Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care

Racial and Ethnic and Rural Variations in Access to Primary Care for Veterans Following the MISSION Act

Importance

The 2018 Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act was implemented to increase timely access to care by expanding veterans' opportunities to receive Veterans Affairs (VA)-purchased care in the community (community care [CC]). Because health equity is a major VA priority, it is important to know whether Black and Hispanic veterans compared with White veterans experienced equitable access to primary care within the VA MISSION Act.

Objective

To examine whether utilization of and wait times for primary care differed between Black and Hispanic veterans compared with White veterans in rural and urban areas after the implementation of the VA MISSION Act.

Design, Setting, and Participants

This cross-sectional study used VA and CC outpatient and consult data from the VA's Corporate Data Warehouse for fiscal years 2021 to 2022 (October 1, 2020, to September 30, 2022). Separate fixed-effects multivariable models were run to predict CC utilization and wait times. Each model was run twice, once comparing Black and White veterans and then comparing Hispanic and White veterans. Adjusted risk ratios (ARRs) were calculated for Black and Hispanic veterans compared with White veterans within rurality status for both outcomes.

Main Outcomes and Measures

VA and CC primary care utilization as measured by primary care visits (utilization cohort); VA and CC primary care access as measured by mean wait times (access cohort).

Results

A total of 5 046 087 veterans (994 517 [19.7%] Black, 390 870 [7.7%] Hispanic, and 3 660 700 [72.6%] White individuals) used primary care from fiscal years 2021 to 2022. Utilization increased for all 3 racial and ethnicity groups, more so in CC than VA primary care. ARRs were significantly less than 1 regardless of rurality status, indicating Black and Hispanic veterans compared with White veterans were less likely to utilize CC for primary care. There were 468 246 primary care consultations during the study period. The overall mean (SD) wait time was 33.3 (32.4) days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. Black veterans compared with White veterans had significantly longer wait times in CC (ARRs >1) but significantly shorter wait times in VA (ARRS <1) regardless of rurality status in VA and CC. CC wait times for Hispanic veterans compared with White veterans were longer in rural areas only and in VA rural and urban areas (ARRs >1).

Conclusion and Relevance

The results of this cross-sectional study suggest that additional research should explore the determinants and implications of utilization differences among Black and Hispanic veterans compared with White veterans. Efforts to promote equitable primary care access for all veterans are needed so that policy changes can be more effective in ensuring timely access to care for all veterans.

Posttraumatic stress disorder, Veterans Health Administration use, and care-seeking among recent-era U.S. veterans

The current study investigated the associations among probable posttraumatic stress disorder (PTSD), recent Veterans Health Administration (VHA) health care use, and care-seeking for PTSD in U.S. military veterans. Analyses were conducted among 19,691 active duty military personnel enrolled in the Millennium Cohort Study who separated from the military between 2000 and 2012 and were weighted to the 1,130,103 active duty personnel who separated across this time period. VHA utilization was identified from electronic medical records in the year before survey completion, and PTSD care-seeking and PTSD symptoms were assessed through self-report on the 2014-2016 survey; thus, the observation period regarding care-seeking and VHA use encompassed 2013-2016. Veterans with probable PTSD were more likely to use VHA services than those without probable PTSD, aOR = 1.12, 95% CI [1.01, 1.24], although the strongest association with recent VHA use was a depression diagnosis, aOR = 2.47, 95% CI [2.26, 2.70]. Among veterans with probable PTSD, the strongest predictor of care-seeking was recent VHA use compared to community care, aOR = 4.01, 95% CI [3.40, 4.74); reporting a diagnosis of depression was the second strongest predictor of PTSD care-seeking, OR = 2.99, 95% CI [2.53, 3.54]. However, the absolute number of veterans with probable PTSD who were not seeking care was approximately equivalent between veterans using VHA services and those not using VHA services. Additionally, certain groups were identified as being at risk of not seeking care, namely Air Force veterans and veterans with high physical and mental functioning despite substantial PTSD symptoms.

Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021

BACKGROUND

Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner.

OBJECTIVE

To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021.

DESIGN

Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors.

PARTICIPANTS

Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey.

MEASURES

Care ratings in nine domains.

KEY RESULTS

The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted.

CONCLUSIONS

This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.

Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers

BACKGROUND

Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers.

MATERIALS AND METHODS

We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics.

RESULTS

In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191).

CONCLUSIONS

Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.

Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury

OBJECTIVE

Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI.

SETTING

Nationwide VA-purchased care from 2016 through 2019.

PARTICIPANTS

Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144).

DESIGN

This was a retrospective, observational study.

MAIN MEASURES

Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019.

RESULTS

Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use.

CONCLUSIONS

Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration

OBJECTIVE

The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP.

METHODS

In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018.

RESULTS

Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP.

CONCLUSIONS

Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.

Veteran Caretaker Perspectives of the Need for Childcare Assistance During Health Care Appointments

PURPOSE

In 2020, Congress passed legislation to establish the national Veterans Child Care Assistance Program (VCAP) targeting eligible veterans receiving care through the Veterans Health Administration (VA). This needs assessment describes the childcare needs of veteran caretakers of young children and explores the implications of inadequate childcare on health care engagement.

METHODS

Survey data were collected from 2,000 VA users with dependent children; data were analyzed using standard descriptive statistics. Qualitative data were collected from 19 veterans through focus groups and analyzed using rapid thematic analysis.

FINDINGS

More than 75% of veterans surveyed indicated that they required childcare assistance during health care appointments and 73% reported barriers to finding childcare. Prominent barriers included the high cost of childcare and not having a trusted source of childcare. Nearly 58% of survey respondents reported missed or canceled VA health care appointments due to childcare challenges. Furthermore, 35% of surveyed veterans reported that their children had accompanied them to an appointment in the past year. Among these veterans, 59% brought their children into the exam room. Focus group participants discussed how having children present during their health care appointments hampered communication with health care providers.

CONCLUSIONS

Veterans report that lack of childcare keeps them from attending and remaining focused on the provider during their health care visits, which could compromise quality of care. As one of the only health systems in the United States that will offer childcare assistance, VCAP presents an opportunity to improve health care access and quality by reducing missed appointments and suboptimal care.

Understanding Barriers and Facilitators to High-Quality Cancer Care Among Veterans With Lung Cancer: A Qualitative Study

PURPOSE

Veteran populations have higher lung cancer incidence and worse overall survival compared with non-Veteran populations. Although recent clinical advancements have reduced lung cancer death rates, these advances are not routinely received among Veteran populations because of multilevel factors, including Veterans' complex comorbidities, limited health literacy, and other economic and social disadvantages. This study aimed to assess Veterans' perspectives regarding their lung cancer care with a specific focus on identifying modifiable barriers to evidence-based care delivery.

METHODS

We conducted 1:1 semistructured interviews with 24 Veterans diagnosed with lung cancer at the Veterans Affairs Palo Alto Health Care System. All interviews were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis.

RESULTS

Four themes emerged. These included (1) social and economic disadvantages can prevent routine delivery of evidence-based cancer care; (2) fragmented care contributes to worsening patient mental and emotional well-being; (3) lack of health system interventions to address limited health literacy inhibits patient engagement in shared decision making regarding diagnosis, genomic and molecular testing, targeted and other treatments, and end-of-life care; and (4) deep appreciation for care and VA trustworthiness facilitates adherence to cancer care recommendations.

CONCLUSION

This study revealed critical gaps in lung cancer care delivery and the role of institution-engendered trust in overcoming barriers in the VA system. Targeted solutions should address the identified barriers to routine, evidence-based lung cancer care delivery among Veterans.

Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data

STUDY OBJECTIVES

This study aimed to estimate the 12-month prevalence of diagnosed sleep disorders among veterans with and without serious mental illnesses (SMI) in Veterans Affairs health record data in 2019. We also examined diagnosed sleep disorders across a 9-year period and explored associations with demographic and health factors.

METHODS

This study used health record data from VISN 4 of the Veterans Health Administration from 2011 to 2019. SMI diagnoses included schizophrenia and bipolar spectrum diagnoses as well as major depression with psychosis. Sleep diagnoses included insomnias, hypersomnias, sleep-related breathing disorders, circadian rhythm sleep-wake disorders, and sleep-related movement disorders. Demographic and health-related factors were also collected from the record.

RESULTS

In 2019, 21.8% of veterans with SMI were diagnosed with a sleep disorder. This is a significantly higher proportion than for veterans without SMI, 15.1% of whom were diagnosed with a sleep disorder. Sleep disorder rates were highest in veterans with a chart diagnosis of major depression with psychosis. From 2011 to 2019, the overall prevalence of sleep disorders in veterans with SMI more than doubled (10.2%-21.8%), suggesting improvements in the detection and diagnosis of sleep concerns for this group.

CONCLUSIONS

Our findings suggest that identification and diagnosis of sleep disorders for veterans with SMI has improved over the past decade, though diagnoses still likely underrepresent actual prevalence of clinically relevant sleep concerns. Sleep concerns may be at particularly high risk of going untreated in veterans with schizophrenia-spectrum disorders.

CITATION

Bonfils KA, Longenecker JM, Soreca I, et al. Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data. J Clin Sleep Med. 2023;19(9):1651-1660.

Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans

BACKGROUND

The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes.

OBJECTIVE

To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery.

DESIGN

Phenomenological qualitative study.

PARTICIPANTS

Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest.

APPROACH

Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis.

KEY RESULTS

We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services.

CONCLUSIONS

Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.

VA-Delivered or VA-Purchased Care: Important Factors for Veterans Navigating Care Decisions

BACKGROUND/OBJECTIVE

The VA MISSION Act aimed to increase Veterans' access to care by allowing eligible Veterans to use VA-paid care from non-VA providers ("VA-purchased care"). We interviewed Veterans who were eligible for both VA-delivered and VA-purchased care to examine factors they consider when making decisions about whether to use VA-delivered or VA-purchased care.

METHODS

We conducted semi-structured interviews with 28 Veterans across the USA who were eligible for VA-delivered and VA-purchased care, using deductive and inductive analysis to develop themes. Participants were recruited from a survey about healthcare access and decision-making. More than half of participants lived in rural areas, 21 were men, and 25 were > 50 years old.

KEY RESULTS

Veteran participants identified (1) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (2) a positive environment or "eco-system of care" characterized by supportive interactions with staff and other Veterans, and exemplary customer service as integral to their decisions about where to receive care. These preferences influenced their engagement with VA and non-VA providers. We discovered corresponding findings related to Veterans' information needs. When making decisions around where to receive care, participants said they would like more information about VA and non-VA providers and services, and about coordination of care and referrals, including understanding processes and implications of utilizing VA-purchased care.

DISCUSSION/CONCLUSION

Current VA-purchased care eligibility determinations focus on common access metrics (e.g., wait times, distance to care). Yet, Veterans discussed other important factors for navigating care decisions, including patient-provider relationship quality and the larger healthcare environment (e.g., interactions with staff and other Veterans). Our findings point to the need for health systems to collect and provide information on these aspects of care to ensure care decisions reflect what is important to Veterans when navigating where to receive care.

Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review

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.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

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.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

INTRODUCTION

Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.

METHODS

In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Health care Experiences of Patients-Patient Centered Medical Home (2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.

RESULTS

A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99).

CONCLUSION

For the most part, routine availability of women's health services in VA primary care clinics enhanced women's health care experiences. These empirical findings offer health care leaders evidence-based approaches for improving women's care experiences.

Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

Importance

Recent legislation expanded veterans' access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance.

Objective

To determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates).

Design, Setting, and Participants

This 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA's Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services' methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period.

Exposures

Of the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased.

Main Outcomes and Measures

The primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility's TKAs.

Results

Among the study sample's 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs.

Conclusions and Relevance

In this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans' decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.

Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming

Background

Rural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy influences. Federal policies over the last decade have relaxed requirements for some veterans to receive primary care services from community providers through their VA benefits, known as community care.

Methods

We used a participatory systems mapping approach involving causal-loop diagramming to identify interrelationships between variables underlying challenges to veteran access to primary care and potential opportunities for change—known as leverage points in systems science. Our methods involved a secondary analysis of semi-structured qualitative interviews with rural veterans, VA staff, non-VA clinic staff and providers who serve rural veterans, and veteran service officers (VSOs) in the Northwest region of the US, followed by a two-part participatory modeling session with a study advisory board. We then applied Meadows’s leverage point framework to identify and categorize potential interventions to improve rural veteran access to primary care.

Results

The final model illustrated challenges at the veteran, clinic, and system levels as experienced by stakeholders. Main components of the diagram pertained to the choice of VA or non-VA primary care, veteran satisfaction with the VA, enrollment in VA benefits and other insurance, community care authorization, reimbursement of non-VA care, referrals to specialty care, record sharing and communication between VA and non-VA providers, institutional stability of the VA, and staffing challenges. Fourteen interventions, including administrative and communications changes, were identified by analyzing the model using the leverage points framework.

Conclusions

Our findings illustrate how challenges rural veterans face accessing health care are interconnected and persist despite recent changes to federal law pertaining to the VA health care system in recent years. Systems mapping and modeling approaches such as causal-loop diagramming have potential for engaging stakeholders and supporting intervention and implementation planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08318-2.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program

OBJECTIVES

Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).

METHODS

We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect.

RESULTS

NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care.

CONCLUSIONS

Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

A Comparison of Patient-Reported Mental Health Outcomes for the Department of Veterans Affairs' Regional Telehealth and Community Care Programs

Objectives

To compare patient‐reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs‐Mental Health (CRH‐MH).

Data Sources

This national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4‐month follow‐up survey.

Study Design

A quasi‐experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH‐MH referrals for new treatment episodes. Patient‐reported outcomes included symptom severity, perceived access, utilization, and patient‐centeredness.

Data Collection

During the baseline and follow‐up surveys, all veterans were administered the Patient Health Questionnaire‐8 (PHQ‐8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM‐5 (PCL‐5) to assess PTSD symptom severity. The 4‐month follow‐up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient‐centeredness of care using the Patient‐Centered Care portion of the Veterans Satisfaction Survey.

Principal Findings

Results indicated that compared to VCCP consults, veterans with CRH‐MH consults reported 0.65 (CI₉₅ = 0.51–0.83, p < 0.01) times the number of barriers to care, but a non‐significant lower number of encounters (−0.792, CI₉₅ −2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient‐centeredness, with both groups “agreeing” on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups.

Conclusions

Overall findings indicate that the CRH‐MH and VCCP generate similar patient‐reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH‐MH programs.

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care

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.

Health Care for Our Nation's Veterans: A Policy Paper From the American College of Physicians

The Veterans Health Administration (VHA) is the United States' largest integrated health care delivery system, serving over 9 million enrollees at nearly 1300 health care facilities. In addition to providing health care to the nation's military veterans, the VHA has a research and development program, trains thousands of medical residents and other health care professionals, and conducts emergency preparedness and response activities. The VHA has been celebrated for delivering high-quality care to veterans, early adoption of electronic medical records, and high patient satisfaction. However, the system faces challenges, including implementation of an expanded community care program, modernization of its electronic medical records system, and providing care to a population with complex needs. The position paper offers policy recommendations on VHA funding, the community care program, medical and health care professions training, and research and development.

Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA

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.

Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration

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.

Rural Veterans' Experiences With Outpatient Care in the Veterans Health Administration Versus Community Care

BACKGROUND

The 2014 Veterans Access, Choice and Accountability Act was intended to improve Veterans' access to timely health care by expanding their options to receive community care (CC) paid for by the Veterans Health Administration (VA). Although CC could particularly benefit rural Veterans, we know little about rural Veterans' experiences with CC.

OBJECTIVE

The objective of this study was to compare rural Veterans' experiences with CC and VA outpatient health care services to those of urban Veterans and examine changes over time.

RESEARCH DESIGN

Retrospective, cross-sectional study using data from the Survey of Healthcare Experiences of Patients (SHEP) and VA Corporate Data Warehouse. Subjects: All Veterans who responded to the SHEP survey in Fiscal Year (FY) 16 or FY19.

MEASURES

Outcomes were 4 measures of care experience (Access, Communication, Coordination, and Provider Rating). Independent variables included care setting (CC/VA), rural/urban status, and demographic and clinical characteristics.

RESULTS

Compared with urban Veterans, rural Veterans rated CC the same (for specialty care) or better (for primary care). Rural Veterans reported worse experiences in CC versus VA, except for specialty care Access. Rural Veterans' care experiences improved between FY16 and FY19 in both CC and VA, with greater improvements in CC.

CONCLUSIONS

Rural Veterans' reported comparable or better experiences in CC compared with urban Veterans, but rural Veterans' CC experiences still lagged behind their experiences in VA for primary care. As growing numbers of Veterans use CC, VA should ensure that rural and urban Veterans' experiences with CC are at least comparable to their experiences with VA care.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey

BACKGROUND

Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness.

OBJECTIVE

Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care.

RESEARCH DESIGN

Cross-sectional analysis of responses to a 2018 mailed survey.

SUBJECTS

VHA outpatients with homeless experiences.

MEASURES

Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey.

RESULTS

Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61).

CONCLUSIONS

Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice

BACKGROUND

The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers.

OBJECTIVES

The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider.

RESEARCH DESIGN

This was a retrospective, observational over fiscal years (FY) 2015-2018.

SUBJECTS

Veterans receiving primary care services paid for by the VA.

MEASURES

Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year.

RESULTS

There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care.

CONCLUSION

As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

Did Access to Care Improve Since Passage of the Veterans Choice Act?: Differences Between Rural and Urban Veterans

BACKGROUND

The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied.

OBJECTIVES

To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans.

RESEARCH DESIGN

Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018).

SUBJECTS

All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC.

MEASURES

Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities.

RESULTS

Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times.

CONCLUSIONS

Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.

County-level Predictors of Growth in Community-based Primary Care Use Among Veterans

BACKGROUND

The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings.

OBJECTIVES

The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities.

DATA AND SAMPLE

A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings.

ANALYSIS

We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth.

RESULTS

Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001).

CONCLUSION

CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

VA Academic Affiliations Matter in the Era of Community Care: A Model From California

Background

The Veterans Health Administration (VHA), 1 of 3 administrative branches in the US Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. The VHA has 4 missions: providing health care to eligible veterans; supporting research to benefit veterans and the larger society; providing education for health care trainees; and supporting emergency response.

Observations

In service of these goals, the VA has academic affiliations with training institutions throughout the country, offering unique and extensive training and research opportunities. These affiliations are a 2-way street where both the VA and the affiliate provide and gain from their partnership. For example, VA affiliations with University of California (UC) medical schools benefit veteran care and are a major contributor to the UC academic mission. This article explores the history of the VA, current veteran demographics and needs, academic affiliations, and the integrated care model of training in all VHA facilities. The VA and UC academic affiliation system is described further with regard to shared research and educational functions.

Conclusions

We identify risks to academic affiliations if a shift occurs from VHA care to VA-managed community-based care following the implementation of recent legislation. We also provide suggestions for VA academic affiliates to help assess and guide the potential impact of increased VA-managed community care.

Health Care Crisis Unabated: A Review of Recent Data on Health Care in the United States

We review recently published studies of US health policy and the nation's health care system. Even prior to the COVID-19 pandemic, health inequalities were widening and care was inequitably distributed. Although the Affordable Care Act's coverage expansion improved access to care and timely cancer diagnoses, a large proportion of US residents continued to avoid medical care due to concerns about costs, and access to mental health services remains particularly inadequate. Yet more evidence of private insurers' profit-driven misbehaviors and of corruption among medical leaders continues to emerge. Misguided incentives and lax regulation encourages nominally nonprofit health care providers to mimic for-profits' misconduct, and rapacious investors own and control an increasing share of physicians' practices. Pharmaceutical firms wield outsize political influence and devote far more funds to rewarding investors than to research and development effort. Yet despite vigorous efforts by pharma and other commercial interests to denigrate national health insurance, polls indicate that the COVID-19 pandemic has led to increasing support for such reform.