Participation of Veterans Affairs Medical Centers in veteran-centric community-based service navigation networks: A mixed methods study

OBJECTIVE

To understand the determinants and benefits of cross-sector partnerships between Veterans Affairs Medical Centers (VAMCs) and geographically affiliated AmericaServes Network coordination centers that address Veteran health-related social needs.

DATA SOURCES AND SETTING

Semi-structured interviews were conducted with AmericaServes and VAMC staff across seven regional networks. We matched administrative data to calculate the percentage of AmericaServes referrals that were successfully resolved (i.e., requested support was provided) in each network overall and stratified by whether clients were also VAMC patients.

STUDY DESIGN

Convergent parallel mixed-methods study guided by Himmelman's Developmental Continuum of Change Strategies (DCCS) for interorganizational collaboration.

DATA COLLECTION

Fourteen AmericaServes staff and 17 VAMC staff across seven networks were recruited using snowball sampling and interviewed between October 2021 and April 2022. Rapid qualitative analysis methods were used to characterize the extent and determinants of VAMC participation in networks.

PRINCIPAL FINDINGS

On the DCCS continuum of participation, three networks were classified as networking, two as coordinating, one as cooperating, and one as collaborating. Barriers to moving from networking to collaborating included bureaucratic resistance to change, VAMC leadership buy-in, and not having VAMCs staff use the shared technology platform. Facilitators included ongoing communication, a shared mission of serving Veterans, and having designated points-of-contact between organizations. The percentage of referrals that were successfully resolved was lowest in networks engaged in networking (65.3%) and highest in cooperating (85.6%) and collaborating (83.1%) networks. For coordinating, cooperating, and collaborating networks, successfully resolved referrals were more likely among Veterans who were also VAMC patients than among Veterans served only by AmericaServes.

CONCLUSIONS

VAMCs participate in AmericaServes Networks at varying levels. When partnerships are more advanced, successful resolution of referrals is more likely, especially among Veterans who are dually served by both organizations. Although challenges to establishing partnerships exist, this study highlights effective strategies to overcome them.

Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act

OBJECTIVE

To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA-delivered colorectal cancer screening colonoscopies after the MISSION Act.

DATA SOURCES AND STUDY SETTING

Secondary data were collected on VHA-enrolled Veterans from FY2017-FY2021.

STUDY DESIGN

This retrospective cross-sectional study measured the volume and share of screening colonoscopies that were VHA-delivered over time and by drive time eligibility-defined as living more than 60 min away from the nearest VHA specialty-care clinic. We used a multivariable logistic regression to adjust for patient and facility factors.

DATA EXTRACTION

Data were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017-FY2021.

PRINCIPAL FINDINGS

In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid-19 pandemic, the average monthly VHA-share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [-4 to -2 pp]) for the non-drive time eligible group and it decreased by 16 pp (95% CI = [-22 to -9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA-delivered screening colonoscopy (average marginal effect [AME]: -2.5 pp; 95% CI = [-5.1 to 0.0 pp]) for the non-drive time eligible group. The drive time eligible group (AME: -9.4 pp; 95% CI = [-13.2 to -5.5 pp]) experienced a larger change.

CONCLUSIONS

The VHA-share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA-purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.

Barriers to accessing pain management services among veterans with bipolar disorder

OBJECTIVE

To identify barriers veterans with bipolar disorder face to accessing chronic pain management services within a Veterans Affairs (VA) health care system.

DATA SOURCES AND STUDY SETTING

Veterans (n = 15) with chronic pain and bipolar disorder and providers (n = 15) working within a mid-Atlantic VA health care system. Data were collected from August 2017-June 2018.

STUDY DESIGN

Veteran interviews focused on their chronic pain experiences and treatment, including barriers that arose when trying to access pain management services. Provider interviews focused on whether they address chronic pain with veteran patients and, if so, what considerations arise when addressing pain in veterans with bipolar disorder and other serious mental illnesses.

DATA COLLECTION

Veterans were at least 18 years old, had a confirmed bipolar disorder and chronic pain diagnosis, and engaged in outpatient care within the VA health care system. Clinicians provided direct care services to veterans within the same VA. Interviews lasted approximately 60 min and were transcribed and analyzed using a rapid analysis protocol.

PRINCIPAL FINDINGS

Four major themes emerged from veteran and provider interviews: siloed care (unintegrated and uncoordinated mental and physical health care), mental health primacy (prioritization of mental health symptoms at expense of physical health symptoms), lagging expectations (unfamiliarity with comprehensive evidence-based pain management options), and provider-patient communication concerns (inefficient communication about pain concerns and treatment options).

CONCLUSIONS

Veterans with co-occurring pain and bipolar disorder face unique barriers that compromise equitable access to evidence-based pain treatment. Our findings suggest that educating providers about bipolar disorder and other serious mental illnesses and the benefit of effective non-pharmacological pain interventions for this group may improve care coordination and care quality and reduce access disparities.

Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study

OBJECTIVE

To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites.

DATA SOURCES AND STUDY SETTING

Semi-structured interviews across seven diverse VA sites.

STUDY DESIGN

Qualitative multiple-site study.

DATA COLLECTION/EXTRACTION METHODS

We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers.

PRINCIPAL FINDINGS

Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts.

CONCLUSIONS

The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity.

DATA SOURCES

Administrative data from the Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects.

DATA COLLECTION

We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity.

PRINCIPAL FINDINGS

Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population.

CONCLUSIONS

Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

From patient outcomes to system change: Evaluating the impact of VHA's implementation of the Whole Health System of Care

OBJECTIVE

To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change.

DATA SOURCES

Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers.

STUDY DESIGN

In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR.

DATA COLLECTION

Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes.

PRINCIPAL FINDINGS

Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191).

CONCLUSIONS

Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.

Relative accuracy of social and medical determinants of suicide in electronic health records

OBJECTIVE

This paper compares the accuracy of predicting suicide from Social Determinants of Health (SDoH) or history of illness.

POPULATION STUDIED

5 313 965 Veterans who at least had two primary care visits between 2008 and 2016.

STUDY DESIGN

The dependent variable was suicide or intentional self-injury. The independent variables were 10 495 International Classification of Disease (ICD) Version 9 codes, age, and gender. The ICD codes included 40 V-codes used for measuring SDoH, such as family disruption, family history of substance abuse, lack of education, legal impediments, social isolation, unemployment, and homelessness. The sample was randomly divided into training (90 percent) and validation (10 percent) sets. Area under the receiver operating characteristic (AROC) was used to measure accuracy of predictions in the validation set.

PRINCIPAL FINDINGS

Separate analyses were done for inpatient and outpatient codes; the results were similar. In the hospitalized group, the mean age was 67.2 years, and 92.1 percent were male. The mean number of medical diagnostic codes during the study period was 37; and 12.9 percent had at least one SDoH V-code. At least one episode of suicide or intentional self-injury occurred in 1.89 percent of cases. SDoH V-codes, on average, elevated the risk of suicide or intentional self-injury by 24-fold (ranging from 4- to 86-fold). An index of 40 SDoH codes predicted suicide or intentional self-injury with an AROC of 0.64. An index of 10 445 medical diagnoses, without SDoH V-codes, had AROC of 0.77. The combined SDoH and medical diagnoses codes also had AROC of 0.77.

CONCLUSION

In predicting suicide or intentional self-harm, SDoH V-codes add negligible information beyond what is already available in medical diagnosis codes.

IMPLICATIONS FOR PRACTICE

Policies that affect SDoH (eg, housing policies, resilience training) may not have an impact on suicide rates, if they do not change the underlying medical causes of SDoH.

Continuity of care and health care cost among community-dwelling older adult veterans living with dementia

OBJECTIVES

To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

DATA SOURCES

Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

STUDY DESIGN

FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.

DATA COLLECTION

Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).

PRINCIPAL FINDINGS

Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost.

CONCLUSIONS

COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

Overcoming Challenges to Evidence-Based Policy Development in a Large, Integrated Delivery System

OBJECTIVE

To describe a new Veterans Health Administration (VHA) program to foster the learning health system paradigm by rigorously evaluating health care initiatives and to report key lessons learned in designing those evaluations.

PRINCIPAL FINDINGS

The VHA's Quality Enhancement Research Initiative and its Health Services Research and Development Service are cooperating on several large, randomized program evaluations aimed at improving the care veterans receive and the efficiency with which it is delivered. The evaluations we describe involve collaborative design, outcomes assessment, and implementation science through partnerships between VHA operations and researchers. We review key factors to assess before committing to an evaluation. In addition to traditional design issues (such as ensuring adequate power and availability of data), these include others that are easily overlooked: the stability of intervention financing, means of controlling and commitment to adhering to randomized roll-out, degree of buy-in from key implementation staff, and feasibility of managing multiple veto points for interventions that span several programs, among others.

CONCLUSIONS

Successful program implementation and rigorous evaluation require resources, specialized expertise, and careful planning. If the learning health system model is to be sustained, organizations will need dedicated programs to prioritize resources and continuously adapt evaluation designs.

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration

OBJECTIVE

Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.

DATA SOURCES

Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.

PRINCIPAL FINDINGS

Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.

CONCLUSIONS

The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

Linkage of VA and State Prescription Drug Monitoring Program Data to Examine Concurrent Opioid and Sedative-Hypnotic Prescriptions among Veterans

OBJECTIVE

To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon.

DATA SOURCES

VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data.

STUDY DESIGN

This retrospective cohort study examined concurrent prescriptions among n = 19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1 days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines).

PRINCIPAL FINDINGS

Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program.

CONCLUSIONS

A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization

OBJECTIVE

To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system.

DATA SOURCES/STUDY SETTING

Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008).

STUDY DESIGN

We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it.

PRINCIPAL FINDINGS

We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging.

CONCLUSIONS

Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

Has Interprofessional Education Changed Learning Preferences? A National Perspective

OBJECTIVE

To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care.

PRIMARY DATA SOURCE

The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers.

STUDY DESIGN

Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor).

PRINCIPAL FINDINGS

Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress.

CONCLUSIONS

Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.

Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings

OBJECTIVE

To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan.

DATA SOURCES/STUDY SETTING

Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units.

STUDY DESIGN

Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings.

PRINCIPAL FINDINGS

Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use.

CONCLUSION

Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.

Care utilization and patient characteristics of veterans who misuse alcohol

Substance abuse treatment utilization and patient characteristics of veterans (N = 167) drinking alcohol at risky levels at a Department of Veterans Affairs hospital were examined. Rates of brief intervention and specialty care were higher than those found in national samples in 2010, but fall short of recommended guidelines. Veterans receiving more care were older, lower-income, and less likely to be in a relationship. Care-receiving veterans had higher rates of mental health comorbidities and mental health treatment in the prior year for an issue other than substance use. Understanding patients' recent care history may help primary care providers to deliver care effectively.

Ten-Year Publication Trajectories of Health Services Research Career Development Award Recipients: Collaboration, Awardee Characteristics, and Productivity Correlates

This study's purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers' collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers.