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Apaydin EA, Paige NM, Begashaw MM, Larkin J, Miake-Lye IM, Shekelle PG. Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review. J Gen Intern Med 2023:10.1007/s11606-023-08207-2. [PMID: 37076605 PMCID: PMC10361919 DOI: 10.1007/s11606-023-08207-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The Veterans Health Administration (VA) serves Veterans in the nation's largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic. METHODS We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps. RESULTS Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed. DISCUSSION VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.
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Affiliation(s)
- Eric A Apaydin
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- RAND Corporation, Santa Monica, CA, USA.
| | - Neil M Paige
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Meron M Begashaw
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Isomi M Miake-Lye
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Paul G Shekelle
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Krishnan S, Hong I, Couture G, Tzen YT, Reistetter T. Pressure Injury on Poststroke Admission Assessment to Skilled Nursing Facilities: Risk Factors, Management, and Impact on Rehabilitation. J Am Med Dir Assoc 2022; 23:1718.e13-1718.e20. [PMID: 35922014 DOI: 10.1016/j.jamda.2022.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To describe pressure injury (PrI) prevalence, comorbidities, and rehabilitation utilization among older adults with stroke at skilled nursing facilities' (SNFs') admission assessment. DESIGN Retrospective cohort. SETTING AND PARTICIPANTS Older Medicare beneficiaries (>65 years old) with stroke admitted to SNFs. METHODS We extracted data between 2013 and 2014 using the Master Beneficiary Summary, Medicare Provider Analysis and Review, and Minimum Data Set 3.0. PI data were assessed during admission assessment. RESULTS Of the 65,330 older adults poststroke admitted to SNFs, 11% had at least 1 PrI present on admission assessment. Individuals who were non-Hispanic Black, with a longer hospital stay, from lower socioeconomic status, with higher proportions of comorbidities (eg, underweight, urinary and bowel incontinence, diabetes, congestive heart failure, arrhythmias, and infections), and higher functional impairments were likely to present with a PrI at SNF admission assessment. Compared with individuals with superficial PrI, individuals with deep PrI were more likely to be young-old (<75 years), non-Hispanic Black, from lower socioeconomic status, present with a shorter hospital stay, an intensive care unit stay, with higher functional impairments, skin integrity issues, system failure, and infections. Compared to those without PrI or superficial PrI, individuals with any-stage PrI or deep PrI were more likely to be cotreated by physical and occupational therapist and less likely to receive individual therapy. Those with PrI poststroke had low documented turning and repositioning rates than those without PrI. CONCLUSIONS AND IMPLICATIONS Identifying modifiable risk factors to prevent PrIs poststroke in SNFs will facilitate targeted preventative interventions and improve wound care efficacy and rehabilitation utilization for optimized patient outcomes. Identifying residents with a higher risk of PrI during acute care discharge and providing early preventive care during post-acute care would possibly decrease costs and improve outcome quality.
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Affiliation(s)
- Shilpa Krishnan
- Division of Physical Therapy, Department of Rehabilitation Science, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Health Care System, US Department of Veterans Affairs, Decatur, GA, USA.
| | - Ickpyo Hong
- Department of Occupational Therapy, Yonsei University, Wonju, Gangwon-do, South Korea
| | - Grace Couture
- Division of Physical Therapy, Department of Rehabilitation Science, Emory University School of Medicine, Atlanta, GA, USA; Emory Healthcare, Atlanta, GA, USA
| | - Yi-Ting Tzen
- Department of Applied Clinical Research, School of Health Professions, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy Reistetter
- Department of Occupational Therapy, UT Health San Antonio, School of Health Professions, San Antonio, TX, USA
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Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open 2021; 4:e2114234. [PMID: 34319358 PMCID: PMC8319757 DOI: 10.1001/jamanetworkopen.2021.14234] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. EXPOSURES Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. MAIN OUTCOMES AND MEASURES Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. RESULTS Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. CONCLUSIONS AND RELEVANCE This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Graham JE, Middleton A, Roberts P, Mallinson T, Prvu-Bettger J. Health Services Research in Rehabilitation and Disability-The Time is Now. Arch Phys Med Rehabil 2018; 99:198-203. [PMID: 28782540 PMCID: PMC5748255 DOI: 10.1016/j.apmr.2017.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/23/2017] [Accepted: 06/28/2017] [Indexed: 01/17/2023]
Abstract
Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.
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Affiliation(s)
- James E Graham
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
| | - Addie Middleton
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | | | - Trudy Mallinson
- School of Medicine & Health Sciences, George Washington University, Washington, DC
| | - Janet Prvu-Bettger
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Jia H, Pei Q, Sullivan CT, Cowper Ripley DC, Wu SS, Vogel WB, Wang X, Bidelspach DE, Hale-Gallardo JL, Bates BE. Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes. J Multidiscip Healthc 2017; 10:75-85. [PMID: 28280351 PMCID: PMC5340183 DOI: 10.2147/jmdh.s123905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors' functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans' health services as well as the geographic variation of the service utilization. AIM The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. METHODS This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans' inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. RESULTS The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to receive restorative nursing care compared with veterans in all other regions, before and after risk adjustment. CONCLUSION The majority of veterans with stroke received rehabilitation therapy, and about one-third had restorative nursing care during their stay at VA-contracted CNHs. Significant regional variations in weekly days for rehabilitation therapy and restorative nursing care utilization were observed even after adjusting for potential risk factors.
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Affiliation(s)
- Huanguang Jia
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Qinglin Pei
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Charles T Sullivan
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Diane C Cowper Ripley
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Samuel S Wu
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - W Bruce Vogel
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Xinping Wang
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
| | - Douglas E Bidelspach
- Physical Medicine and Rehabilitation Service, Department of Veterans Affairs, Washington, DC
| | - Jennifer L Hale-Gallardo
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL
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Hale-Gallardo J, Jia H, Delisle T, Levy CE, Osorio V, Smith JA, Hannold EM. Enhancing health and independent living for veterans with disabilities by leveraging community-based resources. J Multidiscip Healthc 2017; 10:41-47. [PMID: 28182140 PMCID: PMC5279827 DOI: 10.2147/jmdh.s118706] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The number of US veterans with disabilities has increased in recent years as service members have returned home with extensive injuries and veterans from previous wars acquire functional limitations as a consequence of aging with chronic diseases. Veterans with severe disabilities need assistance and support to maintain independence at home and to avoid institutionalization. The US Department of Veterans Affairs (VA) strives to network with community organizations to achieve the best possible outcomes for veterans. Key community resources in the US for individuals with disabilities are Centers for Independent Living (CILs) that provide a wide range of services, promoting independent living and well-being for people across disabilities. The widespread availability and services of CILs nationwide suggest their potential as a community-based resource for veterans, particularly for those with limited access to VA care. In this article, we discuss long-term needs of veterans with disabilities, efforts to address veterans' rehabilitation needs at the VA and opportunities for leveraging the strengths of community-based organizations for veterans. More research is warranted to investigate CIL services and potential for CIL-VA partnerships.
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Affiliation(s)
- Jennifer Hale-Gallardo
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System
| | - Huanguang Jia
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System
| | - Tony Delisle
- Center for Independent Living of North Central Florida
| | - Charles E Levy
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System; Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health Service; The Department of Occupational Therapy, College of Public Health and Health Professions; The Center for the Arts in Medicine, College of the Arts, University of Florida, Gainesville, FL, USA
| | - Valentina Osorio
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System
| | - Jennifer A Smith
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System
| | - Elizabeth M Hannold
- Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System
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