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Cardiovascular (CV) disease is the number one cause of death in American women, and all adult women are potentially at risk for CV disease. There are clear gender differences in the control of CV risk factors such as lipids, blood pressure, and intermediate diabetes outcomes nationally and within the VA, with women Veterans often at higher CV risk than their male counterparts. The combination of disparities and gender-specific CV risk factors suggest an urgent need for CV risk factor management in women Veterans. As one project in the Enhancing Mental and Physical health of Women through Engagement and Retention (EMPOWER) QUERI, the objectives of "Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans" are to implement and evaluate a CV risk reduction toolkit (CV toolkit) designed to increase identification of CV risk among Women Veterans, enhance patient/provider communication about their risk, and increase Women Veterans' engagement and retention in relevant health services including referrals to key health programs (e.g., MOVE!, dieticians, health coaches, and CV specialists as needed). The initial CV Toolkit includes four components: (1) Patient education/activation tools including educational materials and a patient CV self-screener to help make CV risk discussion a priority for women before they enter the exam room; (2) A CV risk assessment computerized template to systematically capture CV disease risk factor history and data from the medical record and then facilitate referrals to Gateway to Healthy Living program and other CV risk reduction services/programs; (3) Provider information and education programs as well as referral tools to internal services; and (4) The Gateway to Healthy Living, a facilitated goal-setting group tailored for women Veterans. The goal is to implement the CV Toolkit at four VA facilities with comprehensive women's health clinics. The implementation of the CV Toolkit will be evaluated using a non-randomized stepped wedge design and will apply the evidence-based Replicating Effective Programs (REP) implementation strategy. For the nonrandomized stepped wedge design, each phase represents when one site moved from inactive to active implementation. It was pre-specified for the non-randomized design to evaluate the outcomes as the odds ratio of active intervention versus inactive for the overall study period and not by individual site/phase. This is a function of the use of the non-randomized design. Since the order of sites being introduced into the active intervention is not random, probabilistically the individual site results are not as meaningful here as they would be in a randomized stepped wedge design. Also, mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Multilevel stakeholder engagement will be prioritized. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, impact and facilitate spread.
Background: Women Veterans are the fastest growing segment of Veterans Health Administration (VHA) users. This dramatic growth has created challenges for VHA. Gender disparities persist in cardiovascular (CV) and diabetes risk factor control, and rates of depression, anxiety, and mental health comorbidity are disproportionately high among women Veterans. Furthermore, a high rate of women Veterans' attrition from VA care, along with organizational barriers to care, substantiate that organizational changes are needed in order to engage and retain women Veteran VHA users in evidence-based, patient-centered care.
Objectives: The Enhancing Mental and Physical health of Women through Engagement and Retention (EMPOWER) QUERI addresses VHA Blueprint for Excellence Strategy 6, by advancing "personalized, proactive, patient-centered" care models, and Transformational Strategy 7.2.g by implementation of innovative care models in women Veterans' health care. The EMPOWER QUERI Program is designed to improve women Veterans' engagement and retention in evidence-based care for three high priority health conditions, i.e., prediabetes, cardiovascular, and mental health. To achieve this impact goal, we propose a cohesive portfolio of projects with the following aims: (1) To use an evidence-based implementation strategy that emphasizes local tailoring of care models, multilevel stakeholder engagement, and systematic evaluation of complex implementation processes in order to enrich organizational capacity for innovations in women Veterans' VHA health care; (2) To implement personalized, proactive, patient-centered innovations in VHA women's health that are acceptable, feasible, satisfactory, relevant, and effective for both providers and patients, thereby encouraging women Veterans' engagement and retention and sustainability of the innovations; and, (3) To generate implementation "playbooks" for our partners that are scalable and serve as guidance for future implementation of a broader array of evidence-based women's health programs and policy.
Methods: Three projects will be conducted by an experienced multidisciplinary team. "Tailoring VA's Diabetes Prevention Program to Women Veterans' Needs" is a one-year QI project to be conducted in VA Greater Los Angeles women's health clinics. Women Veterans with prediabetes will select an in-person, peer-led or online gender-specific, evidence-based diabetes prevention program to address their risk behaviors and health conditions. "Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans" will increase identification of CV risk among women Veterans, enhance patient/provider communication and shared decision-making about CV risk, and provide a supportive, coordinated health coaching intervention to facilitate women Veterans' engagement and retention in appropriate health services. "Implementation of Tailored Collaborative Care for Women Veterans" will evaluate implementation of an evidence-based collaborative care model tailored to enhance provider- and system-level capabilities to address women Veterans' anxiety and depression treatment needs, thereby improving organizational primary care-mental health integration (PC-MHI) effectiveness and women Veterans' engagement and retention in PC-MHI. Both implementation research studies will use a non-randomized stepped wedge design and will apply the evidence-based Replicating Effective Programs (REP) implementation strategy. For the nonrandomized stepped wedge design, each phase represents when one site moved from inactive to active implementation. It was pre-specified for the non-randomized design to evaluate the outcomes as the odds ratio of active intervention versus inactive for the overall study period and not by individual site/phase. This is a function of the use of the non-randomized design. Since the order of sites being introduced into the active intervention is not random, probabilistically the individual site results are not as meaningful here as they would be in a randomized stepped wedge design. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Multilevel stakeholder engagement will be prioritized. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. The original protocol proposes the administration of a follow-up survey that includes four secondary outcome measures (PROMIS Global Health; Patient Satisfaction; Overall Anxiety Severity and Impairment Scale (OASIS); and Depression Screen (PHQ-4)). However, the follow-up survey was not administered (data not collected) due to patient burden and COVID-19. As a coherent program of women's health implementation research and quality improvement, the proposed EMPOWER QUERI will constitute a major milestone in achieving BPE strategies and realizing women Veterans' engagement and, ultimately, empowerment in our VHA system.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Active implementation of the CV Toolkit | Experimental | The investigators will use a non-randomized stepped wedge design to evaluate the implementation in four VA Women's Practice Based Research Network sites. In this design, the intervention is "turned on" when a primary care provider at the site first engages in the Cardiovascular (CV) Toolkit (i.e. uses a CV screening template which maps to the patient CV self-screener). This design relies on sequential roll-out to participating sites over time, while using other sites as controls until they begin implementation. - The non-randomized design explicitly considers the timing of implementation spread and addresses the statistical issues introduced by lack of randomization in implementation starts and processes. The investigators will analytically compensate for the design by collecting patient-, provider-, and site-level data that may be associated with timing of the adoption of each intervention. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| CV Toolkit Components | Behavioral |
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| Measure | Description | Time Frame |
|---|---|---|
| New Participation in MOVE! (Among Women Aged 65 and Older) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | 46 months |
| New Participation in MOVE! (Among Women Less Than 65 Years Old) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | 46 months |
| Participation in HPDP/CIH Programs (Among Women Aged 65 and Older) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Bevanne A Bean-Mayberry, MD MHS | VA Greater Los Angeles Healthcare System, West Los Angeles, CA | Principal Investigator |
| Melissa M Farmer Coste, PhD MS | VA Greater Los Angeles Healthcare System, Sepulveda, CA | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VA Greater Los Angeles Healthcare System, Sepulveda, CA | Sepulveda | California | 91343 | United States | ||
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 41507799 | Derived | Farmer MM, Hamilton AB, Finley EP, Lee ML, Chanfreau C, Than C, Brunner J, Schweizer CA, Moin T, Bean-Mayberry B. Implementation of a cardiovascular toolkit in primary care increased women Veterans' engagement in behavior change programs: results from a non-randomized stepped wedge trial. BMC Prim Care. 2026 Jan 8;27(1):95. doi: 10.1186/s12875-025-03158-5. | |
| 39649163 |
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Non-randomized stepped wedge trial; All women with at least one primary care visit at one of the five participating VA clinic sites during the study period were eligible to receive components of the CV Toolkit when the toolkit was active. Note: one more site implemented the toolkit than the originally proposed four sites.
All women with at least one primary care visit at one of the five participating VA clinic sites during the study period (December 2016 - March 2020).
| ID | Title | Description |
|---|---|---|
| FG000 | Active Implementation of the CV Toolkit | All women with at least one primary care visit at one of the five participating VA clinic sites during the study period were eligible to receive components of the CV Toolkit when the toolkit was active at their site. |
| Title | Milestones | Reasons Not Completed | |||||
|---|---|---|---|---|---|---|---|
| Non-randomized Stepped Wedge Baseline |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Jun 15, 2017 |
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The implementation of the CV Toolkit will be evaluated using a non-randomized stepped wedge design
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| 46 months |
| Participation in HPDP/CIH Programs (Among Women Less Than 65 Years Old) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | 46 months |
| VA Greater Los Angeles Healthcare System, West Los Angeles, CA |
| West Los Angeles |
| California |
| 90073 |
| United States |
| VA Connecticut Healthcare System West Haven Campus, West Haven, CT | West Haven | Connecticut | 06516 | United States |
| South Texas Health Care System, San Antonio, TX | San Antonio | Texas | 78229 | United States |
| Farmer MM, Hamilton AB, Finley EP, Lee M, Chanfreau C, Than C, Brunner J, Schweizer CA, Huynh AK, Moin T, Bean-Mayberry B. Implementation of a cardiovascular toolkit in primary care increased women Veterans' engagement in behavior change programs: results from a non-randomized stepped wedge trial. Res Sq [Preprint]. 2024 Nov 26:rs.3.rs-5347756. doi: 10.21203/rs.3.rs-5347756/v1. |
| 38386795 | Derived | Clair KS, Bean-Mayberry B, Schweizer CA, Chanfreau C, Jackson L, Than CT, Finley EP, Hamilton A, Farmer MM. Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care. J Womens Health (Larchmt). 2024 May;33(5):604-612. doi: 10.1089/jwh.2023.0227. Epub 2024 Feb 21. |
| 30482159 | Derived | Finley EP, Huynh AK, Farmer MM, Bean-Mayberry B, Moin T, Oishi SM, Moreau JL, Dyer KE, Lanham HJ, Leykum L, Hamilton AB. Periodic reflections: a method of guided discussions for documenting implementation phenomena. BMC Med Res Methodol. 2018 Nov 27;18(1):153. doi: 10.1186/s12874-018-0610-y. |
| 29116022 | Derived | Hamilton AB, Farmer MM, Moin T, Finley EP, Lang AJ, Oishi SM, Huynh AK, Zuchowski J, Haskell SG, Bean-Mayberry B. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research. Implement Sci. 2017 Nov 7;12(1):127. doi: 10.1186/s13012-017-0658-9. |
| Intervention | Non-active implementation period (control): no sites were actively implementing the CV Toolkit. |
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| Control |
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| COMPLETED |
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| NOT COMPLETED |
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| Trial Step One |
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| Trial Step Two |
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| Trial Step Three |
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| Trial Step Four |
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| Trial Step Five |
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For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65)
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| ID | Title | Description |
|---|---|---|
| BG000 | Active Implementation of the CV Toolkit | Women with at least one primary care visit at one of the five participating VA clinic sites during the study period were eligible to receive components of the CV Toolkit when the toolkit was active at their site. |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65) | Count of Participants | Participants |
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| Sex/Gender, Customized | All persons identifying as women | For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65) | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65) | Count of Participants | Participants |
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| Race/Ethnicity, Customized | Due to small numbers, American Indian, Alaska Native, Asian, Native Hawaiian, or Other Pacific Islander were collapsed into one group here to protect confidentiality. | For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65) | Count of Participants | Participants |
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| Region of Enrollment | Count of Participants | Participants |
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| Clinic Type | For the non-randomized stepped wedge analysis, the total population of 6,009 was stratified by age (65+ and less than age 65) | Count of Participants | Participants |
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| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Primary | New Participation in MOVE! (Among Women Aged 65 and Older) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | Comparing participation in MOVE at all 5 sites when CV Toolkit was active (turned one) versus not active (model stratified to include women aged 65 and older only) It was pre-specified in the non-randomized design analysis plan to evaluate the primary outcome measures as the odds ratio between the active and inactive intervention for the overall study period and not by individual site/phase. | Posted | Geometric Least Squares Mean | 95% Confidence Interval | Odds Ratio | 46 months |
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| Primary | New Participation in MOVE! (Among Women Less Than 65 Years Old) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | Comparing participation in MOVE at all 5 sites when CV Toolkit was active (turned one) versus not active (model stratified to include women less than age 65 only) It was pre-specified in the non-randomized design analysis plan to evaluate the primary outcome measures as the odds ratio between the active and inactive intervention for the overall study period and not by individual site/phase. | Posted | Geometric Least Squares Mean | 95% Confidence Interval | Odds Ratio | 46 months |
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| Primary | Participation in HPDP/CIH Programs (Among Women Aged 65 and Older) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | Comparing participation in HPDP and CIH services at all 5 sites when CV Toolkit was active (turned one) versus not active (model stratified to include women aged 65 and older only) It was pre-specified in the non-randomized design analysis plan to evaluate the primary outcome measures as the odds ratio between the active and inactive intervention for the overall study period and not by individual site/phase. | Posted | Geometric Least Squares Mean | 95% Confidence Interval | Odds Ratio | 46 months |
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| Primary | Participation in HPDP/CIH Programs (Among Women Less Than 65 Years Old) | The study utilized a non-randomized stepped wedge design, and in this design, there are two arms: the not-active CV Toolkit arm and the active ("turned on") CV Toolkit arm. All five sites were in both arms at some point in the study period. The determination of when a study was in a particular arm was determined using the non-randomized step wedge design. In this design, all sites begin in the not-active arm and then cross-over to the active arm at a time when they are organized to do so (not a random event). In the non-randomized stepped wedge design (which is very similar to the crossover clinical trial) results are not analyzed separately by arm as is done for standard randomized controlled trials. The analysis also considered stratification of the women by age (< and ≥ 65 years of age). The main outcomes examined participation in MOVE! and HPDP and/or CIH services for each age strata. | Comparing participation in HPDP and CIH services at all 5 sites when CV Toolkit was active (turned one) versus not active (model stratified to include women less than age 65 only) It was pre-specified in the non-randomized design analysis plan to evaluate the primary outcome measures as the odds ratio between the active and inactive intervention for the overall study period and not by individual site/phase. | Posted | Geometric Least Squares Mean | 95% Confidence Interval | Odds Ratio | 46 months |
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Given the nature of this study, adverse advents were not monitored. CV Toolkit was a clinic based intervention and was deemed low/minimal risk by the IRB.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Active Implementation of the CV Toolkit | All women who had a VA visit to a primary care or women's clinic at any of the 5 VA sites while the CV toolkit was being implemented across sites | 0 | 0 | 0 | 0 | 0 | 0 |
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Additional implementation outcomes (e.g. provider level) were assessed using qualitative methods and will be reported elsewhere (e.g. final report, manuscripts).
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Bevanne Bean-Mayberry | VA Greater Los Angeles Healthcare System | 818-891-7711 | 36009 | bevanne.bean-mayberry@va.gov |
| Oct 25, 2023 |
| Prot_SAP_000.pdf |
| ID | Term |
|---|---|
| D002318 | Cardiovascular Diseases |
| D006973 | Hypertension |
| D006949 | Hyperlipidemias |
| D050171 | Dyslipidemias |
| D009765 | Obesity |
| D003920 | Diabetes Mellitus |
| D014029 | Tobacco Use Disorder |
| D050177 | Overweight |
| ID | Term |
|---|---|
| D014652 | Vascular Diseases |
| D052439 | Lipid Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D044343 | Overnutrition |
| D009748 | Nutrition Disorders |
| D001835 | Body Weight |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D044882 | Glucose Metabolism Disorders |
| D004700 | Endocrine System Diseases |
| D019966 | Substance-Related Disorders |
| D064419 | Chemically-Induced Disorders |
| D001523 | Mental Disorders |
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| >=65 years |
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| Stratification: Women Less Than Age 65 |
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| Stratification: Women Less Than Age 65 |
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| Not Hispanic or Latino |
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| Unknown or Not Reported |
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| Stratification: Women Less Than Age 65 |
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| Black or African American |
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| White |
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| Unknown or Not Reported |
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| Race (Stratification: Women Less Than Age 65) |
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| South |
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| Midwest |
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| Primary Care |
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| Stratification: Women Less Than Age 65 |
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