HSR&D Home » Research » CRE 12-008 – HSR&D Study
Evaluation of Quality and Coordination of Outsourced Care for Women Veterans
Lori Anne Bastian, MD MPH
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Kristin Mattocks PhD MPH
VA Central Western Massachusetts Healthcare System, Leeds, MA
Funding Period: March 2013 - September 2017
While the number of women Veterans utilizing VA care is rising, many specialized, gender-specific services (e.g. mammography and prenatal care) are not available within the VA. In these instances, federal law enables the VA to pay for Veterans' care at outside facilities when the VA does not offer needed care or on an emergency basis when travel to a VA site would not be feasible. Despite increasing numbers of women Veterans relying on outsourced care for gender-specific services, little is known about the quality of non-VA care, perceptions and experiences of women Veterans who utilize such care, or the experiences of VA providers coordinating care.
The purpose of our study is to understand providers' and fee basis managers' strategies for provision, coordination, and quality oversight of outsourced care, and to assess perceptions and experiences with non-VA care among women Veterans. Follow-up of abnormal mammograms will be used as a case example in Aim 3 for evaluating gender-specific non-VA care.
- Aim #1: To understand providers' and fee basis managers' strategies for provision, coordination, and quality oversight of non-VA care.
- Aim #2: To understand perceptions and experiences with non-VA care among women Veterans.
- Aim #3: Evaluate the quality of gender-specific services for women Veterans using a case example mapped to VHA Handbook priorities (e.g., Do VA facilities utilizing non-VA care for mammography meet key quality standards compared to VA facilities providing in-house mammograms?)
Aims 1 and 2 will use a qualitative approach to examine perceptions and experiences with non-VA care access, provision, and coordination. Specifically, we will use the Women's Health Evaluation Initiative Database (WHEI) to ascertain the top 24 VA sites nationally for non-VA care referrals for women Veterans and to identify women Veterans from each of those facilities that received non-VA care over the past two fiscal years (FY10-FY12). Veterans will be sent letters to participate and we will conduct telephone interviews with a random sample of 6-8 women Veterans from each facility. We will interview women's health providers and fee basis managers from the 24 facilities to understand their perceptions and experiences with non-VA care. We will transcribe interviews and develop a top-level codebook with both women Veterans and VA staff to examine perceptions, experiences, and recommendations for improving non-VA care.
Aim 3 is a retrospective electronic medical chart review. We will use VINCI to pull administrative data including CDW, DSS, TIU text notes, Vital Status, and CAPRI/VistAWeb access to identify women (ages 40-74) at 8 sites with either non-VA or on-site mammograms in FY12. For FY12, we use chart reviews to evaluate whether: (1) results of mammograms were appropriately acknowledged in the patient's medical record, and (2) identified abnormal mammograms received appropriate and timely follow-up. We define abnormal mammogram results, using the existing Breast Imaging Reporting and Data System Atlas (BI-RADS) scoring system, as BI-RADS categories of 0 (indeterminate), 4 (suspicious for cancer), and 5 (highly suspicious for cancer) and we will also examine medical follow-up for BI-RADS 3 (probably benign).
Once we have confirmed the accuracy of FY12 CDW data, using chart reviews, we will use the terminology and coding we learned from FY12 to pull mammography records and subsequent follow-up imaging from FY13-FY16 using electronic CDW data only.
A total of 150 Women Veterans completed phone call interviews about their experience with non-VA care from 13 sites (Aim 2). We completed 15 provider interviews (Aim 1). Four major themes arose in the study: (1) Women Veterans felt responsible for their own care coordination with Veterans Choice Program (VCP) providers; (2) VCP care results are not shared with women Veterans or their VA providers in a timely manner; (3) Mounting unpaid VCP bills led many women to go into 'collections', and (4) Women's perceptions of VA and non-VA care quality varied substantially. In Aim 3, we have identified 34,918 completed mammogram requests between FY12-FY16. Median follow-up time for abnormal mammograms was 11.4 days for on-site mammography compared to 10 days for non-VA mammography; yet, there was also variability between the 8 sites as well. BI-RADS scores were missing in 10% of electronic records and BI-RADS 0 scores ranged from 10-15% depending on year and site. In our chart reviews of FY12 data, we found on-site mammography was more likely to report BI-RADS scores, document patient notification, and notify women more quickly of abnormal results than non-VA sites. On the other hand, non-VA sites were more likely to meet guidelines for timely follow-up (90% of women receive follow-up testing in 30 days).
Decisions regarding use of non-VA care (including fee basis and contract care) are made and monitored almost entirely within each VA facility (i.e., virtually no centralized oversight). Given that the use of non-VA care is increasing within the VA system due to the Choice Act, understanding the provision, coordination, and perceived quality of this type of care is of utmost importance as the VA continues to understand how to provide the best comprehensive health care for women Veterans.
External Links for this Project
NIH ReporterGrant Number: I01HX000947-01
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DRA: Health Systems
DRE: Prevention, Diagnosis
MeSH Terms: none