcare. An alternative would be to provide adequate cash
childcare arrangement for the period of their participation.
Assuring inclusion of women has specific implications for
implementation research that aims to target an entire popula-
tion or practice. Where women (or other under-represented
groups) obtain care outside of traditional clinics/programs, it
may be harder to identify and include them. Several steps are
key to addressing this issue. First, it is essential to appraise
the samples from which the evidence base was drawn (i.e.,
evidence of effectiveness by gender), an important step in any
implementation study. Second, researchers should examine
the distribution of patients in target practices to better
understand how well the evidence relates to the planned
implementation environment. Evaluating local patterns of care
for different sociodemographic or other under-represented
groups will help researchers better design, conduct, and
analyze the results of their implementation studies.30
Over 25 years have passed since the VA required inclusion of
women veterans in VA research, but regulations do not stipulate
that women are to be included in sufficient numbers to enable
subgroup analyses by gender. However, including women with-
out ensuring meaningful ways to use their data wastes research
resources. This “efficiency” argument has preserved the status
quo. We argue that we now face a tipping point. Increased
participation of women in the military is transforming the
demographics of veterans enrolling in VA care, while the VA has
already proactively identified gender disparities in chronic dis-
ease care and preventive practices among existing patients.
These documented quality gaps, in addition to gender-specific
and strategic concerns that are not represented by VA perfor-
mance measures, reflect substantial opportunities for research.
These areas also align with priorities outside the VA, offering the
changes in other health-care settings.31,32
The VA’s ability to contribute to advances in women’s health
research and to improved inclusion of women in non-gender-
specific research is substantial. The VA health-care system has
become a model for health-care reform, having long ago
established high-quality electronic medical records with ex-
tensive decision support capabilities in the context of integrat-
ed service networks and continual performance monitoring
and feedback.33–34These capabilities increase the VA’s ability
to empirically examine gender differences, to evaluate real-
time clinical decision support tools, and to use system-level
policies and practice initiatives to improve quality of care.
Capitalizing on the VA system’s capabilities in the context of
research on the impact of practice structure on the quality of
care for women veterans, the WVHSHG has launched an
ambitious national implementation plan for comprehensive
practice redesign to enhance primary care delivery for women.
This plan, the Women’s Comprehensive Healthcare Implemen-
tation Plan (W-CHIP), is central to the future delivery of health-
care services to women veterans and will have a substantial
impact on existing and future research.
We recommend that funders offer incentives to add women
to existing projects and incorporate them in the design of new
projects, always in sufficient numbers to conduct meaningful
subgroup analyses. We also recommend ongoing funding of
gender-specific research to ensure that VA equitably delivers
high-quality care to all eligible veterans, meeting the needs of
women as they consider whether the VA can be their “provider
of choice.” Adding women to an appropriate subset of VA’s
substantial research portfolio will increase their scientific
yield, extending our knowledge of variations in care and
intervention effectiveness by gender.36–37
Fortunately, many pathways exist to building a more
balanced research portfolio, especially through research-clin-
ical partnerships. The WVHSHG has brought new visibility
and vigor to the systematic appraisal of women veterans’
health-care needs, development and refinement of quality
improvement (QI) initiatives, and evidence-based policy action.
OQP now provides facility- and network-level feedback on
performance by gender, informing managers of areas warrant-
ing action. Researchers have unprecedented opportunities to
contribute to the nation’s QI agenda for women’s health in
general and for women veterans specifically.
Acknowledgments: The issues summarized in this paper were
presented at the National VA Quality Enhancement Research Initiative
(QUERI) Meeting, Phoenix, AZ, December 12, 2008, and at the VA
MD, February 12, 2009. Studies contributing source information were
the Quality of Care for Women Veterans (phase 1 project no. IIR-04-036
and phase 2 project no. IAE-07-170), and the Women Veterans
Ambulatory Care Use project phase II (project no. IAE-06-083). Dr.
Yano’s effort on this work was funded by a VA HSR&D Research
Career Scientist (RCS) Award (project no. 05-195), while Dr. Bean-
Mayberry’s effort was funded by a VA HSR&D Career Development
Transition Award (CDTA) (project no. RCD 02-039). We also acknowl-
edge the VA Office of Quality and Performance (OQP) for direct
contribution of results from internal reports on gender disparities in
VA quality of care. We thank Shirley Meehan, PhD, MBA, VA HSR&D
Service, for her institutional memory.
In addition to several co-authors (EMY, PPS, BBM, DLW), we
would like to acknowledge the contributions of the many VA-based
principal investigators who are actively engaged in the VA HSR&D-
funded women veterans’ research cited in Table 3, including
Ranjana Banerjea, PhD; Katherine Bradley, MD; Cynthia Brandt,
PhD; Susan Eisen, PhD; April Gerlock, PhD; Rachel Kimerling, PhD;
Sarah Krein, PhD, RN; Gudrun Lange, PhD; Steven Luther,
PhD; Anne Sadler, PhD, RN; Nina Sayer, PhD; Jillian Shipherd,
Yano et al.: Inclusion of Women Veterans in VA Research
PhD; Casey Taft, PhD; and Dawne Vogt, PhD. This work would not Download full-text
have been possible without the support of the VA Greater Los
Angeles HSR&D Center of Excellence (project no. 94-028), including
Ismelda Canelo, MPA, and Danielle Rose, PhD.
Conflict of interest: All of the coauthors are employees of the US
Department of Veterans Affairs. Drs. Yano, Bean-Mayberry, Schnurr,
and Washington have received VA research grant funding. None of
the coauthors have specific conflicts of interest related to the
Corresponding Author: Elizabeth M. Yano, PhD, MSPH; VA Greater
Los Angeles HSR&D Center of Excellence, Mailcode 152, 16111
Plummer Street, Sepulveda, CA 91343, USA (e-mail: Elizabeth.
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