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Krishnamurthy S, Li Y, Sileanu F, Essien UR, Vanneman ME, Mor M, Fine MJ, Thorpe CT, Radomski T, Suda K, Gellad WF, Roberts ET. Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021. J Gen Intern Med 2024:10.1007/s11606-024-08818-3. [PMID: 38822210 DOI: 10.1007/s11606-024-08818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. OBJECTIVE To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. DESIGN Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. PARTICIPANTS Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. MEASURES Care ratings in nine domains. KEY RESULTS The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. CONCLUSIONS This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.
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Affiliation(s)
- Sudarshan Krishnamurthy
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Yaming Li
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina Sileanu
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Utibe R Essien
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Megan E Vanneman
- Decision Enhancement and Analytic Sciences Center, VA Informatics, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Maria Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas Radomski
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Suda
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric T Roberts
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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O’Hanlon CE, Zeliadt SB, DeFaccio R, Gaj L, Bokhour BG, Taylor SL. Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers. PLoS One 2024; 19:e0303651. [PMID: 38748671 PMCID: PMC11095679 DOI: 10.1371/journal.pone.0303651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers. MATERIALS AND METHODS We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics. RESULTS In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191). CONCLUSIONS Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.
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Affiliation(s)
- Claire E. O’Hanlon
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
| | - Steven B. Zeliadt
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
- Department of Health Systems and Population Health, Hans Rosling Center for Population Health, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Rian DeFaccio
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
| | - Lauren Gaj
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
| | - Barbara G. Bokhour
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States of America
| | - Stephanie L. Taylor
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024; 159:501-509. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
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Carlo AD, Sterling RA, Mao J, Fiorella RP, Fortney JC, Unützer J, Wong ES. Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration. Psychiatr Serv 2024; 75:349-356. [PMID: 37933135 DOI: 10.1176/appi.ps.202100731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVE The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP. METHODS In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018. RESULTS Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP. CONCLUSIONS Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.
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Affiliation(s)
- Andrew D Carlo
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Ryan A Sterling
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Johnny Mao
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Richard P Fiorella
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - John C Fortney
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Jürgen Unützer
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
| | - Edwin S Wong
- Meadows Mental Health Policy Institute, Dallas, and Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago (Carlo); VA Puget Sound Healthcare System, U.S. Department of Veterans Affairs (VA), Seattle (Sterling, Mao, Fortney, Wong); Earth and Environmental Sciences Division, Los Alamos National Laboratory, Los Alamos, New Mexico (Fiorella); Departments of Psychiatry and Behavioral Sciences (Fortney, Unützer) and Health Systems and Population Health (Wong), School of Medicine, University of Washington, Seattle
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Ramalingam NS, Barnes C, Patzel M, Kenzie ES, Ono SS, Davis MM. "It's Like Finding Your Way Through the Labyrinth": a Qualitative Study of Veterans' Experiences Accessing Healthcare. J Gen Intern Med 2024; 39:596-602. [PMID: 37904070 DOI: 10.1007/s11606-023-08442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/22/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans. OBJECTIVE To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans. DESIGN Qualitative descriptive design. PARTICIPANTS United States (US) Veterans in Northwestern states engaged in VA and/or community care. APPROACH Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis. KEY RESULTS We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation. CONCLUSIONS Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans-especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare.
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Affiliation(s)
- NithyaPriya S Ramalingam
- Oregon Rural Practice Based Research Network, Portland, USA
- Oregon Health & Science University, Portland, USA
| | - Chrystal Barnes
- Oregon Rural Practice Based Research Network, Portland, USA
- Oregon Health & Science University, Portland, USA
| | - Mary Patzel
- Oregon Rural Practice Based Research Network, Portland, USA.
- Oregon Health & Science University, Portland, USA.
| | - Erin S Kenzie
- Oregon Health & Science University, Portland, USA
- OHSU-PSU School of Public Health, Portland, USA
| | - Sarah S Ono
- Veterans Rural Health Resource Center-Portland, VA Portland Health Care System, Portland, USA
- Department of Veterans Affairs Office of Rural Health, Washington, D.C, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, USA
| | - Melinda M Davis
- Oregon Rural Practice Based Research Network, Portland, USA
- Oregon Health & Science University, Portland, USA
- Department of Family Medicine and OHSU-PSU School of Public Health, Portland, USA
- Oregon Clinical and Translational Research Institute, Portland, USA
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Levy C, Magid KH, Corneau E, Cornell PY, Haverhals L. Community Nursing Home Program Oversight: Can the VA Meet Increased Demand for Community-Based Care? Fed Pract 2023; 40:338-343. [PMID: 38567301 PMCID: PMC10984685 DOI: 10.12788/fp.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background The US Department of Veterans Affairs (VA) Community Nursing Home (CNH) program provides in-person oversight monitoring the quality of care of veterans in VA-contracted community-based skilled nursing homes. The number of veterans receiving CNH care is projected to increase by 80% by 2037. Methods Retrospective observational data describing the distance between contracted facilities and VA medical centers (VAMCs) were linked to Centers for Medicare and Medicaid monthly Nursing Home Compare and Brown University Long Term Care: Facts on Care in the US data. Qualitative interviews with CNH-based staff and VA-based CNH program oversight team members were conducted using a semistructured interview guide. Quantitative and qualitative data were analyzed independently and integrated during the interpretation of results. Results The number of CNHs per VAMC ranged from 1 to 68 (mean, 18). One in 4 CNHs were > 70 miles from the associated VAMC; among CNHs with 2 to 5 veterans, 44% were located > 50 miles away. Four qualitative themes emerged regarding VA CNH oversight: (1) benefits of VA CNH team engagement/ visits, including quality assurance and care coordination; (2) burden of VA CNH oversight due to geographic dispersion with too few or too many veterans at each to achieve efficiency; (3) oversight burdens and limited staffing restricted ability to add CNHs; and (4) remote access and interoperability of electronic health records and balancing the number of CNH veterans with staffing could facilitate successful oversight. Conclusions The success of the CNH program will depend on the exchange of information and matching available resources to veterans' needs. At a time when strategies to ease the burden on NHs and VA CNH coordinators are needed, the VA needs to improve to properly scale the program.
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Affiliation(s)
- Cari Levy
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
- University of Colorado School of Medicine, Aurora
| | - Kate H. Magid
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
| | - Emily Corneau
- Providence Veterans Affairs Medical Center, Rhode Island
| | - Portia Y. Cornell
- Providence Veterans Affairs Medical Center, Rhode Island
- Brown University School of Public Health, Providence, Rhode Island
| | - Leah Haverhals
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado
- University of Colorado School of Medicine, Aurora
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Riblet NB, Soncrant C, Mills P, Yackel EE. Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care. Mil Med 2023; 188:e3173-e3181. [PMID: 37002596 PMCID: PMC10533708 DOI: 10.1093/milmed/usad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/22/2023] [Accepted: 03/10/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. MATERIALS AND METHODS A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. RESULTS Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. CONCLUSIONS It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.
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Affiliation(s)
- Natalie B Riblet
- Mental Health Service Line, Veterans Affairs Medical Center, White River Junction, VT 05009, USA
- Department of Psychiatry and Dartmouth Institute, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | | | - Peter Mills
- VA National Center for Patient Safety, Ann Arbor, MI 48106, USA
- Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Edward E Yackel
- VA National Center for Patient Safety, Ann Arbor, MI 48106, USA
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Damush TM, Wilkinson JR, Martin H, Miech EJ, Tang Q, Taylor S, Daggy JK, Bastin G, Islam R, Myers LJ, Penney LS, Narechania A, Schreiber SS, Williams LS. The VA National TeleNeurology Program implementation: a mixed-methods evaluation guided by RE-AIM framework. FRONTIERS IN HEALTH SERVICES 2023; 3:1210197. [PMID: 37693238 PMCID: PMC10484508 DOI: 10.3389/frhs.2023.1210197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023]
Abstract
Introduction The Veteran Affairs (VA) Office of Rural Health (ORH) funded the Veterans Health Administration (VHA) National TeleNeurology Program (NTNP) as an Enterprise-Wide Initiative (EWI). NTNP is an innovative healthcare delivery model designed to fill the patient access gap for outpatient neurological care especially for Veterans residing in rural communities. The specific aim was to apply the RE-AIM framework in a pragmatic evaluation of NTNP services. Materials and methods We conducted a prospective implementation evaluation. Guided by the pragmatic application of the RE-AIM framework, we conceptualized a mixed-methods evaluation for key metrics: (1) reach into the Veteran patient population assessed as total NTNP new patient consult volume and total NTNP clinical encounters (new and return); (2) effectiveness through configurational analysis of conditions leading to high Veteran satisfaction and referring providers perceived effectiveness; (3) adoption and implementation by VA sites through site staff and NTNP interviews; (4) implementation success through perceived management, implementation barriers, facilitators, and adaptations and through rapid qualitative analysis of multiple stakeholders' assessments; and (5) maintenance of NTNP through monitoring quarterly TeleNeurology consultation volume. Results NTNP was successfully implemented in 13 VA Medical Centers over 2 years. The total NTNP new patient consult volume in fiscal year 2021 (FY21) was 836 (58% rurally residing); this increased to 1,706 in fiscal year 2022 (FY22) (55% rurally residing). Total (new and follow-up) NTNP clinical encounters were 1,306 in FY21 and 3,730 in FY22. Overall, the sites reported positive experiences with program implementation and perceived that the program was serving Veterans with little access to neurological care. Veterans also reported high satisfaction with the NTNP program. We identified the patient level of perceived excellent teleneurologist-patient communications, reduced need to drive to get care, and that NTNP provided care that the Veteran otherwise could not access as key factors related to high Veteran satisfaction. Conclusions The VA NTNP demonstrated substantial reach, adoption, effectiveness, implementation success, and maintenance over the first 2 years of the program. The NTNP was highly acceptable to both the clinical providers making the referrals and the Veterans receiving the referred video care. The pragmatic application of the RE-AIM framework to guide implementation evaluations is appropriate, comprehensive, and recommended for future applications.
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Affiliation(s)
- Teresa M. Damush
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Jayne R. Wilkinson
- Corporal Michael J Crescenz VAMC, Philadelphia, PA, United States
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Holly Martin
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Edward J. Miech
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Stanley Taylor
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
| | - Joanne K. Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Grace Bastin
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
| | - Robin Islam
- Corporal Michael J Crescenz VAMC, Philadelphia, PA, United States
| | - Laura J. Myers
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Lauren S. Penney
- South Texas Veterans Health Care System, San Antonio, TX, United States
| | - Aditi Narechania
- Jesse Brown VAMC, Chicago, IL, United States
- University of Illinois Chicago, Chicago, IL, United States
- Northwestern University, Chicago, IL, United States
| | - Steve S. Schreiber
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Linda S. Williams
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, United States
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Patzel M, Barnes C, Ramalingam N, Gunn R, Kenzie ES, Ono SS, Davis MM. Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans. J Gen Intern Med 2023:10.1007/s11606-023-08126-2. [PMID: 37340259 DOI: 10.1007/s11606-023-08126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes. OBJECTIVE To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery. DESIGN Phenomenological qualitative study. PARTICIPANTS Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest. APPROACH Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis. KEY RESULTS We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services. CONCLUSIONS Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.
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Affiliation(s)
- Mary Patzel
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA.
| | - Chrystal Barnes
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - NithyaPriya Ramalingam
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | | | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - Sarah S Ono
- Department of Veterans Affairs Office of Rural Health, Veteran Rural Health Resources Center, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
- Department of Family Medicine and OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
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10
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Cusick A, Gronek J, Gorman M, Hausman MS, Schildhouse RJ. Michigan Market Referral Coordination Initiative: a Regional Market Approach to VA Specialty Care. J Gen Intern Med 2023:10.1007/s11606-023-08112-8. [PMID: 36941422 DOI: 10.1007/s11606-023-08112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 02/23/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The Maintaining Internal Systems and Integrated Outside Networks (MISSION) Act of 2018 was created in response to reports of prolonged wait times for veterans accessing health care within the Veterans Affairs (VA) system. In Michigan, the MISSION Act Community Care Program led to an increased number of veterans receiving specialty care outside the VA system, in part due to the complicated process of coordinating specialty care within the VA system. From 2018 to 2020, the percentage of veterans referred to the VA Ann Arbor Healthcare System (AA) for specialty care from its two referring facilities, Battle Creek VA Medical Center (BC) and Saginaw VA Healthcare System (SAG), decreased from 54.4 to 27%. OBJECTIVE Improve the number of Michigan veterans choosing VA specialty care. INTERVENTION In 2021, three VA facilities in Michigan (AA, BC, and SAG) created a market-level referral system named the Michigan Market Referral Initiative (MMRCI). This unique approach used a centralized nurse-driven team to manage specialty referrals, working directly with the veteran to explore both VA and community care (CC) options. MAIN MEASURES Referrals triaged and acceptance rates for VA care were tracked. The localized Standard Episode of Care model was used to estimate cost savings. Post-intervention AA patient wait times were compared to local CC wait times. KEY RESULTS In the 14 months after implementation of the MMRCI, the rate of veteran retention increased by 32.4%. The estimated dollars retained within the VA by MMRCI efforts was $24,105,251 as of 7/1/2022. Post-intervention AA wait times were superior to community care except in 3 specialties. CONCLUSIONS This multifacility effort is an example of a highly coordinated, veteran-centered collaboration that has led to successful retention of veterans within the VA system with resultant large-scale cost avoidance and comparable clinic wait times. Focusing on central care coordination and veteran engagement in the referral process are keys to its success, along with leveraging existing referral patterns between nearby VA facilities. This model could be extrapolated to other VA markets throughout the country where similar relationships exist.
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Affiliation(s)
- Alice Cusick
- VA Ann Arbor Healthcare System, Medicine Service (111), 2215 Fuller Road, Ann Arbor, MI, 48197, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Julie Gronek
- Battle Creek VA Medical Center, Battle Creek, MI, USA
| | - Mary Gorman
- VA Ann Arbor Healthcare System, Medicine Service (111), 2215 Fuller Road, Ann Arbor, MI, 48197, USA
| | - Mark S Hausman
- VA Ann Arbor Healthcare System, Medicine Service (111), 2215 Fuller Road, Ann Arbor, MI, 48197, USA
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard J Schildhouse
- VA Ann Arbor Healthcare System, Medicine Service (111), 2215 Fuller Road, Ann Arbor, MI, 48197, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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11
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Govier DJ, Hickok A, Edwards ST, Weaver FM, Gordon H, Niederhausen M, Hynes DM. Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time. J Gen Intern Med 2023; 38:889-897. [PMID: 36307640 PMCID: PMC9616400 DOI: 10.1007/s11606-022-07800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.
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Affiliation(s)
- Diana J Govier
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
| | - Alex Hickok
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
| | - Samuel T Edwards
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Frances M Weaver
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Loyola University Chicago, Chicago, IL, USA
| | - Howard Gordon
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Meike Niederhausen
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Denise M Hynes
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA.
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA.
- College of Public Health and Human Sciences and the Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA.
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12
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Palani S, Garrido MM, Tenso K, Pizer SD. Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals. Acad Emerg Med 2023; 30:379-387. [PMID: 36660799 DOI: 10.1111/acem.14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. METHODS We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit. Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics. RESULTS A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit. CONCLUSIONS Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.
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Affiliation(s)
- Sivagaminathan Palani
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Kertu Tenso
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Steven D Pizer
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
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13
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Gurewich D, Beilstein-Wedel E, Shwartz M, Davila H, Rosen AK. Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity. JAMA Netw Open 2023; 6:e2252061. [PMID: 36689224 PMCID: PMC9871804 DOI: 10.1001/jamanetworkopen.2022.52061] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/30/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Prior studies indicate that Black and Hispanic vs White veterans wait longer for care. However, these studies do not capture the COVID-19 pandemic, which caused care access disruptions, nor implementation of the US Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION), which is intended to improve care access by increasing veterans' options to use community clinicians. Objective To determine whether wait times increased differentially for Black and Hispanic compared with White veterans from the pre-COVID-19 to COVID-19 periods given concurrent MISSION implementation. Design, Setting, and Participants This cross-sectional study used data from the VA's Corporate Data Warehouse for fiscal years 2019 to 2021 (October 1, 2018, to September 30, 2021). Participants included Black, Hispanic, and White veterans with a new consultation for outpatient cardiology and/or orthopedic services during the study period. Multivariable mixed-effects models were used to estimate individual-level adjusted wait times and a likelihood ratio test of the significance of wait time disparity change over time. Main Outcomes and Measures Overall mean wait times and facility-level adjusted relative mean wait time ratios. Results The study included 1 162 148 veterans (mean [SD] age, 63.4 [14.4] years; 80.8% men). Significant wait time disparities were evident for orthopedic services (eg, Black veterans had wait times 2.09 [95% CI, 1.57-2.61] days longer than those for White veterans) in the pre-COVID-19 period, but not for cardiology services. Mean wait times increased from the pre-COVID-19 to COVID-19 periods for both services for all 3 racial and ethnic groups (eg, Hispanic wait times for cardiology services increased 5.09 [95% CI, 3.62-6.55] days). Wait time disparities for Black veterans (4.10 [95% CI, 2.44-5.19] days) and Hispanic veterans (4.40 [95% CI, 2.76-6.05] days) vs White veterans (3.75 [95% CI, 2.30-5.19] days) increased significantly from the pre-COVID-19 to COVID-19 periods (P < .001). During the COVID-19 period, significant disparities were evident for orthopedic services (eg, mean wait times for Hispanic vs White veterans were 1.98 [95% CI, 1.32-2.64] days longer) but not for cardiology services. Although there was variation in wait time ratios across the 140 facilities, only 6 facility wait time ratios were significant during the pre-COVID-19 period and 26 during the COVID-19 period. Conclusions and Relevance These findings suggest that wait time disparities increased from the pre-COVID-19 to COVID-19 periods, especially for orthopedic services for both Black and Hispanic veterans, despite MISSION's goal to improve access. Facility-level analyses identified potential sites that could be targeted to reduce disparities.
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Affiliation(s)
- Deborah Gurewich
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Erin Beilstein-Wedel
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Michael Shwartz
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Heather Davila
- Center for Access & Delivery Research and Evaluation, VA Iowa City Health Care System, Iowa City, Iowa
- General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Amy K. Rosen
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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14
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Mull HJ, Kabdiyeva A, Ndugga N, Gordon SH, Garrido MM, Pizer SD. What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery. Health Serv Res 2022; 58:654-662. [PMID: 36477645 PMCID: PMC10154155 DOI: 10.1111/1475-6773.14113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To investigate the relationship between community care (CC) treatment and a postoperative surgical complication in elective hernia surgery among Veterans using multiple approaches to control for potential selection bias. DATA SOURCES AND STUDY SETTING Veterans Health Administration (VHA) data sources included Corporate Data Warehouse (VHA encounters and patient data), the Program Integrity Tool and Fee tables (CC encounters), the Planning Systems Support Group (geographic information), and the Paid file (VHA primary care providers). STUDY DESIGN Prior works suggest patient outcomes are better in VHA than in CC settings; however, these studies may not have appropriately accounted for the selection of higher-risk cases into CC. We estimated (1) a naïve logistic regression model to calculate the effect of CC setting on the probability of a complication, controlling for facility fixed effects and patient and procedure characteristics, and (2) a 2-stage model using the hernia patient's primary care provider's 1-year prior CC referral rate as the instrument. DATA COLLECTION We identified patients residing ≤40 miles from a VHA surgical facility with elective VHA or CC hernia surgery from 2018 to 2019. PRINCIPAL FINDINGS Of 7991 hernia surgeries, 772 (9.7%) were in CC. The overall complication rate was 4.2%; 286/7219 (4.0%) among VHA surgeries versus 51/5772 (6.6%, p < 0.05) in CC. We observed a 2.8 percentage point increase in the probability of postoperative complication given CC surgery (95% confidence interval: 0.7, 4.8) in the naïve model. After accounting for the VHA provider's historical rate of CC referral, we no longer observed a relationship between surgery setting and risk of postoperative complication. CONCLUSIONS After accounting for the selection of higher-risk patients to CC settings, we found no difference in hernia surgery postoperative complications between CC and VHA. Future VHA and non-VHA comparisons should account for unobserved as well as observed differences in patients seen in each setting.
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Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Aigerim Kabdiyeva
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, Massachusetts, USA
| | - Nambi Ndugga
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, Massachusetts, USA
| | - Sarah H Gordon
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Melissa M Garrido
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Steven D Pizer
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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15
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“We Are Working Harder, Not Smarter:” a Qualitative Inquiry Into Care Coordination for Department of Veterans Affairs Mammograms Referred to the Community. Womens Health Issues 2022:S1049-3867(22)00140-2. [DOI: 10.1016/j.whi.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 11/04/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
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16
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Meyer AND, Singh H, Zimolzak AJ, Wei L, Choi DT, Marinez AD, Murphy DR. Cancer Evaluations During the COVID-19 Pandemic: An Observational Study Using National Veterans Affairs Data. Am J Prev Med 2022; 63:1026-1030. [PMID: 36055880 PMCID: PMC9359503 DOI: 10.1016/j.amepre.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/06/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Fewer cancer diagnoses have been made during the COVID-19 pandemic. Pandemic-related delays in cancer diagnosis could occur from limited access to care or patient evaluation delays (e.g., delayed testing after abnormal results). Follow-up of abnormal test results warranting evaluation for cancer was examined before and during the pandemic. METHODS Electronic trigger algorithms were applied to the Department of Veterans Affairs electronic health record data to assess follow-up of abnormal test results before (March 10, 2019-March 7, 2020) and during (March 8, 2020-March 6, 2021) the pandemic. RESULTS Electronic triggers were applied to 8,021,406 veterans' electronic health records to identify follow-up delays for abnormal results warranting evaluation for 5 cancers: bladder (urinalysis with high-grade hematuria), breast (abnormal mammograms), colorectal (positive fecal occult blood tests/fecal immunochemical tests or results consistent with iron deficiency anemia), liver (elevated alpha-fetoprotein), and lung (chest imaging suggestive of malignancy) cancers. Between prepandemic and pandemic periods, test quantities decreased by 12.6%-27.8%, and proportions of abnormal results lacking follow-up decreased for urinalyses (-0.8%), increased for fecal occult blood tests/fecal immunochemical test (+2.3%) and chest imaging (+1.8%), and remained constant for others. Follow-up times decreased for most tests; however, control charts suggested increased delays at 2 stages: early (pandemic beginning) for urinalyses, mammograms, fecal occult blood tests/fecal immunochemical test, iron deficiency anemia, and chest imaging and late (30-45 weeks into pandemic) for mammograms, fecal occult blood tests/fecal immunochemical test, and iron deficiency anemia. CONCLUSIONS Although early pandemic delays in follow-up may have led to reduced cancer rates, the significant decrease in tests performed is likely a large driver of these reductions. Future emergency preparedness efforts should bolster essential follow-up and testing procedures to facilitate timely cancer diagnosis.
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Affiliation(s)
- Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Andrew J Zimolzak
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Debra T Choi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Abigail D Marinez
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
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17
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Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med 2022; 37:3937-3946. [PMID: 35048300 PMCID: PMC8769678 DOI: 10.1007/s11606-021-07370-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN Cross-sectional nationally representative study. PARTICIPANTS US military veterans (N = 2,836). MAIN MEASURES In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.
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18
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Finkel AG. Headaches in Veterans: Different or the Same? Neurology 2022; 99:779-780. [PMID: 36100440 DOI: 10.1212/wnl.0000000000201081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alan G Finkel
- From the Carolina Headache Institute, Durham, NC; University of North Carolina, Chapel Hill.
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19
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Gopisetty DD, Shaw JG, Gray C, Frayne S, Phibbs C, Shankar M. Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care. Mil Med 2022; 188:usac275. [PMID: 36151892 DOI: 10.1093/milmed/usac275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/21/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams. MATERIALS AND METHODS Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes. RESULTS Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians. CONCLUSIONS The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.
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Affiliation(s)
- Deepti Divya Gopisetty
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jonathan G Shaw
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Division of Primary Care & Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Caroline Gray
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
| | - Susan Frayne
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Division of Primary Care & Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ciaran Phibbs
- VA Palo Alto Health Care System, Health Economics Resource Center (HERC), Palo Alto, CA 94304, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304-5660, USA
| | - Megha Shankar
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Stanford University School of Medicine, Stanford, CA 94305, USA
- Division of General Internal Medicine, Department of Medicine, UC San Diego, La Jolla, CA 92093, USA
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20
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Zeliadt SB, Douglas JH, Gelman H, Coggeshall S, Taylor SL, Kligler B, Bokhour BG. Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain. BMC Health Serv Res 2022; 22:1053. [PMID: 35978421 PMCID: PMC9387037 DOI: 10.1186/s12913-022-08388-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/28/2022] [Indexed: 12/21/2022] Open
Abstract
Background The opioid crisis has necessitated new approaches to managing chronic pain. The Veterans Health Administration (VHA) Whole Health model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing patients’ use of opioids. We aim to assess whether the VHA’s Whole Health pilot program impacted longitudinal patterns of opioid utilization among patients with chronic musculoskeletal pain. Methods A cohort of 4,869 Veterans with chronic pain engaging in Whole Health services was compared with a cohort of 118,888 Veterans receiving conventional care. All patients were continuously enrolled in VHA care from 10/2017 through 3/2019 at the 18 VHA medical centers participating in the pilot program. Inverse probability of treatment weighting and multivariate analyses were used to adjust for observable differences in patient characteristics between exposures and conventional care. Patients exposed to Whole Health services were offered nine complementary and integrative health therapies alone or in combination with novel Whole Health services including goal-setting clinical encounters, Whole Health coaching, and personal health planning. Main measures The main measure was change over an 18-month period in prescribed opioid doses starting from the six-month period prior to qualifying exposure. Results Prescribed opioid doses decreased by -12.0% in one year among Veterans who began complementary and integrative health therapies compared to similar Veterans who used conventional care; -4.4% among Veterans who used only Whole Health services such as goal setting and coaching compared to conventional care, and -8.5% among Veterans who used both complementary and integrative health therapies combined with Whole Health services compared to conventional care. Conclusions VHA’s Whole Health national pilot program was associated with greater reductions in prescribed opioid doses compared to secular trends associated with conventional care, especially when Veterans were connected with complementary and integrative health therapies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08388-2.
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Affiliation(s)
- Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA. .,Department of Health Services, School of Public Health, University of Washington, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA.
| | - Jamie H Douglas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.,Department of General Internal Medicine and Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Benjamin Kligler
- Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, USA.,US Department of Veterans Affairs Office of Patient Centered Care and Cultural Transformation, Washington, DC, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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21
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Hutchins F, Thorpe J, Maciejewski ML, Zhao X, Daniels K, Zhang H, Zulman DM, Fihn S, Vijan S, Rosland AM. Clinical Outcome and Utilization Profiles Among Latent Groups of High-Risk Patients: Moving from Segmentation Towards Intervention. J Gen Intern Med 2022; 37:2429-2437. [PMID: 34731436 PMCID: PMC9360385 DOI: 10.1007/s11606-021-07166-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The ability of latent class models to identify clinically distinct groups among high-risk patients has been demonstrated, but it is unclear how healthcare data can inform group-specific intervention design. OBJECTIVE Examine how utilization patterns across latent groups of high-risk patients provide actionable information to guide group-specific intervention design. DESIGN Cohort study using data from 2012 to 2015. PATIENTS Participants were 934,787 patients receiving primary care in the Veterans Health Administration, with predicted probability of 12-month hospitalization in the top 10th percentile during 2014. MAIN MEASURES Patients were assigned to latent groups via mixture-item response theory models based on 28 chronic conditions. We modeled odds of all-cause mortality, hospitalizations, and 30-day re-hospitalizations by group membership. Detailed outpatient and inpatient utilization patterns were compared between groups. KEY RESULTS A total of 764,257 (81.8%) of patients were matched with a comorbidity group. Groups were characterized by substance use disorders (14.0% of patients assigned), cardiometabolic conditions (25.7%), mental health conditions (17.6%), pain/arthritis (19.1%), cancer (15.3%), and liver disease (8.3%). One-year mortality ranged from 2.7% in the Mental Health group to 14.9% in the Cancer group, compared to 8.5% overall. In adjusted models, group assignment predicted significantly different odds of each outcome. Groups differed in their utilization of multiple types of care. For example, patients in the Pain group had the highest utilization of in-person primary care, with a mean (SD) of 5.3 (5.0) visits in the year of follow-up, while the Substance Use Disorder group had the lowest, with 3.9 (4.1) visits. The Substance Use Disorder group also had the highest rates of using services for housing instability (25.1%), followed by the Liver group (10.1%). CONCLUSIONS Latent groups of high-risk patients had distinct hospitalization and utilization profiles, despite having comparable levels of predicted baseline risk. Utilization profiles pointed towards system-specific care needs that could inform tailored interventions.
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Affiliation(s)
- Franya Hutchins
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA.
- Caring for Complex Chronic Conditions Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes & Policy, Eshelman School of Pharmacy, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Matthew L Maciejewski
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Karin Daniels
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Donna M Zulman
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Stephan Fihn
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Sandeep Vijan
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Ann-Marie Rosland
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, University Drive (151C), Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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22
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Radomski TR, Zhao X, Lovelace EZ, Sileanu FE, Rose L, Schwartz AL, Schleiden LJ, Oakes AH, Pickering AN, Yang D, Hale JA, Gellad WF, Fine MJ, Thorpe CT. Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration. JAMA Intern Med 2022; 182:832-839. [PMID: 35788786 PMCID: PMC9257674 DOI: 10.1001/jamainternmed.2022.2482] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/08/2022] [Indexed: 01/11/2023]
Abstract
Importance Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. Objective To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. Design, Setting, and Participants This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. Main Outcomes and Measures VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Results Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). Conclusions and Relevance This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.
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Affiliation(s)
- Thomas R. Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, VA Palo Alto Healthcare System, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Aimee N. Pickering
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Dylan Yang
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy
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23
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O'Hare AM, Butler CR, Laundry RJ, Showalter W, Todd-Stenberg J, Green P, Hebert PL, Wang V, Taylor JS, Van Eijk M, Matthews KL, Crowley ST, Carey E. Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Intern Med 2022; 182:710-719. [PMID: 35576068 PMCID: PMC9112136 DOI: 10.1001/jamainternmed.2022.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
IMPORTANCE Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. OBJECTIVE To describe the implications for the VA system of recent increases in VA-financed non-VA care. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. EXPOSURES Mentions of community care in participant EHRs. MAIN OUTCOMES AND MEASURES Dominant themes pertaining to VA-financed non-VA care. RESULTS Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. CONCLUSIONS AND RELEVANCE The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.
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Affiliation(s)
- Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Catherine R Butler
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington.,VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine and Kidney Research Institute, University of Washington, Seattle
| | - Ryan J Laundry
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Whitney Showalter
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Jeffrey Todd-Stenberg
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Pam Green
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington
| | - Paul L Hebert
- VA Health Services Research and Development, Seattle-Denver COIN, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Ontario, Canada
| | | | | | - Susan T Crowley
- Department of Medicine, Yale University, New Haven, Connecticut.,VA Connecticut Health Care System, West Haven, Connecticut
| | - Evan Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver
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24
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Purchasing High-Quality Community Nursing Home Care: A Will to Work With VA Diminished by Contracting Burdens. J Am Med Dir Assoc 2022; 23:1757-1764. [DOI: 10.1016/j.jamda.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 02/18/2022] [Accepted: 03/12/2022] [Indexed: 11/23/2022]
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25
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Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM Policy Pract 2021; 6:23814683211057902. [PMID: 34820527 PMCID: PMC8606928 DOI: 10.1177/23814683211057902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background. Veterans' access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.
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Affiliation(s)
- Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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