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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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Woolhandler S, Toporek A, Gao J, Moran E, Wilper A, Himmelstein DU. Administration's Share of Personnel in Veterans Health Administration and Private Sector Care. JAMA Netw Open 2024; 7:e2352104. [PMID: 38236601 PMCID: PMC10797450 DOI: 10.1001/jamanetworkopen.2023.52104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Importance Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). Objective To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. Design, Setting, and Participants This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. Exposure VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. Main Outcome and Measure The proportion of staff working in administrative occupations. Results Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. Conclusions and Relevance In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.
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Affiliation(s)
- Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Harvard Medical School, Boston, Massachusetts
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs
| | - Andrew Wilper
- Office of the Chief of Staff, Boise Veterans Affairs Medical Center, Boise, Idaho
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - David U. Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, New York
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Harvard Medical School, Boston, Massachusetts
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Erickson BA, Hoffman RM, Wachsmuth J, Packiam VT, Vaughan-Sarrazin MS. Location and Types of Treatment for Prostate Cancer After the Veterans Choice Program Implementation. JAMA Netw Open 2023; 6:e2338326. [PMID: 37856123 PMCID: PMC10587787 DOI: 10.1001/jamanetworkopen.2023.38326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/01/2023] [Indexed: 10/20/2023] Open
Abstract
Importance The Veterans Choice Program (VCP) was implemented in 2014 to help veterans gain broader access to specialized care outside of the Veterans Health Administration (VHA) facilities by providing them with purchased community care (CC). Objective To describe the prevalence and patterns in VCP-funded purchased CC after the implementation of the VCP among veterans with prostate cancer. Design, Setting, and Participants This cohort study used VHA administrative data on veterans with prostate cancer diagnosed between January 1, 2015, and December 31, 2018. These veterans were regular VHA primary care users. Analyses were performed from March to July 2023. Exposures Driving distance (in miles) from residence to nearest VHA tertiary care facility. The location (VHA or purchased CC) in which treatment decisions were made was ascertained by considering 3 factors: (1) location of the diagnostic biopsy, (2) location of most of the postdiagnostic prostate-specific antigen laboratory testing, and (3) location of most of the postdiagnostic urological care encounters. Main Outcomes and Measures The main outcome was receipt of definitive treatment and proportion of purchased CC by treatment type (radical prostatectomy [RP], radiotherapy [RT], or active surveillance) and by distance to nearest VHA tertiary care facility. Quality was evaluated based on receipt of definitive treatment for Gleason grade group 1 prostate cancer (low risk/limited treatment benefit by guidelines). Results The cohort included 45 029 veterans (mean [SD] age, 67.1 [6.9] years) with newly diagnosed prostate cancer; of these patients, 28 866 (64.1%) underwent definitive treatment. Overall, 56.8% of patients received definitive treatment from the purchased CC setting, representing 37.5% of all RP care and 66.7% of all RT care received during the study period. Most patients who received active surveillance management (92.5%) remained within the VHA. Receipt of definitive treatment increased over the study period (from 5830 patients in 2015 to 9304 in 2018), with increased purchased CC for patients living farthest from VHA tertiary care facilities. The likelihood of receiving definitive treatment of Gleason grade group 1 prostate cancer was higher in the purchased CC setting (adjusted relative risk ratio, 1.79; 95% CI, 1.65-1.93). Conclusions and Relevance This cohort study found that the percentage of veterans receiving definitive treatment in VCP-funded purchased CC settings increased significantly over the study period. Increased access, however, may come at the cost of low care quality (overtreatment) for low-risk prostate cancer.
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Affiliation(s)
- Bradley A. Erickson
- Veterans Health Administration (VHA) Office of Rural Health, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City
| | - Richard M. Hoffman
- Veterans Health Administration (VHA) Office of Rural Health, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Jason Wachsmuth
- Veterans Health Administration (VHA) Office of Rural Health, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Vignesh T. Packiam
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City
| | - Mary S. Vaughan-Sarrazin
- Veterans Health Administration (VHA) Office of Rural Health, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- VHA Office of Rural Health, Iowa City Veterans Affairs Health Care System, Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
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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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Mull HJ, Kabdiyeva A, Ndugga N, Gordon SH, Garrido MM, Pizer SD. What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery. Health Serv Res 2023; 58:654-662. [PMID: 36477645 PMCID: PMC10154155 DOI: 10.1111/1475-6773.14113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To investigate the relationship between community care (CC) treatment and a postoperative surgical complication in elective hernia surgery among Veterans using multiple approaches to control for potential selection bias. DATA SOURCES AND STUDY SETTING Veterans Health Administration (VHA) data sources included Corporate Data Warehouse (VHA encounters and patient data), the Program Integrity Tool and Fee tables (CC encounters), the Planning Systems Support Group (geographic information), and the Paid file (VHA primary care providers). STUDY DESIGN Prior works suggest patient outcomes are better in VHA than in CC settings; however, these studies may not have appropriately accounted for the selection of higher-risk cases into CC. We estimated (1) a naïve logistic regression model to calculate the effect of CC setting on the probability of a complication, controlling for facility fixed effects and patient and procedure characteristics, and (2) a 2-stage model using the hernia patient's primary care provider's 1-year prior CC referral rate as the instrument. DATA COLLECTION We identified patients residing ≤40 miles from a VHA surgical facility with elective VHA or CC hernia surgery from 2018 to 2019. PRINCIPAL FINDINGS Of 7991 hernia surgeries, 772 (9.7%) were in CC. The overall complication rate was 4.2%; 286/7219 (4.0%) among VHA surgeries versus 51/5772 (6.6%, p < 0.05) in CC. We observed a 2.8 percentage point increase in the probability of postoperative complication given CC surgery (95% confidence interval: 0.7, 4.8) in the naïve model. After accounting for the VHA provider's historical rate of CC referral, we no longer observed a relationship between surgery setting and risk of postoperative complication. CONCLUSIONS After accounting for the selection of higher-risk patients to CC settings, we found no difference in hernia surgery postoperative complications between CC and VHA. Future VHA and non-VHA comparisons should account for unobserved as well as observed differences in patients seen in each setting.
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Affiliation(s)
- Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonMassachusettsUSA
- Department of SurgeryBoston University School of MedicineBostonMassachusettsUSA
| | - Aigerim Kabdiyeva
- Partnered Evidence‐based Policy Resource Center (PEPReC)Department of Veterans AffairsBostonMassachusettsUSA
| | - Nambi Ndugga
- Partnered Evidence‐based Policy Resource Center (PEPReC)Department of Veterans AffairsBostonMassachusettsUSA
| | - Sarah H. Gordon
- Department of Health LawPolicy and Management, Boston University School of Public HealthBostonMassachusettsUSA
| | - Melissa M. Garrido
- Partnered Evidence‐based Policy Resource Center (PEPReC)Department of Veterans AffairsBostonMassachusettsUSA
- Department of Health LawPolicy and Management, Boston University School of Public HealthBostonMassachusettsUSA
| | - Steven D. Pizer
- Partnered Evidence‐based Policy Resource Center (PEPReC)Department of Veterans AffairsBostonMassachusettsUSA
- Department of Health LawPolicy and Management, Boston University School of Public HealthBostonMassachusettsUSA
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Govier DJ, Hickok A, Edwards ST, Weaver FM, Gordon H, Niederhausen M, Hynes DM. Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time. J Gen Intern Med 2023; 38:889-897. [PMID: 36307640 PMCID: PMC9616400 DOI: 10.1007/s11606-022-07800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.
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Affiliation(s)
- Diana J Govier
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
| | - Alex Hickok
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
| | - Samuel T Edwards
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Frances M Weaver
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Loyola University Chicago, Chicago, IL, USA
| | - Howard Gordon
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Meike Niederhausen
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Denise M Hynes
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA.
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA.
- College of Public Health and Human Sciences and the Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA.
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Itani KMF, Rosen AK. Association of Expanded Health Care Options for Community Care With Veterans' Surgical Outcomes. JAMA Surg 2022; 157:1123-1124. [PMID: 36223140 DOI: 10.1001/jamasurg.2022.4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Kamal M F Itani
- Department of Surgery, VA Boston Health Care System, Boston, Massachusetts.,Department of Surgery, Boston University, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston University, Boston, Massachusetts.,Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts
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Giori NJ, Beilstein-Wedel EE, Shwartz M, Harris AHS, Vanneman ME, Wagner TH, Rosen AK. Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery. JAMA Netw Open 2022; 5:e2233259. [PMID: 36178687 PMCID: PMC9526089 DOI: 10.1001/jamanetworkopen.2022.33259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/08/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas J. Giori
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Department of Orthopedic Surgery, Stanford University, Redwood City, California
| | - Erin E. Beilstein-Wedel
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | - Michael Shwartz
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | - Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford University, Stanford, California
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
| | - Todd H. Wagner
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amy K. Rosen
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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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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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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