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Yoon J, Chow A, Jiang H, Wong E, Chang ET. Comparing Quality, Costs, and Outcomes of VA and Community Primary Care for Patients with Diabetes. J Gen Intern Med 2024:10.1007/s11606-024-08968-4. [PMID: 39103601 DOI: 10.1007/s11606-024-08968-4] [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: 04/01/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded access to independent community providers outside the Veterans Health Administration (VA). Little is known how quality, costs, and outcomes of primary care received in the community compare to that of the VA. OBJECTIVE To compare quality, costs, and outcomes of community and VA-provided primary care for patients with diabetes over a 12-month episode. DESIGN A cross-sectional study using VA administrative data and community care claims. Adjusted analyses were conducted using inverse probability weighted regression adjustment to balance patient characteristics. PARTICIPANTS Veterans with diabetes receiving primary care in the VA or community. MAIN MEASURES Quality measures included receipt of hemoglobin A1C tests, eye exams, microalbumin urine tests, and flu shots. Outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC). Costs were measured for VA and community outpatient care, inpatient care, and prescription drugs. KEY RESULTS There were 652,648 VA patients and 3650 community care patients. VA patients were less likely to be White, had shorter mean drive time to VA primary care, and were less likely to be rural than community care patients. In adjusted analyses, community care patients had significantly lower probability of receiving a hemoglobin A1C test, eye exam, microalbumin urine test, and flu shot compared to the VA group. There was no difference in probability of an ACSC hospitalization. Community care patients had higher mean total costs ($1741 [95% CI, $431, $3052]), driven by higher inpatient and prescription drug costs but lower emergency care costs than VA patients. CONCLUSION Patients receiving community primary care had worse diabetes quality and higher costs than patients receiving VA primary care. There was no difference in health outcomes. Care provided by an integrated delivery system may have advantages in quality and value.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
| | - Adam Chow
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Hao Jiang
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Emily Wong
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Buys MJ, Anderson Z, Bayless K, Zhang C, Presson AP, Hales J, Brooke BS. Postsurgical opioid prescribing among veterans using community care for orthopedic surgery at non-VA hospitals compared to a VA hospital with a transitional pain service: a retrospective cohort study. Reg Anesth Pain Med 2024:rapm-2023-105162. [PMID: 38677883 DOI: 10.1136/rapm-2023-105162] [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: 11/15/2023] [Accepted: 04/17/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The USA provides medical services to its military veterans through Veterans Health Administration (VHA) medical centers. Passage of recent legislation has increased the number of veterans having VHA-paid orthopedic surgery at non-VHA facilities. METHODS We conducted a retrospective cohort study among veterans who underwent orthopedic joint surgery paid for by the VHA either at the Salt Lake City VHA Medical Center (VAMC) or at non-VHA hospitals between January 2018 and December 2021. 562 patients were included in the study, of which 323 used a non-VHA hospital and 239 patients the VAMC. The number of opioid tablets prescribed at discharge, the total number prescribed by postdischarge day 90, and the number of patients still filling opioid prescriptions between 90 and 120 days after surgery were compared between groups. RESULTS Veterans who underwent orthopedic surgery at a non-VHA hospital were prescribed more opioid tablets at discharge (median (IQR)); (40 (30-60) non-VHA vs 30 (20-47.5) VAMC, p<0.001) and in the first 90 days after surgery than patients who had surgery at the Salt Lake City VAMC (60 (40-120) vs 35 (20-60), p<0.001). Patients who had surgery at Salt Lake City VAMC were also significantly less likely to fill opioid prescriptions past 90 days after hospital discharge (OR (95% CI) 0.06 (0.01 to 0.48), p=0.007). CONCLUSION These results suggest that veterans who have surgery at a veterans affairs hospital with a transitional pain service are at lower risk for larger opioid prescriptions both at discharge and within 90 days after surgery as well as persistent opioid use beyond 90 days after discharge than if they have surgery at a community hospital.
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Affiliation(s)
- Michael Jacob Buys
- Department of Anesthesiology, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Angela P Presson
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Meer E, Gutkind N, Hua P, Ying GS, Sulewski M, Bhatt N. Outcomes of resident physician-performed cataract surgery in a diverse veterans affairs health system population. Indian J Ophthalmol 2023; 71:3344-3351. [PMID: 37787233 PMCID: PMC10683690 DOI: 10.4103/ijo.ijo_285_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 10/04/2023] Open
Abstract
Purpose To evaluate visual acuity (VA) outcomes and complications from resident physician-performed cataract surgery in a diverse Veterans Affairs Hospital population. Methods A retrospective chart review was conducted for patients who underwent cataract surgery performed by resident physicians from 01/01/2013 to 12/31/2015 at the Veterans Affairs Medical Center. Intraoperative and postoperative clinical information, best-corrected VA (BCVA) (1 day, months 1, 2-3, and 6), and surgery complications were extracted. Univariable and multivariable linear regression models were performed for risk factors of BCVA change. Results This study included 1183 patients, with mean (SD) age of 70.8 (9.3) years. 1154 (97.5%) were males, 493 (41.7%) African-American, and 681 (57.6%) Caucasian. The mean (SD) VA in logMAR was 0.69 (0.74) at baseline, improved to 0.19 (0.36) at 1 month, 0.16 (0.34) at 2-3 months, and 0.14 (0.36) at 6 months. 1080 (91.3%) patients experienced VA improvement from baseline and 1023 (86.5%) patients achieved at least 20/40 BCVA at 1 month. There were 86 (7.3%) complications, most commonly including 47 (4.0%) posterior capsular tears and 64 (5.4%) vitreous loss. In multivariable analysis, younger age (P < 0.0001), worse baseline VA (P < 0.0001), and absence of iris prolapse (P < 0.001) were significantly associated with greater improvement in VA at 1 month. Conclusion In a diverse VAMC, resident-performed cataract surgeries achieved significant improvement in VA with a cumulative complication rate lower than previously reported. Resident physician education may benefit from specific focus on prevention of iris prolapse and better incision construction during surgery as these intraoperative events often led to delayed stabilization of visual outcome beyond 1 month.
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Affiliation(s)
- Elana Meer
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Ophthalmology, University of California, San Francisco, United States
| | - Naomi Gutkind
- Department of Ophthalmology, University of California, San Francisco, United States
- Department of Ophthalmology, University of Miami Bascom Palmer Eye Institute, Miami, FL, United States
| | - Peiying Hua
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Gui-Shuang Ying
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael Sulewski
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Ophthalmology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Nirali Bhatt
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Ophthalmology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
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Mattocks KM, Kroll-Desrosiers A, Crowley S, Tuozzo K, Rifkin I, Moore D, Walker L, Bonegio R. Using RE-AIM to examine implementation of a tele-nephrology program for veterans living in rural areas. FRONTIERS IN HEALTH SERVICES 2023; 3:1205951. [PMID: 37780402 PMCID: PMC10533984 DOI: 10.3389/frhs.2023.1205951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023]
Abstract
Introduction Chronic kidney disease (CKD) and refractory hypertension (rHTN) are common, chronic conditions that affect 10%-16% of Veterans. Several small studies have suggested that tele-nephrology can deliver nephrology care effectively to rural Veterans. The purpose of this evaluation was to examine perceptions and experiences with this tele-nephrology program among spoke site staff and clinicians using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide our understanding of tele-nephrology implementation. Methods We conducted semi-structured interviews with fourteen clinicians at five tele-nephrology spoke sites. We used content analysis to analyze the results using our RE-AIM framework. Results Five major themes arose: (1) Active engagement of a centralized clinical champion was a key factor in early success of tele-nephrology program; (2) Transition from community-based nephrology to VA tele-nephrology was heralded as the most meaningful indicator of the effectiveness of the intervention; (3) Effective adoption strategies included bi-weekly training with Hub nephrology staff and engagement of a local renal champion; (4) Meeting the needs of Veterans through proper staffing during tele-nephrology examinations was a key priority in facility program implementation; and (5) Growing reliance on Hub nephrologists may give rise to insufficient availability of nephrology appointments in some Spoke sites. Discussion This evaluation represents an important step forward as VA considers how to provide care to Veterans at facilities without VA specialty providers. The COVID-19 pandemic has drastically shifted options for Veterans, and increasingly, the VA is moving to shift care from community to VA via virtual care. Further research should examine how the VA manages potential problems related to access to virtual providers and examine Veteran perspectives on community in-person vs. virtual VA care.
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Affiliation(s)
- Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Susan Crowley
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale University School of Medicine, New Haven, CT, United States
| | | | - Ian Rifkin
- VA Boston Healthcare System, Boston, MA, United States
- Boston University School of Medicine, Boston, MA, United States
| | - David Moore
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale University School of Medicine, New Haven, CT, United States
| | - Lorrie Walker
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
| | - Ramon Bonegio
- VA Boston Healthcare System, Boston, MA, United States
- Boston University School of Medicine, Boston, MA, United States
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5
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Blegen M, Ko J, Salzman G, Begashaw MM, Ulloa JG, Girgis M, Shekelle P, Maggard-Gibbons M. Comparing Quality of Surgical Care Between the US Department of Veterans Affairs and Non-Veterans Affairs Settings: A Systematic Review. J Am Coll Surg 2023; 237:352-361. [PMID: 37154441 PMCID: PMC10344435 DOI: 10.1097/xcs.0000000000000720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/31/2023] [Indexed: 05/10/2023]
Abstract
In response to concerns about healthcare access and long wait times within the Veterans Health Administration (VA), Congress passed the Choice Act of 2014 and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 to create a program for patients to receive care in non-VA sites of care, paid by VA. Questions remain about the quality of surgical care between these sites in specific and between VA and non-VA care in general. This review synthesizes recent evidence comparing surgical care between VA and non-VA delivered care across the domains of quality and safety, access, patient experience, and comparative cost/efficiency (2015 to 2021). Eighteen studies met the inclusion criteria. Of 13 studies reporting quality and safety outcomes, 11 reported that quality and safety of VA surgical care were as good as or better than non-VA sites of care. Six studies of access did not have a preponderance of evidence favoring care in either setting. One study of patient experience reported VA care as about equal to non-VA care. All 4 studies of cost/efficiency outcomes favored non-VA care. Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.
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Affiliation(s)
- Mariah Blegen
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- National Clinician Scholars Program (Blegen, Salzman) University of California–Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Jamie Ko
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Garrett Salzman
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- National Clinician Scholars Program (Blegen, Salzman) University of California–Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Meron M Begashaw
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Jesus G Ulloa
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Mark Girgis
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Paul Shekelle
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
| | - Melinda Maggard-Gibbons
- From the Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA (Blegen, Salzman, Begashaw, Ulloa, Girgis, Shekelle, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine (Blegen, Ko, Salzman, Ulloa, Girgis, Maggard-Gibbons) University of California–Los Angeles, Los Angeles, CA
- Olive View—University of California–Los Angeles Medical Center, Sylmar, CA (Maggard-Gibbons)
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Aggarwal S, Wisely CE, Pepin MJ, Bryan W, Raghunathan K, Challa P. Resident involvement in cataract surgery at the Veterans Health Administration: complications, case complexity, and the role of experience. J Cataract Refract Surg 2023; 49:259-265. [PMID: 36378266 DOI: 10.1097/j.jcrs.0000000000001092] [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: 07/04/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To characterize intraoperative complications, case complexity, and changes in complication rates with surgical experience for cataract surgeries involving residents at the Veterans Health Administration (VHA). SETTING All VHA facilities where cataract surgery was performed. DESIGN Multicenter, retrospective cohort study. METHODS A retrospective review of all cataract surgeries within the VHA between July 2010 and June 2021 was conducted. Several parameters, including resident involvement, intraoperative complications, and case complexity as determined by Current Procedural Terminology codes, and use of pupil expansion or capsular support devices, were collected. Complication rates were compared between residents and attendings. RESULTS Of 392 428 cataract surgeries completed across 108 VHA facilities, 90 504 were performed by attendings alone, while 301 924 involved a resident. Of these, 10 244 (11.3%) of attending cases were complex compared with 32 446 (10.7%) of resident cases. Pupil expansion devices were required in 8191 of attending cases (9.05%) and 31 659 (10.5%) of cases involving residents ( P < .001). Similarly, cases involving residents were more likely than attending-only cases to require a capsular support device (0.835% vs 0.586%, P < .001). Cases involving residents were more likely to have posterior capsular rupture (4.75% vs 2.58%, P < .001) and dropped nucleus (0.338% vs 0.198%, P < .001). Higher resident case volumes were associated with significantly lower complication rates for posterior capsular rupture, dropped nucleus, zonular loss, and suprachoroidal hemorrhage. CONCLUSIONS Although residents had higher intraoperative complication rates than attendings, these rates were reduced with surgical experience. Residents were involved in a similar number of complex surgical cases as attendings.
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Affiliation(s)
- Sahil Aggarwal
- From the Duke Eye Center, Durham, North Carolina (Aggarwal, Wisely, Challa); Durham Veterans Affairs Medical Center, Durham, North Carolina (Pepin, Bryan, Raghunathan, Challa); Duke Anesthesiology, Durham, North Carolina (Raghunathan)
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7
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COVID-19 pandemic and surgical training: cataract surgery in the Veterans Health Administration. J Cataract Refract Surg 2023; 49:105-107. [PMID: 36573764 DOI: 10.1097/j.jcrs.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/19/2022] [Indexed: 12/28/2022]
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Sterling RA, Liu CF, Hebert PL, Fortney JC, Swankoski KE, Katon JG, Wong ES. How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program? Med Care 2022; 60:784-791. [PMID: 35950930 DOI: 10.1097/mlr.0000000000001764] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. OBJECTIVES We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. RESEARCH DESIGN We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. SUBJECTS 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. MEASURES We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. RESULTS Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). CONCLUSIONS Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.
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Affiliation(s)
- Ryan A Sterling
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Chuan-Fen Liu
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Paul L Hebert
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - John C Fortney
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Medicine, University of Washington, Seattle, WA
| | - Kaylyn E Swankoski
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Jodie G Katon
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
| | - Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Health System and Population Health
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Baxter SL, Nwanyanwu K, Legault G, Lee AY. Data Sources for Evaluating Health Disparities in Ophthalmology: Where We Are and Where We Need to Go. Ophthalmology 2022; 129:e146-e149. [PMID: 36058733 PMCID: PMC9509471 DOI: 10.1016/j.ophtha.2022.06.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/17/2022] [Accepted: 06/06/2022] [Indexed: 10/14/2022] Open
Abstract
Data provide an opportunity to discover disparities and inequities that may otherwise be unrecognized. Within the American Academy of Ophthalmology (AAO) Task Force on Disparities in Eye Care, the Leveraging Data Sub-task Force was charged with identifying data sources to study health disparities in eye care and to leverage data to advance health equity. We evaluated large data sources to determine their strengths, deficiencies, and relative accessibility in relation to the likelihood of identifying eye care disparities. We highlight the current challenges with these data sources and review key recommendations for improving future sources for studying health disparities in eye care.
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Affiliation(s)
- Sally L Baxter
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, California; Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Kristen Nwanyanwu
- Department of Ophthalmology and Visual Science, Yale University, New Haven, Connecticut
| | - Gary Legault
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Aaron Y Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington.
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Rosen AK, Beilstein-Wedel EE, Harris AHS, Shwartz M, Vanneman ME, Wagner TH, Giori NJ. Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care. Med Care 2022; 60:178-186. [PMID: 35030566 DOI: 10.1097/mlr.0000000000001678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. OBJECTIVE We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. METHODS Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. PRINCIPAL FINDINGS Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. CONCLUSIONS Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.
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Affiliation(s)
- Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin E Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Departments of Internal Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- VA Health Economics Resource Center (HERC), Menlo Park, CA
| | - Nicholas J Giori
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA
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11
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Harris AHS, Beilstein-Wedel EE, Rosen AK, Shwartz M, Wagner TH, Vanneman ME, Giori NJ. Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA. Health Aff (Millwood) 2021; 40:1312-1320. [PMID: 34339235 DOI: 10.1377/hlthaff.2020.01679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community. Policy makers, administrators, health care providers, and veterans frequently face decisions about which services should be delivered versus purchased by the VA. Comparisons of quality across settings are essential if veterans are to receive care that is consistently accessible, patient centered, effective, and safe. We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased. However, hospital-level comparisons revealed five locations where VA-purchased care outperformed VA-delivered care. As the amount of VA-purchased care continues to increase under the Veterans Access, Choice, and Accountability Act of 2014 and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, these results support VA monitoring of overall and local comparative hospital performance to improve the quality of the care that the VA delivers while ensuring optimal outcomes in VA-purchased care.
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Affiliation(s)
- Alex H S Harris
- Alex H. S. Harris is a research career scientist at the Veterans Affairs (VA) Palo Alto Health Care System's Center for Innovation to Implementation, in Menlo Park, California
| | - Erin E Beilstein-Wedel
- Erin E. Beilstein-Wedel is a research scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research, in Boston, Massachusetts
| | - Amy K Rosen
- Amy K. Rosen is a senior research career scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
| | - Michael Shwartz
- Michael Shwartz is a research scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
| | - Todd H Wagner
- Todd H. Wagner is the director of the Health Economics Resource Center and assistant director and research career scientist at the VA Palo Alto Health Care System's Center for Innovation to Implementation
| | - Megan E Vanneman
- Megan E. Vanneman is a research scientist at the VA Salt Lake City's Informatics, Decision-Enhancement and Analytic Sciences Center, in Salt Lake City, Utah
| | - Nicholas J Giori
- Nicholas J. Giori is the chief of orthopedic surgery at the VA Palo Alto Health Care System
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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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Mengeling MA, Mattocks KM, Hynes DM, Vanneman ME, Matthews KL, Rosen AK. Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care. Med Care 2021; 59:S232-S241. [PMID: 33976072 PMCID: PMC8132916 DOI: 10.1097/mlr.0000000000001488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Michelle A. Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE) and VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Denise M. Hynes
- Center to Improve Veterans Involvement in Care (CIVIC) and Evidence Synthesis Program, Portland VA Healthcare System, Portland
- Health Management and Policy, College of Public Health and Human Sciences, and Health Data and Informatics, Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT
| | - Kameron L. Matthews
- Office of Community Care, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
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Pettey WB, Wagner TH, Rosen AK, Beilstein-Wedel E, Shwartz M, Vanneman ME. Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Med Care 2021; 59:S307-S313. [PMID: 33976081 PMCID: PMC8132907 DOI: 10.1097/mlr.0000000000001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS Veterans who had cataract surgery in federal fiscal year 2015. MEASURES We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.
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Affiliation(s)
- Warren B.P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H. Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT
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Rosen AK, Vanneman ME, O'Brien WJ, Pershing S, Wagner TH, Beilstein‐Wedel E, Lo J, Chen Q, Cockerham GC, Shwartz M. Comparing cataract surgery complication rates in veterans receiving VA and community care. Health Serv Res 2020; 55:690-700. [PMID: 32715468 PMCID: PMC7518823 DOI: 10.1111/1475-6773.13320] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act. DATA SOURCES Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery. STUDY DESIGN Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex). DATA COLLECTION We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex). PRINCIPAL FINDINGS Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC. CONCLUSIONS As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."
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Affiliation(s)
- Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusetts
| | - Megan E. Vanneman
- InformaticsDecision‐Enhancement and Analytic Sciences Center (IDEAS)VA Salt Lake City Health Care SystemSalt Lake CityUtah
| | - William J. O'Brien
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusetts
| | - Suzann Pershing
- Department of OphthalmologyVA Palo Alto Health Care SystemPalo AltoCalifornia
| | - Todd H. Wagner
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCalifornia
| | - Erin Beilstein‐Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusetts
| | - Jeanie Lo
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCalifornia
| | - Qi Chen
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusetts
| | - Glenn C. Cockerham
- Department of OphthalmologyStanford University School of MedicineStanfordCalifornia
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusetts
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