Publication Briefs

Publication Briefs
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Caring Letters Not Associated with Suicide Attempts Following Veterans Crisis Line Contact, But Are Associated with Higher Probability of VA Mental Healthcare Use This study examined the effectiveness of the Veterans Crisis Line (VCL) Caring Letters intervention and determined whether there were differences in outcomes by signatory. Findings showed that Caring Letters were not associated with suicide attempts following VCL contact, but were associated with higher probability of VHA outpatient and inpatient mental healthcare use. There was no association among clinician vs. peer Veteran signatory and suicide attempts; VHA inpatient, outpatient, and emergency healthcare use; or all-cause mortality. Caring Letters may support access to care for high-risk Veterans who contact the VCL. Date: April 29, 2024 Prolonged Deployment to Military Bases with Open Burn Pits Increases Risk of Adverse Health Outcomes This study sought to determine whether the duration of deployment to military bases with open burn pits was associated with an increased risk of diagnosed respiratory and cardiovascular disease. Findings showed that prolonged deployment to military bases with open burn pits may increase the risk of developing adverse health outcomes. For every 100 days of deployment to bases with burn pits, the adjusted odds ratios for asthma, COPD, hypertension, and ischemic stroke were elevated, but not for interstitial lung disease, myocardial infarction, congestive heart failure, or hemorrhagic stroke. Most of the study cohort had been assigned to bases with burn pits at some time (86%), with an overall median duration of 244 days. Healthcare for OEF/OIF Veterans should consider the potential impact of exposure to emissions from open burn pits, with implications for access to care and benefits. Date: April 25, 2024 Veterans with COVID-19 have Greater Risk of Potentially Preventable Hospitalization than Non-infected Veterans This study sought to determine whether infection with SARS-CoV-2 is associated with an increased risk of a potentially preventable hospitalization and, if so, how long this association persists after infection. Findings showed that Veterans with COVID-19 had three times greater risk of potentially preventable hospitalization than matched uninfected Veterans within 30 days after infection and more than 40% greater risk at 1 year. Potentially preventable hospitalizations for acute conditions (i.e., bacterial pneumonia, urinary tract infection) accounted for 20% of all preventable hospitalizations; those for exacerbations of chronic conditions (e.g., diabetes complications, asthma) accounted for the remainder. Although exploratory, subgroup results suggest sub-optimal access to ambulatory care either before or after infection increases the risk of a potentially preventable hospitalization in those with COVID-19. Solutions are needed to mitigate preventable hospitalization after COVID-19. Date: April 10, 2024 VA’s Referral Coordination Initiative Does Not Measurably Affect VA or Community Care Wait Times or Community Care Referrals This study investigated whether the Referral Coordination Initiative (RCI) was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. Findings showed that in the initial years of the RCI program, RCI implementation did not measurably affect CC referral rates or wait times at VA facilities or CC providers for most specialties. Investigators did not find a strong association between RCI implementation and wait times at VA facilities for any of the specialties regardless of the type of staffing models the high RCI use facilities adopted. They also did not observe a significant relationship between RCI implementation and wait times at CC providers for most specialties, regardless of the staffing model. The results do not support concerns that RCI might impede Veterans’ access to CC providers and suggest that VA carefully consider the value of RCI, given RCI’s use of scarce resources. Date: March 30, 2024 JGIM Supplement Highlights VA’s Unique Advances in Virtual Care This supplemental issue of the Journal of General Internal Medicine (JGIM) describes opportunities to advance VA virtual care research and presents a collection of articles reporting on novel virtual care research and evaluation initiatives across the healthcare system. Date: March 13, 2024 Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic This study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Date: January 22, 2024 Veterans with a Racial/Ethnic Minority Background, Rural Residence, or Mental Health Disability History Were Less Likely to Complete Preoperative Goals of Care Documentation This study assessed factors – including race, ethnicity, rurality, history of mental health disability, and VA facility type – that are known or hypothesized to be linked with disparities in preoperative life-sustaining treatment (LST) documentation. The study also described the COVID-19 pandemic’s effect on completion of preoperative LST. Findings showed that Veterans with a racial or ethnic minority background, rural residence, mental health disability history, or who were seen at low-complexity, low-volume facilities were significantly less likely to complete preoperative LST compared to Veterans who were white or non-Hispanic, urban residents, without a mental health disability history, or who had access to a high-complexity, high-volume facility. Of the 229,737 Veterans in the cohort, 13,408 (6%) completed preoperative LST documentation within 30 days prior to surgery. With each passing year, Veterans undergoing surgical procedures had greater likelihoods of completing LST before surgery, including during the COVID-19 pandemic. Findings suggest there is continued need for interventions that target Veteran groups at risk of not engaging in serious illness communication. Date: December 19, 2023 Study Suggests Racial Inequalities in VA Pancreatic Cancer Care This study examined whether there were significant racial disparities in the continuum of pancreatic cancer care in the VA system, hypothesizing that there would be no racial disparities in the receipt of pancreatic cancer care among Black and White Veterans. Findings showed that even in a healthcare system with equal access to care, racial inequalities exist in the timing of pancreatic cancer diagnosis and receipt of treatment. Black Veterans were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. After adjusting for sociodemographic characteristics and medical comorbidities, Black Veterans had 13% higher mortality risk compared to White Veterans. However, this was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment. Date: November 13, 2023 Veterans with COVID-19 Have Elevated Rates of Suicide Attempt and Other Self-Directed Violence In this study, researchers used electronic health record data to examine associations between suicide attempt and other self-directed violence (SDV) and time since COVID-19 infection in VA patients who were infected between March 1, 2020, and March 31, 2021, and similar but uninfected VA patients. Findings showed that Veterans infected with COVID-19 had a 41% higher risk of a suicide attempt and 38% higher risk of other SDV compared to members of the uninfected cohort for at least one year following infection. Suicide attempt and SDV rates were higher in the COVID-19 group than in the uninfected group during all of the reviewed time periods, with the highest rates occurring in the first 30 days following the date of infection. Among the infected and uninfected cohorts, rates of suicide attempts and other SDV were substantially lower than those reported during the two years prior to the pandemic, possibly indicating that care disruption and limited care access during the pandemic reduced the opportunity to report these events. Results support suicide risk screening of those infected with COVID-19 to identify opportunities to prevent self-harm. Date: October 26, 2023 Equal-Access Healthcare Is Associated with Significantly Improved Clinical Outcomes in Black and Hispanic Veterans with Prostate Cancer This study examined clinical outcomes by race and ethnicity in Veterans with nonmetastatic castration-resistant prostate cancer (nmCRPC). Findings showed that among patients with nmCRPC in VA—an equal-access system—self-identified Black and Hispanic men had better clinical outcomes than White or other patients, including time to metastasis and overall survival. Median time elapsed from nmCRPC to metastasis or death was 5.96 years for Black Veterans, 5.62 years for Hispanic Veterans, 4.11 years for White Veterans, and 3.59 years for other Veterans. Median unadjusted overall survival was 6.26 years among all Veterans, 8.36 years for Black Veterans, 8.56 years for Hispanic Veterans, 5.48 years for White Veterans, and 4.48 years for other Veterans. Findings provide evidence that the racial and ethnic disparities long observed in prostate cancer might stem from systemic socioeconomic inequity rather than molecular or genetic factors. Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting. Date: October 11, 2023 Multi-Level VA System Improvements are Needed to Ensure Equitable and Accessible Gender-Affirming Hormone Therapy Investigators in this study conducted interviews with transgender and gender diverse (TGD) patients and with VA healthcare providers to determine barriers and facilitators to gender-affirming hormone therapy (GAHT) at the individual (i.e., knowledge, coping mechanisms), interpersonal (i.e., interactions with other individuals or groups), and structural (i.e., societal gender norms, institutional policies) level and also asked participants for recommendations for overcoming perceived barriers. Findings showed that multi-level system improvements are needed within and outside VA to ensure equitable and efficient access to GAHT. To overcome barriers, study participants recommended increasing provider capacity and support, providing opportunities for continual provider education in GAHT, and enhancing communication to both patients and providers around VA policy and training regarding GAHT. Date: July 12, 2023 Deployment of Medical Scribes Improves Provider Productivity and Wait Times in Cardiology and Orthopedics This study evaluated the impact of medical scribes on VHA provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. Findings showed that randomization into the scribes pilot was associated with increased productivity in cardiology and orthopedics, decreased wait times in orthopedics, and no changes in patient satisfaction. Randomization was also associated with a decrease of 8.5 days in request to appointment day wait times in orthopedics. No change in wait times for cardiology was observed. Date: July 1, 2023 Significant Racial Disparities Found in VA Uterine Fibroid Treatment This study examined differences in uterine fibroid (UF) treatment among Black and White Veterans in VA, including variation by UF severity as indicated by anemia. Findings showed that there were significant Black-White disparities in receipt of any treatment for symptomatic UF. Across age and UF severity subgroups, Black Veterans were less likely than White Veterans to receive any treatment. Racial disparities were most pronounced among Veterans with severe UF as indicated by anemia (<45 years: 60% of Black Veterans vs 71% of White Veterans received any treatment; >45 years: 46% of Black Veterans vs 67% of White Veterans received any treatment). Across age groups, among those who received any treatment, Black Veterans were less likely than White Veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. These disparities may indicate delays in care among Black Veterans, differential ability to access desired treatments, and/or differential or biased care. Date: July 1, 2023 JGIM Special Issue on Improving Access to VA Care This special issue of the Journal of General Internal Medicine titled “Veterans’ Access to Care” highlights recent advancements in access-related research and illustrates how VA has evolved in its ongoing journey to be a high-reliability organization using a learning healthcare system framework to improve access to care. Date: July 1, 2023 Despite Equal Access and Use of VA Care, Black Veterans are More Likely to Experience Postpartum Rehospitalization and Low-Birthweight Infants This study sought to determine whether Black/white racial disparities in access, use, and outcomes are present among pregnant and postpartum Veterans and their infants using VA maternity care. Findings showed no statistically significant racial disparities in access or use of care during the perinatal period; nevertheless, Black Veterans were more likely than white Veterans to experience postpartum rehospitalization and to have a low-birthweight infant. After adjusting for age, rurality, and parity, Black Veterans were 67% more likely than white Veterans to have a postpartum rehospitalization and 67% more likely to have a low-birthweight infant. No other racial disparities in outcomes for birthing Veterans or their infants were detected. Approximately one-third of both Black and white Veterans reported needing mental healthcare during pregnancy. However, one in five Veterans were unable to access needed mental healthcare indicating there may be a persistent unmet need for perinatal mental healthcare. Study findings underscore the idea that access is necessary but not sufficient for ensuring health equity. Date: July 1, 2023 Thirty-Day Mortality Higher for Older Veterans Hospitalized with COVID-19 in Community vs. VA Hospitals This study compared outcomes among Veterans ages 65+ admitted for COVID-19 in VA and community hospitals. Findings showed that admission to community hospitals was associated with higher unadjusted (27% vs. 18%) and risk adjusted 30-day mortality compared to admission to VA hospitals. Readmission within 30 days was less common following admission to community compared to VA hospitals (13% vs. 14%). This difference was not sensitive to adjustment for patient characteristics, suggesting that higher readmission in VA hospitals may reflect a feature of the VA healthcare system and not case-mix. Community hospitals played a disproportionate role in care for rural Veterans with COVID-19, likely because of poor geographic access to VA hospitals among this population: 46% of community hospitals caring for VA enrollees with COVID-19 were in rural areas. Date: May 30, 2023 VA Surgical Care Comparable or Better than Non-VA Surgical Care Investigators conducted a systematic review to compare VA and non-VA care for surgical conditions across domains of quality and safety, access, patient experience, and comparative cost/efficiency using studies published between 2015 and 2021 – following implementation of the Choice and MISSION Acts. Findings showed that in all but two studies, VA care had comparable or better quality and safety outcomes than non-VA care. For access to care, neither VA nor non-VA care was found to be consistently better. Studies of patient experience were too limited to draw conclusions, and the few studies of cost and efficiency outcomes favored non-VA care. Findings suggest that expanding eligibility for Veterans to receive care in the community may not provide benefits in terms of increasing access to surgical procedures or result in better quality, but may reduce inpatient length of stay and cost. Date: May 8, 2023 Giving Veterans an Active Voice in Creating a Veteran-Centered Chronic Pain Research Agenda Veterans Action League (VAL) 2.0 was a two-year community engagement project (2019–2021) that sought to develop a national Veteran-centered chronic pain research agenda that includes Veteran-generated recommendations for chronic pain management and chronic pain research priorities. Findings showed that Veterans’ most frequently cited need for chronic pain management and treatment was better access to care, with easier appointment booking and shorter wait times. Veterans also requested improved coordination among providers, and more thorough, holistic assessments for identifying contributors to their chronic pain. Some Veterans perceived that many providers overprescribed opioids as a “quick fix,” while other Veterans warned that the anti-opioid pendulum had swung too far. Veterans across states strongly agreed that they wanted to be offered choices for chronic pain management, with their options clearly outlined and their preferences sought. Veterans’ preferred approaches for managing chronic pain were diverse and included acupuncture, an anti-inflammatory diet, and epidural injections. Many Veterans voiced that they would like to see more studies on the efficacy of non-traditional therapies, including cannabis, chiropractic treatments, and therapeutic massage. Date: March 23, 2023 Black and Hispanic Veterans Experienced Greater Access Barriers to VA Care During Pandemic This study sought to determine whether wait times increased differentially for Black and Hispanic compared with White Veterans for VA outpatient orthopedic and cardiology services from the pre–COVID-19 to COVID-19 periods. Findings showed that national wait time disparities increased significantly for Black and Hispanic Veterans for orthopedic services. During the COVID-19 period, Black and Hispanic Veterans’ mean wait times exceeded those of White Veterans by 2.45 days for Black Veterans and 1.98 days for Hispanic Veterans. There were only modest national disparities for cardiology services (<1-day difference). There was variation in wait times across the 140 VA facilities. For example, pre-COVID, there were Black/White differences for cardiology at 6 facilities (Black Veterans waited longer at 4 facilities, White Veterans waited longer at 2 facilities). During COVID, 21 facilities had Black/White differences for cardiology (Black Veterans waited longer at 14 facilities, while White Veterans waited longer at 7 facilities). Although differences in wait times were only a few days, any wait time disparity is concerning. It will be important for future work to monitor these trends, understand their sources, and implement appropriate interventions as needed. Findings also underscore the critical importance of facility-level analyses for highlighting opportunities to reduce disparities and target quality improvement efforts. Date: January 23, 2023 Male and Female Veterans Differ in Attitudes to Referral to VA Care after Calling the Veterans Crisis Line This study described Suicide Prevention Coordinator (SPC) referral outcomes for Veterans who contacted the Veterans Crisis Line (VCL) with active thoughts of suicide during calendar years 2018–2019. Reasons given for declining SPC referral suggest that concerns about or discomfort with VA care were a key concern, particularly among women Veterans. Women had a higher rate of declining SPC referrals than men (6% vs. 5%). Men who expressed negative sentiment toward VA appeared to express anger broadly at VA. In contrast, women who expressed negative experiences or views of VA were more likely than men to express frustrations with VA treatment. Compared with men, women who reported a negative experience with or perception of VA care had concerns regarding potentially losing access to their children, being “locked up,” or even fear of retaliation or judgement from VA staff if they pursued an SPC referral. Veterans who called the VCL and were rated as lower risk were more likely to decline referral to future care. This suggests that the VCL interaction itself may have been sufficient in managing the Veteran’s needs at the time – and it helped mitigate an immediate mental health crisis. Date: January 1, 2023 Black Veterans with Chronic Pain Express Dissatisfaction with VA Telehealth Options during Pandemic This study sought to understand how Black Veterans with chronic pain experienced pandemic-related changes in VA healthcare delivery. Investigators conducted qualitative interviews with Black Veterans who had completed a randomized controlled trial of an intervention focused on communication and patient activation for Black patients with chronic pain. Findings showed that Veterans described mostly negative effects from the shift to telecare after the pandemic’s onset including: decreased ability to self-manage their chronic pain; difficulty obtaining non-pharmacological services such as physical therapy; difficulty seeing their primary care providers; and trouble scheduling surgery. Many Veterans said phone and video visits were inadequate to handle complaints related to their pain. Some Veterans were willing to accept the tradeoff of telehealth to avoid possible exposure to COVID-19, while others saw positive aspects to a virtual format. Date: November 14, 2022 Timeliness of VA Purchased Community Primary Care Did Not Improve Following Early Expansion Under MISSION Act This study examined whether early Community Care Network (CCN) implementation impacted community primary care (PC) appointment wait times. Findings showed that expanded contracting with community providers and new provider network adequacy standards implemented through CCNs did not, in early stages, improve the timeliness of community primary care for Veterans. Wait times increased sharply for both CCN and comparison appointments after CCN implementation, ranging from approximately 30 to 40 days, which is beyond VA’s new urban and rural network adequacy wait-time standard for community care. Date: October 28, 2022 Increased Access to VA-Paid Community Care Resulted in Shift in Location of Surgery but No Difference in Outcomes for Veterans VA’s Veterans Choice Program (VCP) expanded access to healthcare in community settings outside VA for eligible Veterans, but little is known about the effect of VCP on access to surgery and post-operative outcomes. This study explored the healthcare use of Veterans undergoing either VA-provided or VA-paid surgery (i.e., community care) between October 1, 2014, to June 1, 2019, when VCP ended. Findings showed that expanded access to VA healthcare resulted in a shift in the location of surgical procedures but had no measurable effect on surgical outcomes. Investigators found no difference in post-operative ED visits, inpatient readmissions, or mortality between VA-provided and VA-paid surgical procedures done in a community setting. Patients who underwent VA-paid vs. VA-provided procedures were significantly more likely to be female (13% vs. 9%), younger than 65 (49% vs. 46%), and White (74% vs. 73%), and they had a significantly lower comorbidity burden. Overall, 15% of the procedures were VA-paid (community care), and the proportion of VA-paid procedures varied by procedure type (e.g., spinal fusion and knee prosthesis had higher proportions of VA-paid care). Results emphasize the importance of access to community care and help assuage concerns of worsened outcomes due to care fragmentation. However, study results are less applicable to some select procedures (i.e., transplant, gastric bypass, or transcatheter aortic valve replacement), and VA should continue to make these decisions on a case-by-case basis. Date: October 12, 2022 Compared to Medicare, Veterans with VA-Financed Care are More Likely to Receive Dialysis and Hospice for Kidney Disease In contrast to Medicare, VA is committed to ensuring that Veterans have access to hospice services regardless of whether they are still receiving disease-modifying treatments, such as dialysis for end-stage kidney disease (ESKD). This study sought to answer the question: Does the frequency of concurrent hospice and dialysis (“concurrent care”) among Veterans with ESKD vary by hospice payer? Findings showed that rates of concurrent care were substantially higher among Veterans receiving VA-financed, compared with Medicare-financed, hospice services. The proportion of Veterans receiving concurrent care was lower for those receiving Medicare-financed hospice (25%) than for those receiving VA-financed hospice, either under VA Community Care (42%) or in VA inpatient hospice (55%). Regardless of hospice payer, VA paid for the majority (87%) of dialysis treatments after Veterans were enrolled in hospice. Veterans who received concurrent care had a median hospice length-of-stay of 43 days, compared with 4 days for those who did not. Findings suggest that there is probably a substantial unmet need for concurrent care among the large majority of Veterans with ESKD receiving hospice services under Medicare. Date: October 7, 2022 VA Outperforms Wait Times Compared to Community Care This study sought to describe geographic variation in wait times experienced by Veterans for three categories of care: primary care, mental health, and other specialties, comparing differences between VA-provided and community-provided care. Findings showed that mean VISN-level wait times were shorter for VA than for community care: 29 vs 39 days for primary care, 34 vs 44 days for mental health, and 35 vs 42 days for all other specialties. A sizeable proportion of Veterans experienced wait times that exceeded the VA standard (20 days or less): 44% of VA appointments and 50% of community care appointments. There was substantial geographic variation in appointment wait times. For example, the mean wait time for a mental health appointment in VISN 1 was 33 days for community care and 31 days for VA care, while the wait times were 55 days and 42 days for VISN 6. Findings suggest that increased access to community care under the Choice and MISSION Acts may not result in lower wait times in many areas of the country. Date: August 25, 2022 New Metric Determines Adequacy of VA Primary Care Staffing This study created a primary care provider (PCP) staffing measure using clinic-level provider FTE and number of assigned patients to identify primary care (PC) clinics at risk of insufficient staffing and describe rural-urban staffing variation. Using this metric, over the 3.5-year study period at 916 clinics, 38 (4%) were always under-staffed, 21 (2%) were always marginally staffed, and 200 (22%) were always fully staffed. At the end of the study period (March 2021), 351 PC clinics (39%) were not fully staffed and 179 of these clinics (51%) had a gap of at least 0.5 Advanced Practice Provider FTE, representing a potential minimum threshold for hiring a new provider. But 559 clinics were fully staffed with excess clinic capacity of 11-15%. Depending how FTE is distributed (e.g., across clinics vs. within each clinic) and the provider type, 228 to 521 PCP FTE are needed to fully staff all PC clinics as of March 2021. This represents a 4-8% provider staffing deficit. Over the entire study period, rural clinics, on average, were under-staffed for 21% of months compared to 14% of months for urban clinics, a 50% higher rate. The gap staffing metric may be a beneficial tool to identify PC clinics that are persistently over- or under-staffed, facilitating strategic workforce planning and allowing better distribution of provider FTE to address patient care needs. Date: August 4, 2022 VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care. Date: July 28, 2022 Gulf-War Era Veterans with Depression and/or PTSD were More Likely to Receive Mental Healthcare if They were Enrolled in VA The aim of this study was to explore factors associated with treatment utilization for depression and PTSD. Findings showed that Veterans who used VA healthcare were significantly more likely to receive mental health treatment than those who did not. VA enrollment was associated with three- and five-times higher odds of being treated for depression or PTSD, respectively. VA enrollment was the strongest predictor of receiving mental health treatment, after controlling for all other variables. Higher reported income was associated with a higher likelihood of receiving treatment for both PTSD and depression. Increased enrollment in VA healthcare may result in more Veterans receiving mental health treatment for diagnoses that often go untreated, such as depression and PTSD. Expanding eligibility and retaining enrolled Veterans may aid in increasing Veterans’ contact with the VA healthcare system. Date: July 4, 2022 Early Expansion of Benefits under Choice Act Increased Community Hospital Use but Did Not Change Mortality This study examined changes in VA enrollees’ use of VA and non-VA hospitals from 2012-2017, as well as mortality associated with policies intended to increase access to care, such as the Choice Act. Findings showed that over the five-year study period, Veterans increased their use of community hospitals paid by VA and Medicaid and decreased their use of VA hospitals when access to non-VA care expanded. This shift in hospitalizations from VA to the community was not associated with changes in mortality rates, however, other outcomes need to be assessed to understand how changes in hospital use affected the quality of care for Veterans. Shifting inpatient care to non-VA hospitals poses significant challenges for care coordination across providers and healthcare systems and requires that outcomes be closely monitored. The VA MISSION Act of 2018 further expanded Veterans’ access to community care and is expected to amplify the trends observed in this study. Date: June 10, 2022 Challenges and Strain on VA System Associated with VA-Funded Community Care for Veterans with Advanced Kidney Disease This study sought to further the understanding of the internal challenges of cross-system healthcare use to the VA healthcare system and enrolled Veterans. Three dominant themes pertaining to VA-financed community care were identified. Themes described VA as mothership, the hidden work of Veterans, and strain on the VA system. ‘VA as mothership’ describes extensive care coordination by VA staff members and clinicians to facilitate care outside VA – and the tendency of Veterans and their non-VA clinicians to rely on VA to fill gaps in this care. ‘Hidden work of Veterans’ refers to the efforts of Veterans and family members to navigate the referral process – and to serve as intermediaries between VA and non-VA clinicians. ‘Strain on the VA system’ refers to the challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes, particularly for social workers who often served as a point-of-contact for Veterans. Overall, 607 (61%) members of the study cohort had at least one active or paid claim for VA-financed non-VA care during follow-up. Date: May 16, 2022 Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth). The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access. Date: April 11, 2022 Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a suicide-related ED visit, and a 22% reduction in the likelihood of suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via telehealth and for preventing suicides among rural residents. Date: April 6, 2022 Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more effective than usual care, as well as feasible to implement. Compared with Veterans who received usual care, those who received the SMI PACT intervention had greater improvement in screenings, treatment quality, chronic illness care (e.g., goal setting, counseling), care experience (e.g., doctor-patient interaction, care coordination, access), psychotic symptoms, and mental health-related quality of life at 12 months. Investigators saw no signs of worsening of mental health status under the SMI PACT model of care. This care model can be effective and should be considered among the interventions for improving medical care in patient populations with serious mental illness. Date: April 5, 2022 Increased Risk for Cardiovascular Conditions among Veterans for Up to One Year Following COVID-19 Infection This study evaluated the risks and 12-month burdens of cardiovascular outcomes among Veterans who survived the first 30 days of COVID compared to VA healthcare users with no COVID and Veterans who used VA healthcare before the COVID pandemic. Findings showed that COVID-19 increased the risk of developing cardiovascular conditions – spanning several categories – within the first month to one year after infection. The risk increased even in Veterans without previous heart conditions and in those with mild COVID-19 infection. Overall, heart disease was seen in 4% more people who contracted COVID-19 than in those without. COVID-19 patients were 72% more likely to suffer from coronary artery disease, 63% more likely to have a heart attack, and 52% more likely to have a stroke. Health systems should prepare for a significant contribution of COVID-19 to a rise in the burden of cardiovascular diseases and the potential long-lasting consequences for patients and the health system. Date: February 7, 2022 Reasons Why Women Veterans Leave or Stay in VA Healthcare This study sought to characterize women Veterans’ decision-making related to departing from (attriting) or continuing to use VA – and to explore factors that help retain/attract women to the VA healthcare system. Women Veterans described complex reasons why they left or continued using VA, with cost and affordability playing an important role even in considerations of returning to VA after a long hiatus. Personal experiences with VA care were regarded similarly by both attriters and non-attriters and considered greatly influential in their decision to use VA or not. Care experiences that influenced women’s decisions not to continue using VA included: strained patient-provider interactions (e.g., feelings of mistrust); disruptive provider turnover; service-connection compensation/pension claim challenges; billing and care coordination disputes regarding VA-purchased care; burdensome access (i.e., clinic-initiated appointment cancellations and rescheduling problems); inconvenient appointment times; and travel distance to the main medical center. More than one-third of women originally categorized as attriters described subsequently re-entering or planning to re-enter VA care. Suggestions to reduce attrition included increasing outreach, improving access, and continuing to tailor care delivery to women Veterans’ needs. Date: December 28, 2021 Expanded Provider Options are Associated with Increased Healthcare Utilization among Veterans This study sought to determine the association of expanded healthcare options with Veterans’ healthcare choices and outcomes, particularly as they relate to the introduction of the Choice Act (2014), which expanded coverage to more Veterans for non-VA care. Findings showed that expanding provider options among more than 2.7 million Veterans with VA care was associated with higher outpatient use, as well as increased lab visits, prescriptions, and psychotherapy visits. Outpatient use was 3% higher among Veterans with an expanded provider network. Lab testing also increased by 3%, while medications only increased by 1%. In contrast, individual and group psychotherapy increased substantially, with an 8% increase overall and an 8% increase for Veterans with more comorbidities. Increased outpatient use was most concentrated among Veterans with more service-connected disabilities – and among younger Veterans without service-connected disabilities. There was no evidence of changes to inpatient use or mortality. Date: October 26, 2021 Receipt of COVID-19 Vaccine is Higher among Racial/Ethnic Minorities than Whites within VA Healthcare System VA began administering COVID-19 vaccinations shortly after the US rollout began, allowing for an examination of vaccination rates among racial/ethnic minorities in an integrated healthcare system with few barriers to access. Findings showed that in contrast to disparities reported in the general population, COVID-19 vaccine receipt in the VA healthcare system was higher among most racial/ethnic minority groups than in Whites, suggesting reduced vaccination barriers compared with non-VA care. Overall, 24% of the cohort received at least one vaccine dose as of 2/23/21. Black (29%), Hispanic (27%), and Asian (27%) Veterans were significantly more likely than White (24%) Veterans to receive a vaccination through VA, while American Indian and Alaska Native (AI/AN) Veterans were less likely. Only AI/ANs in Contract Health Service Delivery Area counties, which indicates residence in/adjacent to federally reserved tribal lands were less likely than Whites to be vaccinated. Since AI/AN Veterans were less likely to obtain COVID-19 vaccinations through VA when close to a tribal area, the Indian Health Service may provide a safety net that is effective at reaching this population despite disparities in other contexts. Influenza vaccination history was positively associated with COVID-19 vaccine uptake. Date: October 21, 2021 VHA In-Person Care Declined Substantially More than Community Care During Pandemic – And Has Yet to Recover This study sought to describe how VA care patterns shifted in response to the pandemic, including all forms of care either purchased (Community Care) or provided by VA. Findings showed that overall VA healthcare use dropped precipitously in March and April of 2020, while virtual care expanded swiftly. However, VA in-person care declined substantially more than Community Care, and total encounters have yet to recover to pre-pandemic levels. The estimated total volume of missing encounters relative to the previous year (2019) was 16.5 million. Virtual care in VA increased from 6% (n=454,399) in April 2019 to 44% (n=1,894,674) in April 2020 before falling to 29% (n=1,861,922) in December 2020. As of December 2020, VA in-person care constituted just 30% of VA paid or provided care while non-acute community care accounted for 29% of all encounters. VA likely adopted a more conservative reopening strategy compared to community providers, who have different financial incentives to resume in-person care and returned close to pre-pandemic patient volume by September 2020. In the wake of concerns about access, VA has steadily increased spending on Community Care, and study results indicate existing trends pushing VA toward being a mixed payer and provider may have accelerated. Date: October 1, 2021 Best Practices for Equitable COVID-19 Vaccination Drive In collaboration with HSR&D investigators, the Interdisciplinary Vaccine Team at the VA Puget Sound Healthcare System worked to develop an equitable, coordinated, and data-driven COVID-19 vaccination drive for Veterans (carried out from December 21, 2020 to May 30, 2021). As of July 28, 2021, the VA Puget Sound facility had administered 79,643 vaccinations to 41,386 Veterans, representing 42% of its total population, and including 42% of Black enrollees, 29% of American Indian/Native Alaskan enrollees, and 35% of white enrollees. Key takeaways include: develop an intentional vaccine delivery strategy in conjunction with experts in population-level barriers to vaccination; explicitly include demographic and social determinants of health data to prioritize vulnerable populations in accessing vaccination; utilize multiple communication channels to reach patients in different formats. Date: September 15, 2021 High Acute Inpatient Psychiatric Bed Occupancy Associated with Increased Rates of Suicide among Veterans This study examined the relationship between the incidence of suicide among Veterans and acute inpatient psychiatric bed availability using occupancy as a measure of hospital strain and access. Findings showed that high acute VA psychiatric bed occupancy (>95%), not beds per capita, was associated with a 10% higher incidence of death by suicide. Extrapolated over the 6-year study across 145 hospital quarters with occupancy >95%, this hospital strain contributed to an estimated excess of 64.5 suicides. The absolute number of acute VA inpatient psychiatric beds decreased by 13% from 4,419 in 2011 to 3,860 in 2016, while mean occupancy decreased from 68% to 65% over the same time period; the number of deaths by suicide increased from 2,193 in 2011 to 2,464 in 2016. The VA national average of 65.5 acute psychiatric beds per 100,000 Veterans was three times the US national average of 22/100,000 in 2016. Changes in VA acute psychiatric beds, non-VA (i.e., community) psychiatric beds, spending on community mental health per capita, and the proportion of Veterans with a mental health diagnosis were not associated with the incidence of suicide among Veterans enrolled in VA care. Measuring hospital occupancy and establishing occupancy benchmarks should be included in patient safety reports as psychiatric bed overcrowding joins overall hospital, emergency department, and intensive care unit occupancy as a risk for higher mortality. Date: August 16, 2021 Personal and Community Risk Factors Associated with Unsheltered Homelessness among Veterans This study sought to answer the question, “Among Veterans who have experienced homelessness, what distinguishes those who were recently unsheltered from those who were not?” Findings showed that among Veterans experiencing homelessness, being unsheltered correlated with individual (e.g., poverty) and community risk factors (e.g., poor access to shelter). Veterans who reported being unsheltered were more likely to report a criminal justice history, poor social support, medical and drug problems, and financial hardship, and they were more likely to be unmarried. Unsheltered Veterans more often came from communities with warmer weather and higher rent burden, and from communities with lower shelter bed availability. Having a greater number of personal and community risk factors was associated with a greater likelihood of having been unsheltered. Date: July 15, 2021 Veterans’ Concerns on Using Community Emergency Services This qualitative study explored Veterans’ experiences with VA coverage when accessing community emergency care. Veterans emphasized three major concerns when navigating community emergency care: 1) they lack information about benefits and eligibility when they need it most; 2) they require assistance with medical billing to avoid financial hardship and future delays in care; and 3) they desire multimodal communication about VA policies or updates in emergency coverage. After using community emergency care, Veterans were often subject to out-of-pocket medical expenses including co-pays, uncovered medical bills, ambulance fees, and prescription costs. Veterans emphasized stress and frustration associated with these financial issues and debt. Veterans recommended ways VA could improve and tailor communication about community emergency care coverage and updates in policies, including emails, letters, text messaging, phone calls, and face-to-face conversations. Findings suggest the following strategies should be considered: 1) increasing transparency regarding eligibility and estimated out-of-pocket costs for community emergency care; 2) resolving billing errors and rejections in a timely fashion; 3) improving access to prescriptions and ambulance services for community emergency care; and 4) maximizing communication preferences by using multifaceted, bi-directional strategies. Date: May 24, 2021 Both “High-Needs” Patients and Facility Leaders Praise VA’s Intensive Primary Care Pilot Program This qualitative evaluation explored the perspectives of patients and healthcare facility leaders to identify additional important outcomes that could augment utilization and cost studies of intensive primary care (IPC) programs for high-needs patients. Findings indicated that IPC programs may yield benefits beyond healthcare cost and use, including improved quality of care, patient satisfaction, quality of life, and patient health behaviors. Patients perceived improvements in their experience of VA care, including improved patient-provider relationships and access to their healthcare team. Patients frequently reported feeling a sense of connection with their IPC team because they could rely on them for support with health and non-health-related issues. Primary care leaders also observed greater proactive patient engagement with the IPC team, increased motivation for health behavior change and self-care, and improvements in patient health behaviors, physical and mental health, and social needs. Despite benefits, patients and providers noted how some patient health characteristics (e.g., chronic health conditions) and contextual factors (e.g., housing insecurity) may have limited the effectiveness of the program on healthcare costs and utilization. Date: May 13, 2021 Medical Care Supplement Highlights VA Efforts to Increase Healthcare Options for Veterans through Community Care In this Medical Care Supplement, 12 articles highlight research focusing on Veterans’ use of community care and how VA facilities interact with community care providers. The Supplement offers a broad examination of VA’s expanded Community Care program, from the Choice Act through the first two years of MISSION Act implementation, and highlights areas where additional research is needed to understand Veterans’ perceptions, satisfaction, and use of VA Community Care. Date: May 13, 2021 VA Workgroup Consensus Statement on Suicide among Homeless Veterans and What We Still Need to Learn This article serves as a consensus statement by the recently formed VA Suicide Prevention among Veterans Experiencing Homelessness Workgroup – and provides a brief overview of current initiatives to prevent suicide among homeless Veterans. This consensus statement also discusses methods of conducting research within this complex subset of the Veteran population, as well as future research endeavors necessary to inform gaps in knowledge. While VA has implemented several initiatives to prevent suicide among homeless Veterans, there is a continued need to understand how best to tailor these initiatives. Further, because homeless Veterans often access various community services (e.g., homeless shelters, community emergency departments), an effective collaboration between VA and the community is needed. Date: April 1, 2021 Important IT Issues Impede Implementation of VA Mobile Teledermatology Application To improve access to teledermatology for Veterans, VA created the web-based VA Telederm application (app), which interfaces with the EHR (electronic health record). This study evaluated the initial implementation process for the VA Telederm app – and assessed organizational readiness for change (ORC). Findings showed that at all sites, technical issues including sub-optimal information technology infrastructure negatively affected adoption, leading to the inoperability of the app at two sites. There also were technical inefficiencies related to users’ unfamiliarity with new devices and inconsistent Internet access. Each site had a high level of organizational commitment for change, including support from leadership and clinical champions, but this was insufficient to surmount the technological barriers. Communication and early-user involvement encouraged individual and system-wide adoption. Thus, information obtained from users at an early stage of implementation provided an understanding of needed communication strategies. Leadership support, commitment to change, staff perceptions about the value of a change and their ability to implement it, and a clinical champion were important for implementation effectiveness, but were not enough to overcome technological barriers. Date: March 1, 2021 Inequities in Enhanced Pension Benefit for Veterans This study examined sociodemographic, medical, and healthcare use characteristics associated with receipt of the Aid and Attendance (A&A) benefit among Veterans receiving pension. Findings identified potential inequities in Veterans’ receipt of the A&A enhanced pension. Among 89,845 Veterans who received a pension but not the A&A enhanced benefit in FY2016, 8,724 Veterans (10%) newly received the A&A enhanced pension in FY2017. Veteran pensioners who received A&A were significantly older and more likely to be white and married than those who did not receive A&A. Pensioners who were black, Hispanic, or other non-white race had a lower probability of receiving A&A than white Veterans after adjusting for indicators of need. Most indicators of need for assistance (e.g., home health use, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with PTSD or enrolled in Medicaid had lower probabilities of receiving A&A. Among Veterans receiving pension, receipt of A&A varied by medical center. While provider education and wider dissemination of information about A&A may help reduce observed inequities, action is required at the system level that will eliminate the possibility of bias in which some eligible pensioners are able to access this enhanced pension benefit and others are not. Date: February 25, 2021 Referral Coordination Team Improves Timeliness of VA Specialty Care Delivery and Patient Experience In 2018, the Office of Veterans Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team to manage new referrals in sleep medicine. Investigators then compared the referral coordination team and the traditional specialist-led referral method in terms of timeliness and community care referrals. Findings showed that the referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%). Each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, valued at $420,368. Although referrals to community care were low among patients in both groups, patients whose consults had been managed by the referral coordination team were slightly less likely to be referred outside of VA to community care, consistent with more timely service delivery. Informed by these results, national VA partners, including OVAC and the Office of Specialty Care, are working to disseminate referral coordination to other specialties nationwide. Date: February 1, 2021 Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting This quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about this, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or limitations being placed on access to firearms. Veterans also noted the need to provide a clear reason for why a discussion on FSS was happening, such as promoting mental health or concern for household safety and wellbeing. Discussing FSS with Veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts but must be conducted in a Veteran-centric manner. Date: January 26, 2021 Use of VHA Homeless Programs Decreases Suicide This study assessed whether participation in VHA Homeless Programs is associated with reduced risk of all-cause and suicide mortality among Veterans with housing instability. Findings showed that the use of VHA Homeless Programs among Veterans reporting housing instability was significantly associated with reduced hazards of all-cause and suicide mortality. More than one-half of Veterans reporting unstable housing on the Homelessness Screening Clinical Reminder accessed homeless services during the observation period, and the use of any homeless service was associated with a 6% reduction in risk for all-cause mortality. The risk of both all-cause and suicide mortality was reduced significantly with each additional service used. With each additional VHA Homeless Program accessed, the risk of dying by suicide was lowered by 19%. Veterans who accessed 4 or more VHA Homeless Programs had 78% reduced hazards of suicide death compared with those who did not access any VHA Homeless Programs. Veterans’ receipt of interventions to address housing instability may be particularly important for reducing suicide risk, perhaps by addressing unmet basic human needs such as housing. Date: November 18, 2020 VA’s Primary Care-Mental Health Integration Affects Access Differently for Women and Men Veterans This study of 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, set out to answer the following question: Did VA’s national Primary Care-Mental Health Integration (PC-MHI) initiative improve access to care equally among men and women Veterans? Findings showed that PC-MHI was associated with greater use of all outpatient services among men but with lower use of services (except primary care visits) among women. Both men and women had more primary care visits (+22% and +40%, respectively) and total costs over time, but women had 74% fewer hospitalizations (versus +2% in men) related to mental health integration. Each percentage point increase in the proportion of Veterans who saw an integrated specialist was associated with 38% fewer mental health visits per year for women, but 39% more visits for men. Women Veterans had twice the rates of depression and anxiety and used more mental health and primary care services than men. Also, women Veterans were more likely than men to receive care in hospital-based (vs. community-based) clinics, where average PC-MHI penetration rates are higher and where women-only treatment settings are more commonly located. Date: October 20, 2020 Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment among Veterans with Diabetes Geography is a well-known determinant of health and an improved understanding of the relationships between geographic factors (social and environmental) and diabetes outcomes may lead to targeted interventions. This retrospective cohort study sought to answer the following questions: 1) Do rates of metabolic control exhibit geographic patterning or “hotspots”? and 2) Does patterning vary by race-ethnicity? Findings showed that after adjusting for age, gender, race-ethnic group, service-connected disability, marital status and comorbidities, the prevalence of uncontrolled diabetes varied by VA catchment area, with values ranging from 19% to 29%. These differences persisted after further adjustment for medication use and adherence, as well as use and access metrics. Disparities in sub-optimal control appeared consistent across most but not all catchment areas, with Black and Hispanic Veterans having higher odds of sub-optimal control than White Veterans. Prevalence of uncontrolled diabetes in the VA catchment area with the poorest control rates was estimated as high as 28% for Whites, 30% for Blacks, and 35% for Hispanics. Patterns of uncontrolled diabetes within VA did not mirror patterns of diabetes prevalence across the country. While high diabetes prevalence in the general population overlapped with sub-optimal diabetes control in parts of Appalachia, Georgia, Alabama, Mississippi, and Tennessee, parts of the Diabetes Belt had lower than average rates of uncontrolled diabetes in VA, indicating that areas of high diabetes prevalence can have below average rates of uncontrolled diabetes. Geographic as well as racial-ethnic differences in diabetes control rates were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, healthcare use, access metrics, or medication adherence, suggesting there is a geographic component to diabetes control that needs to be further explored. Date: October 1, 2020 VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly. Date: September 22, 2020 Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Findings showed that overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users. Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white, or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline. Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments. Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care. Date: September 10, 2020 Higher Mortality for Veterans Choosing Community Hospitals Rather than VA for Percutaneous Coronary Intervention This study compared the clinical outcomes of Veterans undergoing elective percutaneous coronary revascularization (PCI) at VA and community hospitals after the significant expansion of the community care program. Findings showed that Veterans receiving elective PCI in the community were at higher risk of dying—especially within the first month—than those treated at a VA medical center. There was a 33% increase in death risk for Veterans treated at community hospitals versus within VA, with an absolute risk difference of 1.4%. Restricting the analysis to just the first month after the procedure showed an even sharper increase in relative risk—143%, with an absolute difference of 0.7%—for the community-hospital setting. Two-thirds (67%) of Veterans received elective PCI within VA, while 33% received PCI in community facilities. However, over the period of 2015 to 2018, the probability of having PCI performed at a non-VA hospital rose from 39% to 52%. Date: September 1, 2020 Wait Times Longer for Specialty Community Care vs VA Specialty Care Since Implementation of Veterans Choice Program This study sought to: 1) Determine whether VA wait times declined after Veterans Choice Program (VCP) implementation, 2) Compare appointment wait times for specialty care in VA versus community medical centers, and 3) Identify the proportions of community care wait times that were attributable to VA administrative processes. Findings showed that within VA, orthopedics experienced the largest decline in mean wait times – from 53 days to 30 days. Lesser declines were observed for urology (42 days to 34 days) and gastroenterology (58 days to 51 days). Wait times for cardiology did not differ over time. Mean wait times for specialty care were lower at most VA medical centers compared with community care alternatives, even after accounting for administrative delays. Mean wait times at VA vs community facilities were 33 vs 38 days for cardiology; 54 vs 60 days for gastroenterology; 36 vs 44 days for orthopedics, 36 vs 51 days for urology and 41 vs 49 days overall. Date: August 26, 2020 Treatment Disparities for Vulnerable VA Patient Populations with Opioid Use Disorder This study examined the association between vulnerable populations, facility characteristics, and receipt of medications for opioid use disorder (OUD). Findings showed that since the last national study of VA patients (using FY2012 data), the prevalence of receipt of medications for OUD increased overall from 33% to 41%; however, vulnerable patient populations – including women, older, Black, rural, homeless, and justice-involved Veterans – had lower odds of receiving medications for OUD than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with OUD, and lower odds of receiving medications at facilities in the Southern region of the United States compared to the Northeast. The prevalence of OUD was notably higher among homeless compared to housed Veterans (10% vs 2%), and justice-involved compared to non-justice-involved Veterans (10% vs 2%). Date: August 18, 2020 Better Patient Experience for Outpatient Care Delivered by VA vs Community Care on Every Measure but Access This study examined trends in Veterans’ experiences with outpatient community care (CC) compared with those in VA during the second and third years after Choice Act implementation. Findings showed that patient experiences were better for VA than community care in all respects except access. For specialty care, access scores were better in the community; and for primary and mental healthcare, access scores were similar in the two settings. There were significant differences in sociodemographic characteristics between VA and CC respondents across all types of outpatient care. Overall, VA respondents were older; had better perceived physical health status and mental health; had different distributions by race and ethnicity (i.e., higher portion of African American respondents); had lower education levels; lived in more urban areas; and were more likely to be insured. As purchased care further expands under the MISSION Act, the monitoring of meaningful differences between healthcare settings should continue, with the results used to inform both VA purchasing decisions and patients’ care choices. Date: August 1, 2020 VA Patients Have Fewer Potentially Avoidable Hospitalizations Post-Chemotherapy than Medicare Patients The Centers for Medicare and Medicaid Services (CMS) released a new quality measure to reduce potentially avoidable hospital admissions among patients receiving outpatient chemotherapy. In this study, investigators used this CMS measure to compare the quality of care received by chemotherapy patients treated through traditional Fee-for-Service Medicare versus VA, using a cohort of dually-enrolled Veterans. Findings showed that Veterans with cancer receiving chemotherapy through VA have higher-quality care with respect to avoidable hospitalizations than Veterans receiving chemotherapy through Medicare. Roughly 7% of Veterans treated through Medicare had potentially avoidable hospitalizations in the 30 days following chemotherapy compared with approximately 5% of Veterans treated by VA. In the entire cohort, the top reasons for an avoidable hospitalization were pneumonia (41%), sepsis (24%), anemia (21%), and pain (11%), though the order of frequency changed when evaluating Medicare versus VA treatment. This study was driven by recent legislation (Choice Act of 2014, MISSION Act of 2018) allowing Veterans to seek care in the private sector if VA care is difficult to access. As these policy changes are implemented, it is critical to understand whether this shift in system of care will impact care quality, especially for conditions as serious as cancer. Date: July 15, 2020 Majority of High-Risk Veterans Assigned to General Primary Care Rather than Specialized Primary Care This study sought to characterize patterns of care for the top 5% highest-risk patients enrolled in VA healthcare nationally (based on Care Assessment Needs – CAN – score). Findings showed that most high-risk Veterans (88%) were cared for in general primary care rather than in specialized primary care; the remaining 12% were assigned to specialized primary care (i.e., women’s health, geriatrics, home-based primary care, homeless primary care). High-risk Veterans assigned to general primary care had more mental health and primary care visits than medical specialty care visits. Compared to low-risk patients, high-risk patients had 2.5 times the face-to-face, 4 times the telephone, and twice the number of secure messaging encounters in primary care during the year prior to being identified as being high risk for hospitalization. Approaches to support high-risk patients will likely need to be embedded within general primary care and mental healthcare if they are to improve outcomes for this population. This may be more beneficial than carve-out specialized or intensive primary care programs. Date: June 29, 2020 Both PTSD Symptoms and Moral Injury are Associated with Adverse Perinatal Outcomes among Women Veterans This longitudinal study is the first to examine the impact of PTSD symptoms and moral injury on adverse perinatal outcomes among women who became pregnant in the first three years after separating from military service. Findings showed that after adjusting for age, racial/ethnic minority status, socioeconomic status, and lifetime trauma, both PTSD symptoms and moral injury were associated with adverse perinatal outcomes. Only women with greater PTSD symptoms were more likely to report having postpartum depression/anxiety, and to describe their pregnancy as being more difficult. The new VA/DoD clinical practice guidelines on pregnancy management published in March 2018 incorporate the importance of screening for mental health conditions regularly during pregnancy, as well as the coordination of care between medical and mental health providers to prevent adverse perinatal outcomes. These findings specifically support increased screening for PTSD and moral injury, in order to increase access to treatment for these problems as warranted. Date: June 1, 2020 Use and Predictors of Healthcare among New Post-9/11 Veterans with Mental Health Conditions This study sought to identify the healthcare programs and services that new post-9/11 Veterans who screened positive for mental health problems used – and any factors that predicted that use within the first 90 days of military separation. Findings showed that Veterans from the most junior enlisted ranks were the least likely to access healthcare programs and services, whereas few differences emerged by gender or racial/ethnic minority status. Nearly half of Veterans in the sample (47%) used VA for their healthcare, while 19% sought services from non-VA providers. Veterans exposed to combat, those with a medical discharge, and those with a chronic medical or mental health problem were all more likely to report using VA healthcare services. Findings suggest that Veterans, particularly those from the junior enlisted ranks who are most at risk for poor transitions, should be encouraged to use programs and services provided by both VA and non-VA healthcare alternatives. Date: May 12, 2020 Veterans Using VA and Non-VA Care Experience More Healthcare “Hassles” than Veterans Using VA Care Only Investigators in this study compared “hassles” experienced by Veterans receiving VA healthcare only versus those receiving dual care from both VA and non-VA community providers. Findings showed that dual-care users experienced more hassles than VA-only users (average 5.5 vs. 4.3 hassles). The overall number of reported hassles ranged from 0 to 16, with 79% of Veterans reporting that they experienced one or more hassles. The top five hassles were: 1) long waits for an appointment for specialty providers or clinics (56%); 2) poor communication between different healthcare providers (44%); 3) lack of information about which treatment options are best for your medical conditions (41%); 4) lack of information about your medical conditions (40%); and 5) difficulty getting questions answered or getting medical advice between scheduled appointments (40%). Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users. Date: May 7, 2020 Veterans Advocate Treating “Sickest First” When Discussing Limited Resources for Hepatitis C Treatment Investigators in this study used Democratic Deliberation (DD) methods as a proof of concept for informing policy decisions related to the allocation of scarce resources for treatment of chronic hepatitis C virus in VA. Findings showed that most Veterans endorsed a sickest-first policy over a first-come-first-served policy, emphasizing the ethical and medical appropriateness of treating the sickest Veterans first. When given the option, almost two-thirds of participants insisted that all Veterans be treated without delay regardless of symptoms or degree of disease severity (note: this is currently VA policy but not common outside of VA). Only when required to choose between the two policies did a majority opt for the SF policy (86% before DD session; 93% after DD session). Veterans also suggested modifications to the “sickest first” policy: 1) need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support to overcome barriers to treatment, 4) improving access to testing/treatment, and 5) improving how allocation decisions are made. The approach of using DD to incorporate the opinions of patients may have implications for how to develop policies around allocation of limited healthcare resources during the current COVID-19 pandemic. Date: May 1, 2020 Patient Satisfaction with VA Virtual Care Delivered by Video-Enabled Tablet In 2016, VA’s Offices of Rural Health and Connected Care developed a pilot initiative to distribute video-enabled tablets to Veterans who did not have the necessary technology and who had a geographic, clinical, or social barrier to in-person healthcare. During this pilot, 5,000 tablets were distributed to 6,745 patients at 86 VA facilities, with approximately half of the tablet recipients living in rural areas. To help inform optimal tablet distribution and technical support, investigators evaluated patient experiences with tablets through baseline and follow-up surveys. Many recipients of VA-issued tablets reported that video care is equivalent to or preferred to in-person care. Among follow-up survey respondents, 32% of tablet recipients indicated that they would prefer to conduct their future VA appointments by video; 32% indicated they would prefer these visits in person; and 36% indicated their preference was “about the same.” The most common barriers to in person care were travel time (66%), travel cost (55%), health conditions (54%), bad weather (57%), and feeling uncomfortable or uneasy at VA (33%). Between baseline and follow-up surveys, there were statistically significant increases in patient satisfaction regarding overall VA care, as well as primary care and mental healthcare. Satisfaction regarding technology and technical assistance also was high: 86% agreed or strongly agreed with statements regarding the ease of using the equipment, receiving help needed to learn the technology (84%), and that it was easy to ask questions (88%) and understand instructions (87%). Strong satisfaction ratings for tablets and the fact that characteristics such as age, health literacy, and prior technology use were not significantly associated with tablet preference suggest that engagement in video-based care is possible for many types of patients, including those often considered part of the “digital divide.” Date: April 15, 2020 New Measure Shows VA Fulfilled Veterans’ Timely Care Requests 86% of the Time Across Three Years This study sought to leverage VA’s data infrastructure to generate an objective measure of the fulfillment of timely care requests, which could be tracked over time at multiple levels and adjusted for demographic, clinical, and geographic factors. Across 160 VA primary care clinics, requests for timely care were fulfilled 86% of the time. Of all timely care requests, 98% were fulfilled by VA, with 61-68% in primary care, followed by 26-31% in other VA clinics, and 3% in mental health clinics. Less than 1% of requests were fulfilled with secure messaging. Between 2014 and 2017, 32% to 39% of VA primary care patients requested timely care, with the number of patients making timely care requests increasing by 24%. The patient population requesting timely care was younger and more likely to be female, black, and living in urban settings. An estimated 12% of timely care requests were not fulfilled, and such delays may drive patients outside VA. Using this timely care measure may assist in identifying reasons underlying access variability – and inform strategies to bring greater consistency of timely care across clinics. Date: April 1, 2020 Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients. Date: April 1, 2020 Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing. Date: March 17, 2020 Eight Organizational Target Areas for Improving Access to Primary Care This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, and two outcomes): 1) Clearly identified group practice management structure; 2) Interdisciplinary primary care site leadership; 3) Patient telephone access to ensure patient safety, scheduling, and coordination; 4) Contingency staffing (planned minimal excess staffing to cover routine absences); 5) Nurse management of demand through care coordination; 6) Proactive demand management by optimizing provider visit schedules; 7) Quality of patients’ experiences of access; and 8) Provider and staff morale in relationship to supply-demand mismatch (e.g., provider vacancies, panels exceeding recommended size). Date: February 1, 2020 All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64 After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men. Date: January 31, 2020 Veterans Participating in a VA National Telehealth Tablet Initiative Save Both Time and Money In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, and/or social access barriers to in-person care so that they could receive services in their homes or other convenient locations. As part of a national evaluation of this initiative, a patient experience survey was conducted with a subset of tablet recipients. Investigators in this study sought to determine patient-reported monetary and time savings, as well as characteristics associated with those savings. Findings showed that 92% of respondents reported that the tablets saved them money or time; 89% reported saving money, and 71% reported saving time. Among those who reported monetary savings, 41% reported saving $25-50 and 31% reported saving >$50 per appointment. Monetary savings were most pronounced among Veterans living a greater distance from VA or experiencing travel barriers and those without mental health conditions. Date: December 26, 2019 Social Stressors Strongly Associated with Suicide Ideation and Attempt among Veterans This study examined documented social stressors in VA’s electronic health record (EHR) and how these stressors were associated with suicidal ideation and suicide attempt. Seven types of social stressors were included: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of access to care or transportation, and 7) non-specific psychological needs. Findings showed that social stressors were strongly associated with suicidal ideation and suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses. Social stressors are as relevant as biological factors (e.g., depression) for suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of suicide. Date: November 19, 2019 Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Of the Veterans with COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions. Date: August 8, 2019 Video Telehealth Tablet Initiative Improves Access to and Continuity of Mental Healthcare for Veterans In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national dissemination of tablets. Findings showed that distributing the tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to the control group, tablet recipients experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months post-tablet receipt. Date: August 5, 2019 Mental Health Integration in VA Primary Care Settings Increased Access to Care – and Costs This study examined the effect of the Primary Care-Mental Health Integration Program (PC-MHI) on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA’s Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate. Findings showed that Veterans treated in clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year. Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits. Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year. Date: August 1, 2019 VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups. Date: August 1, 2019 Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems. Date: July 22, 2019 Significant Cost Savings for VA in Allowing for 12-Month Dispensing of Oral Contraceptive Pills Like most US health plans, VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). This study sought to determine the expected financial and reproductive health implications for the VA healthcare system in implementing a 12-month dispensing option for oral contraceptive pills. Findings showed that adoption of a 12-month dispensing option for oral contraceptive pills is expected to produce substantial cost savings for VA compared to standard 3-month dispensing, while reducing unintended pregnancies among women Veterans. The 12-month dispensing option resulted in anticipated VA cost savings of $87.12/woman/year compared to 3-month dispensing, or an estimated $2,117,800 total saved annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies/1,000 women/year with 12-month dispensing, or 583 unintended pregnancies averted annually. Financial gains are a secondary benefit to improving contraceptive access and facilitating women Veterans’ individual abilities to manage their reproductive lives as they see fit. Date: July 8, 2019 Significant Cost Difference between VA and Community Care for Testing among Veterans with Obstructive Sleep Apnea Traditionally, laboratory-based sleep testing was necessary to diagnose obstructive sleep apnea, but portable home sleep apnea tests provide an efficient patient-centered option, have equivalent accuracy among appropriate patients, and cost much less than lab-based testing. Using data for Veterans’ sleep studies conducted from October 2014 to July 2016 – a period of transition from Fee-Basis to Choice for community care – investigators compared sleep study use among Veterans tested by VA, Fee-Basis, and Choice providers. Findings showed that Veterans referred for community care were much less likely to receive home sleep apnea testing than Veterans cared for in the VA healthcare system, and were more likely to receive in-lab testing, leading to greater costs to the system. VA providers performed 38% of studies as home tests, compared to 19% in Fee-Basis, and 4% in Choice. Due to lower rates of home-testing, every 100 Veterans referred to Fee-Basis represented $8,831 greater costs relative to VA, and every 100 Veterans referred to Choice represented $15,814 greater costs. Results have important implications for VA as it expands the use of community care under the MISSION Act with regard to promoting efficient and patient-centered care for Veterans. Date: June 17, 2019 Veteran-Directed Care Adds to Options for Medically Complex Veterans Living in the Community – Without Raising Costs One way in which VA facilitates independence and supports caregivers is through the Veteran-Directed Care (VDC) program, part of VA’s Office of Geriatrics and Extended Care Services. VDC enables enrollees to hire family members, friends, or neighbors as paid caregivers and also provides caregiver support, including caregiver training and burden monitoring. This study evaluated the incidence of VA hospital admissions, ambulatory care-sensitive admissions, and costs associated with inpatient care in the year after the initial receipt of a VDC service. Findings showed that Veterans enrolled in VDC had indicators of higher chronic disease burden and more functional limitations than Veterans enrolled in other purchased-care service programs, but experienced similar decreases in hospital use and costs from before to after enrollment in services. During the 6th month before receiving services, mean monthly hospital costs were $2,131 for VDC patients, $1,054 for comparison group patients at sites with an active VDC program, and $974 for comparison group patients at sites without an active VDC program. In the 6th month after receiving services, mean monthly costs were $1,569, $1,170, and $1,049, respectively. In the 12th month after receiving services, VDC patients still had higher mean monthly hospital costs ($1,331) than patients in the active or inactive comparison group ($1,007 and $1,027, respectively), but the difference between costs among VDC patients and comparison-group patients had decreased. Given VDC’s popularity among Veterans and caregivers, it is a valuable model for supporting medically complex patients who are living in the community. Date: June 1, 2019 Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions This study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Findings showed substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts, with most of the difference attributable to long-term use. Utilization was lowest in the Northeast and highest in the West. Mean days’ supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days’ supply was 23% for rural vs. 19% for urban Veterans. The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans. Date: May 21, 2019 Women Veterans’ Experience with Research on Intimate Partner Violence Little is known about successful strategies for recruiting and retaining women who have experienced intimate partner violence (IPV) in research, and their experiences of research participation. This study used data on health, safety, empowerment, and engagement with IPV-related services among women VA patients with self-reported IPV in the 12 months prior to enrollment. Findings showed that direct outreach to women VA patients to participate in research interviews about IPV experience was feasible and effective, and proved more fruitful than reliance on provider or patient self-referral. Of the total cohort (N=169), 92% were recruited via direct outreach by the research team (63% via letter, 29% in-person), compared to provider or patient self-referral (3.6% and 4.1%, respectively). While some women experienced emotional strain during or after study visits, they also expressed value in sharing their experiences, and several found the experience personally beneficial. Participants expressed that disclosure was facilitated by interviewers’ empathic and neutral stance, as well as the relative anonymity and time-limited nature of the research relationship. Women Veterans expressed a desire to help others as a primary motivation for study participation. Given that discussing IPV experiences can prompt motivation for further help-seeking and may bring up difficult emotions, it also is important to provide research participants with information about accessing services and support. Date: May 6, 2019 Effect of Intensive Primary Care on Patient Experience Outcomes To address the gap in evidence about patient experiences with intensive primary care, study investigators conducted a survey of Veterans in a five-site randomized trial of intensive primary care in the VA healthcare system. Findings showed that augmenting VA’s patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients’ experiences with care coordination and provider relationships – but did not have a significant impact on most patient-reported access and satisfaction measures. Veterans randomized to PIM (PACT-Intensive Management) were more likely than those in PACT to report that they were asked about their health goals (73% vs. 68%) and about barriers to taking care of their health (60% vs. 55%). Veterans randomized to PIM also were more likely than those in PACT to strongly agree that they could trust their VA healthcare provider (61% vs. 53%) and were more likely to report 10 out of 10 on satisfaction with primary care (37% vs. 32%). Findings suggest that augmenting a medical home with an intensive management program may help fulfill the promise of primary care, with the potential for long-term consequences such as changes in health behaviors and clinical outcomes. Date: May 1, 2019 Benefits of Medical Home Model Tailored for Homeless Veterans Versus Standard Primary Care This study examined whether a homeless-tailored medical home model (H-PACT) offers a better patient experience than standard VA primary care. Findings showed that Veterans empaneled in H-PACT were more likely than those receiving standard primary care in the same facilities to report positive experiences with access, communication, office staff, provider ratings, and comprehensiveness. Veterans receiving standard care in facilities with H-PACT among their services were more likely than Veterans from facilities without H-PACT to report positive experiences with communication and self-management support. Patient-centered medical homes that are designed to address the social determinants of health offer a better care experience for homeless Veterans than standard primary care approaches. Date: April 1, 2019 Increased Hospice Care for Veterans Associated with Less Aggressive Medical Treatment and Lower Medical Costs This study sought to determine if increased availability of hospice for Veterans is associated with reduced aggressive treatments and medical care costs at the end of life. Findings showed that Veterans with newly diagnosed end-stage lung cancer treated at VAMCs with the most expansion in hospice use had a significantly greater likelihood of receiving chemotherapy or radiation therapy after hospice enrollment – but a lower likelihood of having aggressive treatment or intensive care unit use, compared with similar Veterans treated in VAMCs with low hospice growth. Thus, increasing hospice availability – without restricting treatment access for Veterans with advanced lung cancer – was associated with less aggressive medical treatment and significantly lower medical costs, while still enabling Veterans to receive cancer treatment. Veterans treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care. Radiation therapy was more common than chemotherapy. The six-month costs were lower by an estimated $266 per day for the high-quintile group vs. the low-quintile group. There was no survival difference through 180 days post-diagnosis. The substantial reduction in healthcare costs suggests that the investment in hospice care that VA made has paid off, and will likely continue to pay off without restricting Veterans’ access to radiation and chemotherapy. Date: March 28, 2019 Links Between Opioid Use and Suicide This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems. Date: January 3, 2019 Web-Based Program Helps Empower Veterans Who Read their Mental Health Notes Online to Actively Participate in Care The VA OpenNotes initiative has expanded patient access to health information and VA now allows patients to access their electronic health record progress notes online. To reduce unintended harms and increase benefits, investigators developed a web-based educational program with the goal of increasing Veterans’ understanding of their mental health notes and providing guidance on communicating with clinicians about notes. This study sought to evaluate whether the program improved patient-clinician communication and increased patient engagement in their care. Findings showed that overall, improvements were observed among Veterans post-training in patient activation, perceived efficacy in healthcare interactions, and trust in their physician. This web-based educational program may help Veterans who read their mental health notes feel more empowered in their healthcare and improve perceptions of their clinician relationships. Date: January 1, 2019 Women’s Health VA Stakeholders Discuss “Ideal” Care As part of a multisite implementation trial of evidence-based quality improvement for tailoring PACT to women Veterans’ healthcare needs, investigators conducted semi-structured interviews with 86 local leaders. At the conclusion of interviews about women’s primary care, participants were asked to describe their conceptualizations of “ideal care” for women Veterans. Respondents commonly discussed whether women Veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women Veterans; physical appearance of facilities; fostering active interest in women’s health across providers and staff; and the relative priority of women’s health at VA. Paths toward ideal care could include projecting and anticipating growth in women’s health programs; building on VA’s pilot program to provide childcare for patients’ children during visits; designing a hiring process to more consistently recruit providers with a strong interest in caring for women; and conducting listening sessions and creating other opportunities that allow senior VA leadership to hear women Veterans’ perspectives and preferences directly. Date: January 1, 2019 No Difference in Intermediate Outcomes for Veterans with Diabetes by Type of Primary Care Provider This study examined whether intermediate diabetes outcomes differed among Veterans treated at one of 568 VA primary care facilities by a physician, nurse practitioner (NP), or physician assistant (PA) primary care provider. Findings showed that there were no clinically significant differences in intermediate diabetes outcomes – or the control of those outcomes – among patients with NP, PA, or physician primary care providers. There also was no clinically significant difference in the proportions of NP, PA, and physician-treated patients with diabetes who used endocrinology or specialty diabetes services during the year outcomes were calculated. This study provides further evidence that using NPs and PAs as primary care providers may represent a mechanism for expanding access to primary care while maintaining quality standards. Date: December 18, 2018 Prior to Choice Act Elderly Medicare-Enrolled Veterans Increased Use of VA Healthcare versus Medicare This study examined long-term trends in reliance on VA outpatient care at the system level among elderly Medicare-enrolled Veterans from FY2003 to FY2014. Findings showed that the number of elderly Veterans enrolled in VA and Fee-for-Service (FFS) Medicare was 1.7 million in 2003, decreasing to 1.5 million in 2014. Medicare-enrolled Veterans, who had a choice of using VA or Medicare providers, steadily increased their reliance on VA outpatient services (all categories) prior to the Choice Act. Elderly Medicare-enrolled Veterans received most of their mental healthcare from VA (75% in 2003 to 77% in 2014), while receiving most of their primary care (76% in 2003, 65% in 2014), specialty care (86% in 2003, 78% in 2014), and surgical care (85% in 2003, 78% in 2014) through Medicare. The increase in VA reliance was driven by a decrease in Medicare-only users, and an increase in VA-only users. Among users during the study period, the proportion of VA-only users increased in primary care (28% to 40%), mental health (80% to 88%), specialty care (18% to 26%), and surgical care (18% to 28%). Similar trends were seen in seven high-volume medical subspecialties. Despite the recent controversies of access to VA care, elderly Medicare-enrolled Veterans were increasingly reliant on VA outpatient care across a diverse range of services at the life stage of growing healthcare needs. This may reflect their greater satisfaction with VA care. Date: August 27, 2018 External Determinants of VA Healthcare Use This study measured the sensitivity of VA healthcare use to changes in “external determinants” such as unemployment and Medicaid expansion following the Affordable Care Act. Findings showed that all external determinants examined were associated with small but significant changes in VA healthcare use. The largest change occurred between 2013 and 2014 following a 55% increase in Medicaid eligibility in the 26 Medicaid expansion states. Among Veterans aged 18-64, this was associated with a 9% ($833 million) reduction in VA healthcare use in these states. Among Veterans ages 18-64, a 10% increase in unemployment was associated with a 0.65% increase in VA healthcare utilization, while a 10% increase in private employer-sponsored coverage was associated with 1.4% decrease in VA healthcare utilization. Among Veterans aged 18-64, increases in non-VA physician availability and housing prices were associated with an increase in VA healthcare use. Among Veterans aged 65 and older, a 10% increase in housing prices was associated with a 2.2% increase in VA healthcare use. Changes in alternative insurance coverage (Medicaid and private) and other external determinants may affect VA healthcare spending. Policymakers should consider these factors in allocating VA resources to meet local demand. Date: July 31, 2018 Increase in Travel Reimbursement Increases Use of VA Outpatient Services The extent to which VA and non-VA care are substitutes or complements for each other will dictate how the demand for VA care will change as Veterans make use of the Choice Program. This study used another VA policy change – one that increased the reimbursement rate that eligible Veterans receive for VA healthcare-related travel – to understand the use of VA and Medicare services among Medicare-enrolled Veterans. This analysis allowed investigators to determine whether the increased VA utilization due to the travel reimbursement rate increase was accompanied by a decrease in non-VA utilization, indicating that the two were substitutes, or if there was also an increase in non-VA utilization, which would indicate that the two were complements. Findings showed that compared to those not eligible to receive travel reimbursement, Veterans who were eligible for reimbursement had significantly more VA outpatient encounters following the reimbursement rate increases. This was true both for Medicare-enrolled Veterans over and under age 65. Veterans living in rural areas in both age groups significantly decreased their use of non-VA outpatient care following the travel reimbursement increase, suggesting that VA outpatient care may be a substitute for Medicare outpatient care for Medicare-enrolled Veterans in both age groups living in rural areas. Date: July 1, 2018 LGBT Women Veterans Report Missing Needed Health Care Due to Concerns about Interacting with Other Veterans This study sought to examine LGBT women Veterans’ experiences within the VA healthcare system, and whether their experiences impact use of VA care. Findings showed that the majority of women Veterans reported feeling welcome at their VA. However, fewer LGBT women reported feeling welcome and safe at VA compared with non-LGBT women Veterans. After controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women Veterans experiencing harassment from male Veterans at VA in the past 12 months, as well as feeling unwelcome or unsafe at VA. LGBT women Veterans were about 3 times more likely than non-LGBT women Veterans to attribute missing needed care in the previous 12 months to concerns about interacting with other Veterans. Study participant descriptions of harassment indicated that male Veterans’ comments and actions were distressing and influenced LGBT women Veteran’s healthcare accessing behavior. Despite VA’s ongoing efforts to educate employees and change the culture toward a more inclusive environment, more targeted work addressing the needs of LGBT women Veterans may be needed. Date: July 1, 2018 High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care. Date: June 19, 2018 Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers This study examined the potential impacts of reforms to improve access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop telehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers. Date: May 29, 2018 Online Toolkit to Improve Primary Care Coordination within VA and with Community Providers The Coordination Toolkit and Coaching (CTAC) project aims to improve patients’ experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. In this article, investigators describe CTAC’s first phase, which involved selecting tools for an online care coordination toolkit and developing a VA Intranet site to support the tools. The final Care Coordination Toolkit, available on the VA Intranet at https://vaww.visn10.portal.va.gov/sites/Toolkits/toolkit/Pages/Home.aspx, provides access to 18 tools that remained after the selection process noted above, as well as detailed information about tools’ expected benefits, and the resources required for tool implementation. The 18 tools cover 5 topics: 1) managing referrals to specialty care, 2) medication management, 3) patient after-visit summary, 4) patient activation materials, and 5) provider contact information for patients. The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. In addition, the project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems. Date: May 23, 2018 Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging. Date: April 5, 2018 Assessing Expansion of VA’s Home-Based Primary Care Program for American-Indian Veteran Patient Population VA provides home-based primary care (HBPC) in rural communities with American Indian reservations, where prospective patients may qualify for healthcare from VA, Medicare (CMS), and/or the Indian Health Service (IHS). This multi-site study of the effectiveness of HBPC expansion to these rural areas also describes the characteristics of patients who meet the requirements for admission to rural HBPC. Findings showed that expansion of the HBPC program was effective in introducing non-institutional home-based primary medical care to populations residing in American Indian reservations and other rural communities. Among HBPC users, VA enrollment increased by 22%. Results suggest opportunities to identify new clients for services that support aging in rural settings. Date: April 1, 2018 Then and Now: Medications for Opioid Use Disorder in VA As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt. Date: March 29, 2018 Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury. Date: March 1, 2018 Phone Communication and Care Coordination Associated with Access to Needed Care as Reported by Women Veterans This study used a survey of women Veterans to examine associations between key care team functions and patient-rated access to needed care (routine and urgent). Findings showed that overall, 74% of study participants reported usually or always being able to see a provider for routine care, and 68% for urgent care. In addition, 62% of patients gave high ratings of care coordination, and 76% gave high ratings of in-person communication. Among women Veterans who called their provider with a healthcare question, 63% usually or always got an answer as soon as needed. Phone communication was strongly associated with better ratings of access to routine and urgent care (absolute increases of 25% and 33%, respectively). Care coordination was also associated with better ratings of access to routine and urgent care (absolute increases of 8% and 13%). Associations with in-person communication were not statistically significant. Results suggest that approaches to improving access that increase reliance on non-VA providers may prove counter-productive if they compromise the team's ability to coordinate care, or diminish their role as a primary point of contact for patients. Date: March 1, 2018 Racial/Ethnic and Gender Variations in Veteran Satisfaction with VA Healthcare This study of Veterans’ satisfaction with outpatient, inpatient, and specialist care in a diverse sample of Veterans from predominantly minority-serving VAMCs sought to better understand racial/ethnic and gender variations in healthcare satisfaction. Findings showed generally high levels of healthcare satisfaction across 16 domains, with 83% of respondents somewhat or very satisfied with VA healthcare overall. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy services (74% to 76% were very satisfied); the lowest ratings were reported for access to care, pain management, and mental healthcare (21% to 24% were less than satisfied). Contrary to previous studies, there was little evidence of racial, ethnic, or gender disparities in satisfaction with care at minority serving VAMCs. Date: March 1, 2018 Veterans with Heart Disease More Likely to Participate in Cardiac Rehabilitation (CR) When Home-Based CR Program is Available This study examined whether the implementation of new home-based cardiac rehabilitation (HBCR) programs is associated with improved cardiac rehabilitation (CR) participation among Veterans. Findings showed that Veterans hospitalized with ischemic heart disease were more likely to participate in CR when a home-based program was available. Implementation of HBCR increased participation from 6% to 25%, and was associated with four-fold greater odds of participation. Overall, participation in at least one CR session increased from 8% to 13%. Veterans offered HBCR were less likely to drop out after the first session than were those for whom HBCR was not available. Home-based cardiac rehabilitation may be an effective tool for increasing CR participation among Veterans who would otherwise decline participation, thereby improving patient outcomes. Date: January 22, 2018 Study Compares VA Care to Community Care for Veterans Receiving Elective Coronary Revascularization This observational study compared access, quality, and cost of elective coronary revascularization procedures between VA and community care (CC) hospitals. Findings showed that compared to CC hospitals, Veterans who underwent PCI in VA hospitals had lower mortality (1.5% vs. 0.65%), lower costs ($22,025 vs. $15,683), and similar readmission rates. Compared to CC hospitals, Veterans who underwent CABG in VA hospitals had similar mortality, similar readmission rates, but higher cost ($55,526 vs. $63,144). Compared to VA-only care, Community Care reduced net travel distance for PCI by 54 miles, and CABG by 73 miles, on average. CC care also was associated with significantly lower travel costs – an average of $156 less for PCI and $690 less for CABG. One in five coronary revascularizations for VA patients was performed at CC sites. Findings demonstrate that, on average, Veterans seeking high-quality care with low mortality and readmission rates are well-served by VA. As VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimizing outcomes and costs. Date: January 3, 2018 Study Identifies which VA Mental Health Program Characteristics are Associated with Patient Satisfaction This study examined the relationships between a set of patient satisfaction measures and a large collection of mental health program characteristics for Veterans with a recent mental health encounter in the VA healthcare system. Findings showed that broad measures of mental healthcare program reach (i.e., proportion of patients served) and intensity (i.e., number of visits) – and nearly all measures of treatment continuity were consistently and positively associated with patient satisfaction. More narrow performance measures – those that focus on specific diagnostic populations (e.g., those with PTSD and serious mental illness) – were less likely to be positively associated with satisfaction. Satisfaction with access to VA healthcare among Veterans with mental health conditions was higher than satisfaction with care encounters. Date: May 19, 2017 Self-Management Intervention for Chronic Pain Interactive voice response (IVR) – automated telephonic technology that allows patients to report symptoms, functioning, and pain coping skill use and to receive pre-recorded information and feedback – may improve access to cognitive behavioral therapy (CBT) for chronic pain. This randomized trial assessed the efficacy of interactive voice response-based CBT (IVR-CBT) as compared to in-person CBT among 125 Veterans who received treatment for chronic back pain in the VA Connecticut Healthcare System from June 2012 through July 2015. Findings showed that Veterans in both the IVR-CBT and in-person CBT groups experienced statistically significant reductions in average pain intensity at 3 and 6 months post-baseline, but not at 9 months. Veterans in both groups also experienced statistically significant improvements in physical functioning, sleep, and physical quality of life at 3 months relative to baseline, with no advantage for either group. The treatment dropout rate was lower among Veterans in the IVR-CBT group, with patients completing an average 2.3 more sessions. IVR-CBT is a low-burden alternative that can increase access to CBT for patients with chronic pain; it also shows promise as a non-pharmacologic treatment option for chronic pain. Date: April 3, 2017 VA Hepatitis C Care and Experiences with the Choice Program This study examined perspectives and experiences with the VA Choice Program among Veterans with HCV and their providers at three VAMCs in the New England region. Findings showed that the Choice Program has the potential to increase Veterans’ access to hepatitis C virus (HCV) treatment, but Veterans and VA providers described substantial problems in the initial years of the program. Four main themes emerged: (1) Difficulties in enrollment, ongoing support, and billing with third-party administrators (i.e., many Veterans described confusion about eligibility and enrollment for the Program); (2) Veterans experienced a lack of choice in location of treatment (i.e., most Veterans at the study sites did not have the option to receive VA HCV treatment, but many wanted to); (3) Fragmented care led to coordination challenges between VA and community providers (i.e., various challenges arose around sharing medical records, prescription delays, and working with designated VA staff trained on the Choice Program); and (4) VA providers expressed reservations about sending Veterans to community providers (i.e., VA providers were cautious about sending patients to the Choice Program because some community providers lacked specific experience in treating advanced cases of HCV). Date: March 3, 2017 VA’s Patient Aligned Care Teams’ Challenges in Providing Care for Women Veterans In this study, investigators conducted interviews with primary care providers and staff in eight VA medical centers to assess provider and staff experiences with PACT, implementation of core medical home features, and facilitators and barriers encountered in providing PACT care to women Veteran patients. Findings showed that providers and staff have generally positive attitudes toward PACT. However, early challenges to the delivery of PACT-principled care persist in both primary care and women’s health clinics. Ongoing barriers to PACT implementation include short staffing, conflicting performance requirements for continuity and same-day access, space constraints, and sharing of support staff across multiple providers. Challenges unique to the care of women Veterans included a higher prevalence of psychosocial needs and the need for specialized training of primary care personnel in gender-specific care. Primary care providers and staff in women’s health clinics are often physically separated from other PACT and medical neighborhood resources or asked to share their support staff with specialists. Primary care providers and staff face unique challenges in the delivery of comprehensive primary care to women Veterans that may require special policy, practice, and management actions if the full benefits of PACT are to be realized for this patient population. Date: March 1, 2017 VA Pharmacy Use in the First Year of Choice Act This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively. Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns. Date: February 17, 2017 Quality Improvement Tool Shows Organizational Factors Related to Access and Quality Measures in VA Mental Healthcare This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS quality improvement tool showed that organizational factors were associated with performance on key access and quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Date: February 1, 2017 Lessons Learned from VA’s History of Transformation and Potential Future Scenarios An article by O’Hanlon, et al presents an updated view of the evidence on VA’s quality of care and a strong scientific case to support the conclusion that after its dramatic transformation in the 1990s, VA had quality and safety measures that were as good, or better, than the private sector – and even top-rated healthcare organizations. However, does the controversy over wait times demonstrate that VA has reverted to its old ways? If so, how can the VA healthcare system find its way back? A return to VA’s earlier lessons of the value of decentralized decision-making, tight accountability for quality and efficiency, and respect for two-way communication between the field and central management might result in a systematic review of VA 5 to 10 years from now that reaches the same conclusions as O’Hanlon, et al, but includes success in both quality and access. Date: January 1, 2017 Importance of VA’s Quality Enhancement Research Initiative in the Choice Act Era The Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allows Veterans enrolled in VA healthcare who have waited longer than 30 days to see a provider – or who live more than 40 miles from a VA clinic – the option of seeking care from non-VA providers. The Choice Act also mandated an independent assessment of VA business and healthcare practices. This article describes how VA’s Quality Enhancement Research Initiative (QUERI) is responding to the Choice Act, particularly through the implementation strategies that facilitate more rapid uptake of effective practices across different settings, and the rigorous evaluation of new VA programs and policies. Date: December 16, 2016 Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible. Findings showed that the prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to potentially unsafe medications (PUM) overall –and to any “high-risk medications to avoid in older adults.” Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of antipsychotic PUM exposure were 1.5 times greater for dual-users. Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans’ access to non-VA care – and to protect vulnerable patients from risks associated with dual system use. Date: December 6, 2016 “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare. Date: November 15, 2016 More than Half of Privately Insured Veterans Younger than 65 Years of Age Access both VA and Non-VA Healthcare This study sought to quantify use of VA and non-VA care among working-age Veterans with private insurance by linking VA data to private health insurance plan (PHIP) data. Findings showed that more than half (54%) of Veterans younger than 65 who were enrolled in both VA and private health insurance plans accessed both healthcare systems; 39% used non-VA healthcare only, while 5% used VA healthcare only. Dual system users had the lowest percentage of Veterans under age 40 (15%) and the highest percentage of Veterans over age 50 (71%), while VA-only users had the highest percentage of Veterans under age 40 (22%) and the lowest percentage of Veterans over age 50 (61%). Dual system users also had the highest proportion of Veterans residing in rural settings (61%). VA reliance was 33% for outpatient care, 14% for inpatient care, and 40% for pharmacy. Findings suggest that care coordination efforts for Veterans across age groups should include privately insured Veterans under age 65 in order to ensure safe and coordinated care. Date: September 1, 2016 Organizational Factors Associated with Successful Campaign to Increase Influenza Vaccination among VA Healthcare Providers VA’s Office of Public Health commissioned a study to characterize organizational factors and practices associated with vaccination campaign success among health care providers (HCPs) in the VA healthcare system. Findings showed that successful HCP flu campaigns shared several recognizable characteristics, many of which are amenable to adoption or emulation by programs hoping to improve their vaccination rates. Three factors distinguished sites with high flu vaccination rates from those with low rates: 1) High levels of executive leadership involvement that demonstrated visible support, fostered new ideas, facilitated resources, and empowered flu team members; 2) Positive flu team characteristics, including: high levels of collaboration, sense of campaign ownership, sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign; and 3) Several concrete strong practices, such as: advance planning, easy access to the vaccine, ability to track employee vaccination status, use of innovative methods to educate staff, and use of audit and feedback to promote targeted efforts to reach unvaccinated employees. Date: July 4, 2016 Erectile Dysfunction Medication Use among Veterans Eligible for Medicare Part D This retrospective cohort study determined oral phosphodiesterase-5 inhibitor (PDE-5) medication use, which is considered first-line therapy for erectile dysfunction (ED), among Veterans who were dually eligible for VA and Medicare Part D benefits. Findings showed that during the period when PDE-5 inhibitors were allowed on the Medicare Part D formulary, prescriptions from VA pharmacies decreased, while PDE-5 inhibitor fills from Medicare-reimbursed pharmacies increased. However, this trend reversed after PDE-5 inhibitors were removed from the Part D formulary. VA formulary restrictions can increase the likelihood that Veterans who have access to non-VA healthcare obtain medications from the private sector. Since use of non-VA pharmacies may be unknown to VA providers, these Veterans may be at higher risk of adverse events or drug interactions. This is especially a concern for lifestyle drugs, such as those used for ED. Date: July 1, 2016 Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans. Date: June 20, 2016 Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities. Date: June 15, 2016 Data from Electronic Health Records Can Predict and Possibly Prevent Missed Patient Appointments This study sought to develop a model that identifies patients at high risk for missing scheduled appointments (no-shows and cancellations), and to project the impact of predictive over-booking in a gastrointestinal (GI) endoscopy clinic – a resource-intensive environment with a high no-show rate. Findings showed that information from electronic health records can accurately predict whether patients will no-show. The model used in this study was able to correctly classify 711 out of 888 attended appointments, and 317 out of 538 missed appointments. The strongest predictor of no-show was a patient’s cancellation history – the proportion of all outpatient appointments missed. Veterans with histories of mood or substance use disorder, and those with a greater overall disease burden also were less likely to keep appointments. Predictors of being more likely to keep appointments included: being married, having a history of diverticular disease, attending a colonoscopy education class, and having care partly funded by VA. Urgency of appointment, race, ethnicity, and day of the week of appointment were not significant predictors of appointment no-shows. Compared to a strategy that employs a fixed level of overbooking, predictive over-booking was much less likely to lead to days where the clinic was substantially over- or under-booked. Date: December 1, 2015 Effect of Childhood Physical and Sexual Abuse on Female Veterans’ Health and Healthcare Use This study sought to investigate whether childhood physical abuse and childhood sexual abuse predict health symptoms and healthcare use. Findings showed that childhood physical abuse was an important contributor to both physical and mental health for female Veterans. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, greater depressive and PTSD symptoms, and more frequent use of medical healthcare. No significant association was found between childhood sexual abuse and poor physical or mental health, and it was not a predictor for healthcare use. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment, as well as inform mental health assessment and treatment planning, among female Veterans. Date: October 1, 2015 Potential Problems and Suggested Solutions for VA as Veterans Take Advantage of Dual Use Care via the “Choice Act” This Commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and offers suggestions for ensuring its safe and effective implementation. Date: August 20, 2015 NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored. Date: April 15, 2015 VA Maintains Access to Care as Need for Substance Use Treatment Grows VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year. Date: March 12, 2015 Effect of ACA’s Medicaid Expansion on Demand for VA Care This study examined the historical relationships between policy-driven Medicaid expansion and VA enrollment and utilization of inpatient and outpatient care. Findings showed that if the Affordable Care Act’s Medicaid expansion had been implemented in all states – and holding all else constant – VA enrollment, inpatient days, and outpatient clinic visits would have been 9%, 6%, and 12% lower, respectively. For states in which Medicaid did not expand in 2014, VA enrollment, inpatient days, and outpatient clinic visits were 10, 6, and 13 percentage points higher, respectively, than they would have been otherwise; this higher demand may have contributed to longer wait times. These results suggest that Medicaid expansion could reduce the burden of demand placed on VA medical centers. As policymakers continue to address VA capacity issues, the authors suggest they be mindful of the potential role of Medicaid – and that it may change over time if more states adopt the expansion. Date: March 12, 2015 Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans. Date: December 3, 2014 Complementary and Integrative Medicine Use among Veterans and the Military A special supplement to the journal Medical Care: “Building the Evidence Base for Complementary and Integrative Medicine Use among Veterans and Military Personnel,” includes 13 original articles as well as two commentaries that describe efforts within VA and the Department of Defense (DoD) to understand and foster the use of CAM among Veterans and active duty military personnel. Date: December 1, 2014 Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences. Date: November 24, 2014 Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings This trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Findings showed that telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of Veterans randomized to the Telemedicine Outreach for PTSD (TOP) intervention received Cognitive Processing Therapy (CPT) compared to 12% of Veterans who were randomized to usual care. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD). The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months. Date: November 19, 2014 VA PACT Implementation Increases Primary Care among Veterans with PTSD This study assessed the association between PACT and the use of health services among Veterans with PTSD. Findings showed that the period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care. Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits. For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations. Date: November 10, 2014 Poor Communication between VA and Non-VA Primary Care Providers co-Managing Rural Veterans This study examined the perspectives of community-based, non-VA primary care providers (PCPs) regarding their experiences co-managing Veterans with VA providers. Findings showed that communication with VA was viewed as poor by 66% of non-VA primary care providers, and many non-VA PCPs (42%) believed this led to poor patient outcomes. They also felt that they interacted with VA as a system rather than with individual VA providers. While the majority of non-VA providers were dissatisfied with their communication with VA providers, this did not translate into a negative opinion of VA healthcare; most felt the overall quality of VA care was high. Veterans were identified as the main medium for information transfer between VA and non-VA providers, which was viewed as undesirable. When non-VA PCPs were asked about their ideal method of communication, they most commonly identified electronic health records and fax that would occur automatically. They also identified the need for a VA point of contact to triage direct calls from non-VA providers. Date: November 1, 2014 Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important. Date: September 1, 2014 Potential Impact of Affordable Care Act on Massachusetts Veterans’ Enrollment in VA Healthcare This study examined the potential impact of the Affordable Care Act (ACA) on Veterans’ enrollment in VA, private insurance, and Medicaid, using the Massachusetts Health Care Reform Act (MHCRA), implemented in June 2006, as a proxy for ACA. Findings showed that overall, healthcare reform in Massachusetts was associated with significantly greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Compared to other Veterans living in New England, Veterans living in Massachusetts decreased their enrollment in VA and private insurance by 0.2 and 0.9 percentage points, respectively, following healthcare reform. By contrast, Medicaid enrollment increased by 2.5 percentage points. Veterans increasingly took advantage of the expanded Medicaid options that were part of MHCRA; Veterans who might otherwise have enrolled in VA or private insurance opted for Medicaid. Date: August 1, 2014 VA’s “Big Data”: Benefits and Challenges This paper provides an overview of VA’s evolving approach to “big data” and illustrates how advanced analytics support clinical activities, with particular emphasis on the Patient-Aligned Care Team (PACT) model of patient-centered primary care. It also shares some of the challenges, concerns, responses, and future plans that have emerged from these initiatives. Date: July 9, 2014 Only Small Percentage of Veterans with Mental Illness Access VA Employment Services This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically. Date: July 1, 2014 Veterans’ Use of Blue Button Feature in MyHealtheVet The Blue Button feature in VA’s online combined personal health record and patient portal, My HealtheVet (MHV), allows patients to access electronic health record (EHR) components, such as past and future appointments, lab results, and medications. This study aimed to characterize users of the MHV Blue Button, its perceived impact on Veterans’ health, and its role in sharing healthcare information. Findings showed that among users of the Blue Button, the benefit most highly endorsed by Veterans (73%) was the value of having their health history in one place. In addition, 21% of users with a non-VA provider shared their VA health information, and of those, 87% reported the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. The majority of non-users of the Blue Button stated they were not aware of it. However, non-users who were aware of the Blue Button stated they did not use it because they did not know how (34%), they only use MHV for prescription renewal (26%), they preferred other methods to keep track of health information (11%), or they did not know where the Blue Button was located (10%). Age was not associated with Blue Button use. Date: July 1, 2014 “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool. Date: May 15, 2014 Veterans Living Greater Distance from VA or Any Transplant Centers May have Less Chance of Receiving Liver Transplant This study evaluated the association between distance from a VA transplant center (VATC) and access to wait-listing and liver transplantation, as well as mortality. Findings showed that among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of wait-listing or transplantation, and greater likelihood of death. Of the 50,637 Veterans classified as potentially transplant-eligible during the study period, 6% were waitlisted (49% at a VATC and 51% at a non-VATC). Overall, 7% of Veterans at a VA medical center =100 miles from a VATC were waitlisted at a VATC, and 11% at any transplant center, compared with 3% and 5%, respectively, living >100 miles from a VATC. Three-year survival from first hepatic decompensation event for waitlisted Veterans differed by distance: 72% (=100 miles from VATC) vs. 66% (>100 miles). Increasing distance to a VATC was associated with significantly increased risk of mortality, with a 3% increased risk of mortality for every doubling of distance from local VAMC to VATC. Date: March 26, 2014 Affordable Care Act May Have Significant Implications for Veterans and the VA Healthcare System This study sought to: 1) Describe the proportion and characteristics of Veterans currently uninsured, as they will likely be required to obtain coverage under the ACA; 2) Determine who among the uninsured are likely eligible for the Medicaid expansion (LEME); and 3) Compare the sociodemographic and health characteristics of those uninsured and LEME – and not LEME, and those who currently have health insurance coverage. Findings showed that of 22 million Veterans, about 7% – or more than 1.5 million Veterans – were uninsured in 2010 and would need to obtain healthcare coverage by enrolling in VA healthcare, the Medicaid expansion, participating in the health insurance exchanges, or finding some other form of health coverage. Of the uninsured Veterans, more than 800,000 are likely eligible for the Medicaid expansion. However, states that do not implement the Medicaid expansion may have many poor, uninsured Veterans who are not able to afford coverage through the health insurance exchanges because of ineligibility for federal subsidies. Compared to Veterans with health coverage, the uninsured were younger and more likely to be single, African American, low-income, and to have been deployed to Iraq and Afghanistan. Among Veterans who were uninsured, those who were LEME reported poorer general health and were more likely to use emergency department services than Veterans who were not LEME. Date: March 1, 2014 Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy. Date: February 3, 2014 Changes in Care Processes and Patient Outcomes Related to VA’s Implementation of PACT Model This study examined whether changes in VA healthcare delivery under the PACT transformation led to changes in organizational processes of care and patient outcomes. Findings showed that medical home implementation in the VA healthcare system resulted in large changes in the structure of care, but few changes in patient-level organizational processes or outcomes. There were significant improvements in two-day post-hospital discharge contact, but not primary care visits occurring by telephone or within three days of the requested date. There was no association between medical home implementation and rates of emergency department use by Veterans. Over the study period, the percentage of PCPs who were part of the PACT model more than tripled, and the percentage of PCPs that implemented elements of the PACT model increased significantly. Date: January 30, 2014 Prevalence of “Polytrauma Triad” among Iraq and Afghanistan War Veterans This study sought to determine the prevalence of TBI, PTSD, and pain among Veterans from the OEF/OIF/OND wars, who received VA healthcare. Findings showed that large and increasing numbers of OEF/OIF/OND Veterans accessed the VA healthcare system over the three-year study period. Of these Veterans, about 10% were diagnosed with TBI, 30% with PTSD, and 40% with pain. Approximately 6% had all three diagnoses — or the polytrauma triad. Overall, while the absolute number of OEF/OIF/OND Veterans increased by more than 40% from FY09 through FY11, the relative proportion of Veterans diagnosed with TBI, and the high rate of comorbid PTSD and pain in this population have remained stable. Date: January 1, 2014 Factors Associated with Use of VA MOVE! Program for Obese and Overweight Veterans This study sought to describe facility-level variability in the utilization of MOVE! (defined as 1 or more visits) – and to examine patient- and facility-level correlates of program use. Findings showed that although substantial variation exists across VA facilities in MOVE! utilization rates (0.05% to 16%), Veterans most in need of obesity management services were more likely to access the weight management program, although at a low level. Among the 2 million VA patients meeting criteria for obesity in 2010, 4.4% had at least one MOVE! visit. Among Veterans younger than 70, to whom the program is targeted, 6% had at least one visit. Veterans were more likely to have at least one MOVE! visit if they had a higher BMI, were female, unmarried, younger, a minority, or had a psychiatric or obesity-related comorbidity. Veterans at facilities with a higher proportion of Veterans with home instability and lower obeseogenic drug prescription rates were more likely to access MOVE!. Date: December 10, 2013 Better Experiences among Homeless Patients with Tailored Primary Care This study compared assessments of recently or currently homeless patients across five settings that varied in their degree of homeless-tailored service design – from none (i.e., “mainstream primary care”) to intensive tailoring. Four of the five sites were in VA. Findings showed that patients rated their primary care experience more highly when their healthcare was obtained in settings that explicitly tailored services for the homeless population through variations in service design. Survey scores at the tailored non-VA site were higher (reflecting more positive experiences with care) than at the three mainstream VA sites. The tailored VA site generally had scores that were either similar to the three mainstream VA sites or somewhat higher, depending on the subscale of interest. An unfavorable experience was a 1.5 to 2 times more common in domains of patient-clinician relationship, cooperation, and accessibility/coordination for the mainstream VA sites compared to the tailored non-VA site, with the tailored VA site attaining intermediate results. Date: December 1, 2013 VA’s Online Quality Improvement Toolkits In 2009, VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) was tasked by VHA leadership to develop online toolkits that would facilitate the spread of locally developed innovations to improve quality of care for Veterans. The QI Toolkit Series was designed as a two-year pilot project that would offer VHA staff access to innovations to help improve performance on specific performance measures across a variety of high-priority care conditions. The Toolkit Series is now an enhanced Intranet website, accessible by all staff using the VHA network. This article describes the general approach to creating such toolkits, aspects of implementation, and a brief evaluation. Date: December 1, 2013 Electronic Patient Portals and their Effect on Health Outcomes Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Date: November 19, 2013 Veterans with Non-Specific Anxiety Diagnosis Less Likely to Access Mental Healthcare than Veterans with Specific Anxiety Disorders This study sought to determine the rates of specific and non-specific anxiety diagnoses in a national sample of Veterans receiving outpatient care at VAMCs – and to examine patterns of mental healthcare use in the year following diagnosis. Findings showed that “Anxiety Disorder Not Otherwise Specified” (anxiety NOS) was diagnosed in 38% of this Veteran cohort. Most Veterans with a specific anxiety diagnosis received mental health services, with treatment rates for patients with the most frequently diagnosed specific anxiety disorders (PTSD, generalized anxiety disorder, and panic disorder) ranging between 60% and 67%. In contrast, only 32% of patients with anxiety NOS received mental health services during the 12 months following diagnosis. Most Veterans with an anxiety NOS diagnosis did not go on to receive a specific diagnosis in the next 12 months. However, most anxiety NOS patients who later received a diagnosis of a specific anxiety disorder (87%) received mental health services in the year following their index date, compared to 29% of Veterans who did not receive a subsequent specific anxiety disorder diagnosis. Patient factors that increased the likelihood of an anxiety NOS diagnosis included: female gender, older age, the absence of specific comorbid diagnoses (i.e., substance-use disorders, bipolar disorder), and absence of service-connected disability. Veterans diagnosed in specialty mental health or integrated primary care-mental health settings were less likely to receive an anxiety NOS diagnosis than patients in primary care. Date: October 22, 2013 Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007. Date: October 1, 2013 Low Rates of VA Vocational Service Use among OEF/OIF Veterans with Mental Health Conditions This study assessed nationwide patterns of supported employment and vocational service use among OEF/OIF Veterans with the top four mental health conditions: PTSD, depression, substance use disorder, or traumatic brain injury (TBI). Findings showed that of the Veterans with mental health diagnoses included in this study, only 8% had a vocational services encounter during the study period, with 2% of these receiving evidence-based supported employment. Moreover, retention was low, with most Veterans attending just one to two appointments. Veterans with TBI – and those with more mental health conditions overall – were more likely to access vocational services. Among Veterans whose employment was tracked, 51% with at least one supported employment encounter worked competitively, compared to 21% of those who did not receive supported employment. Thus, supported employment was effective when it was provided. Results indicate that recovery-oriented, evidence-based, supported employment is the best way to assist unemployed Veterans with mental health conditions to achieve competitive employment. However, resources are limited for Veterans without psychosis and those who are not homeless. Given that OEF/OIF Veterans with TBI are more likely to need vocational services, the authors suggest supported employment could be effectively integrated into VA polytrauma clinics. Date: August 1, 2013 Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days). Date: July 30, 2013 Changes in VA Care since PACT Implementation This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11. Date: July 10, 2013 Issues for Sexual and Gender Minority Veterans Receiving VA Healthcare This article summarizes emergent research findings regarding sexual and gender minority (SGM) Veterans, and the first initiatives that have been implemented by VA to promote quality care. Being a member of both the Veteran and SGM communities may contribute to a higher level of risk for poor health than membership in just one of these populations. A recent VA study indicated that only 33% of SGM Veterans reported open communication about their sexual orientation with VA healthcare providers, while 25% reported avoiding certain VA services because of concerns about stigma. In another study of 202 VA providers and 58 SGM Veterans, less than one-third of all participants viewed VA as welcoming to SGM Veterans. To address these issues, VA has created new programs, such as the Office of Health Equity LGBT Workgroup, which works to address inequities in the healthcare environment for SGM Veterans. VA also created two new part-time LGBT Program Coordinator positions, through the Office of Patient Care Services, who advise leadership on policy and practice issues related to SGM Veterans. In June 2011, VA released the first national policy to describe the services that are available to transgender Veterans. Other recent VA policy changes include “sexual orientation” and “gender identity and expression” now being included in VA non-discrimination and caregiver policies. Educational resources and trainings have been developed for VA staff about culturally appropriate care for SGM Veterans. Further research is needed to better understand the SGM population, their healthcare needs, and how these needs vary in relation to gender, race/ethnicity, and other factors, as well as in evaluation of provider training and policies. Date: July 1, 2013 Cancer Genetics Toolkit Improves Quality and Frequency of Family History Documentation among VA Primary Care Patients Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation. Date: June 13, 2013 Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics. Date: March 26, 2013 Factors Affecting Readiness for Implementation of VA’s Patient-Aligned Care Team Model This study sought to describe the impact of readiness for implementation on the efforts of 32 pilot PACT teams to make changes to improve access to healthcare for Veterans – and to identify successful strategies to overcome barriers to change. Findings showed that key factors related to readiness for implementation (or lack thereof) had an impact on which interventions pilot teams could put into place, as well as viability and sustainability of access gains. Leadership Engagement. Lack of leadership engagement/support posed a barrier to open access, however, strategies to engage/educate administrators led to successful interventions to improve access. Staffing Resources. Lack of personnel to staff PACT teams was a barrier to improving access; at sites where funds were made available to hire new staff or where teams were able to re-configure existing staff, access interventions were more often implemented. Access to Information and Knowledge. Having experienced staff who could generate reports from the electronic medical record was a major facilitator of access interventions. Pilot teams used a number of effective strategies for improving access, i.e., extending time between appointments for some Veterans; reorganizing clinic schedules in order to provide a mix of face-to-face, telephone, and same-day appointments; and contacting Veterans after an ED visit to determine appropriate follow-up care. The authors note that wide variations in interventions to improve access occurred across sites, which has important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems level indicators of the PACT model’s success. Date: November 29, 2012 Systematic Review Evaluates Patient-Centered Medical Home Model for Primary Care Transformation This systematic review sought to describe how studies conducted to date have implemented patient-centered medical homes (PCMH) – and to evaluate the current evidence of the effect of PCMH interventions on patient, staff, and economic outcomes. Findings showed that there is moderately strong evidence that the patient-centered medical home has a small positive impact on patient experiences and small to moderate positive effects on delivery of preventive care services. Staff experiences are also improved by a small to moderate degree (low strength of evidence [SOE]), but no study reported effects on staff retention. Current evidence is insufficient to determine effects on clinical and most economic outcomes, with the exception of emergency department utilization, which was reduced among older adults (low SOE). Given the relatively small number of studies directly evaluating the PCMH, and the evolving approaches to designing and implementing the medical home model, the authors caution that these findings should be considered preliminary. The PCMH evidence base is expected to double in the next two to three years. Date: November 27, 2012 OEF/OIF Veterans Most in Need of Psychiatric Care are Accessing Mental Health Services, Primarily at VA In this study, investigators conducted the first survey to employ a random sample of U.S. military post-9/11 that examined treatment use and perceived problems with treatment, including both VA and non-VA service users. Findings showed that 43% of the Veterans in this study screened positive for PTSD, major depression, or alcohol misuse. Overall, 40% of Veterans had ever received VA inpatient mental health care, 46% had ever received VA outpatient care, and 16% had ever received inpatient or outpatient care in both VA and non-VA settings. Nearly 70% of Veterans with probable PTSD or major depression and 45% of Veterans with probable alcohol misuse reported accessing mental health care in the past year. Authors suggest that Veterans who are ambivalent about accessing mental healthcare may be more willing to do so if they are made aware that a substantial number of Veterans are getting the help they need. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express stigma beliefs and concern about being seen as weak. This suggests barriers to accessing care may be distinct from barriers to engaging in care. Veterans with higher PTSD and depression symptoms were more likely to access care. This finding suggests that, above a certain threshold of symptoms, Veterans were significantly more likely to seek mental health services, even if they viewed those services in a negative light. Date: November 15, 2012 Telemental Health Expands in VA between 2006-2010 This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare. Date: November 1, 2012 Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on suicide, including risks related to guns, for VA patients, family members, and clinicians. Date: September 5, 2012 Veterans’ Communication Preferences for Primary Care Needs Overall, 54% of the Veterans in this study reported being regular computer users (daily, 2-3 times per week, or once per week). On average, a greater proportion of infrequent users (2-3 times per month, less than once per month, or do not typically use a computer) were male, older, and in fair/poor health compared to regular users. Among Veteran primary care patients, telephone communication was preferred for the majority of primary care issues, including general medical questions, medication questions and refills, as well as preventive care reminders, scheduling, and test results. In-person visits were preferred for new medical conditions, concerns about ongoing conditions, treatment instructions, and information about next steps in care. Of regular computer users, about 1/3 preferred electronic communication (email or Internet portal, including MyHealtheVet) for preventive care reminders (37%), test results (34%), and prescription refills (32%). Veterans who used the Internet did so for a variety of reasons, with e-mail (85%) and accessing health information (39%) among the top two. Date: September 1, 2012 Majority of OEF/OIF Veterans with PTSD Use VA Healthcare for PTSD-Related Treatment, and Users are Increasing Approximately 58% of OEF/OIF Veterans with PTSD used VA healthcare services and received some PTSD-related treatment from 2002 through 2010. Moreover, OEF/OIF Veterans with PTSD have been increasingly likely to use VA services over time. There is insufficient information about the quality of PTSD-related services. Developing a broader understanding of the concept of quality as it relates to PTSD treatment may lead to a better understanding of the services that OEF/OIF Veterans with PTSD receive when they access VA care. Date: July 1, 2012 Government Paying Twice for Some Veterans’ Healthcare The federal government spends a substantial and increasing amount of potentially duplicative funds on two separate managed care programs for care of the same patients. The number of Veterans concurrently enrolled in VA and Medicare Advantage (MA) increased from 485,651 in 2004 to 924,792 in 2009. The estimated VA healthcare costs for MA enrollees totaled $13 billion over six years, increasing from $1.3 billion in 2004 to $3.2 billion in 2009. Among MA plans, the proportion of Veterans eligible for VA healthcare ranged from 0.5% to 21%, and the proportion of VA users within these plans ranged from 0.2% to 16%. For this dually-enrolled patient population, VA financed 44% of outpatient visits, 15% of acute medical and surgical inpatient admissions, and 18% of acute medical and surgical hospital days. Date: June 26, 2012 Effects and Costs of Mobile, Team-Based Outpatient Care Model for Veterans with Serious Mental Illness Assertive Community Treatment (ACT) – called Mental Health Intensive Case Management (MHICM) in VA – is a mobile, team-based outpatient service model for providing comprehensive psychiatric care and case management support to individuals with serious mental illness who intensively use inpatient psychiatric care. In this study, the proportion of ACT enrollees admitted to inpatient mental health care did not differ significantly from non-enrollees admitted (62% vs. 63%). However, compared to non-enrollees, ACT enrollees had 16 fewer mental health inpatient bed days during the first 12 months of enrollment. For ACT program participants, savings depended on new clients’ “intensity” of psychiatiric inpatient utilization prior to entering the ACT program. VA ACT services are cost-saving for Veterans with serious mental illness and more than 95 mental health inpatient bed days in the 12 months prior to entering ACT, but cost-increasing for Veterans with fewer than 95 bed days. Between FY01 and FY04, new VA ACT clients had just over 68 bed days in the 12 months prior to entering ACT on average, and their entry into ACT was estimated to result in an increase of $4,529 in VA mental health costs. Trends in psychiatric inpatient use among ACT program entrants remained stable after FY04, through FY10. However, eligibility for ACT declined by 37% because fewer Veterans met eligibility based on high prior inpatient use. Thus, authors suggest that the “high hospital use” criterion may impose a trade-off between program cost-effectiveness and program access. Fewer Veterans are attaining the high hospital use threshold as inpatient use falls. This winnowing of the target population may indicate a need to reconsider the administrative criteria for entry into VA ACT services. Date: May 17, 2012 VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel. Date: April 1, 2012 Use of Mental Health and Non-Mental Health Outpatient Care by OEF/OIF Veterans with Military Sexual Trauma The most notable factor that influenced the receipt and intensity of MST-related care was gender. Male Veterans used less care than female Veterans and had a lower intensity of MST-related care compared to women, even after controlling for total number of healthcare visits. Other sociodemographic and military variables associated with less use and/or less intensity of MST-related care were younger age, unknown race/ethnicity, being in the Marines or Air Force, and being in the National Guard or Reserve. Among all Veterans who screened positive for MST, the majority (76%) received at least one MST-related care visit within a year of the positive screen. In examining diagnostic characteristics of MST-related care, the most common primary diagnoses related to a Veterans’ MST-related care were mental health diagnoses. Overall, more than half of all Veterans received MST-related care with an associated mental health primary diagnosis (57% of women and 50% of men); the most common diagnoses were PTSD, depression, and other anxiety disorders. The authors note that the high proportion of Veterans accessing MST-related care confirms the effectiveness of VA’s universal screening program to promote the use of mental health services for Veterans with positive MST screens. Date: March 7, 2012 Majority of Veterans Interested in Sharing Personal Health Record Information with Caregivers and non-VA Healthcare Providers This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status. Date: December 20, 2011 Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008 This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care. Date: December 1, 2011 JGIM Special Supplement Highlights Access to VA Healthcare The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare. Date: November 1, 2011 Barriers to Healthcare Access for Women Veterans This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault. Date: November 1, 2011 Distance Most Important Barrier for Rural-Residing Veterans Seeking Healthcare This study of rural Veterans, providers, and staff examined the impact of travel distance on the use of VA healthcare services, satisfaction, and impact on care delivery. Findings showed that distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. The average one-way distance that Veterans traveled to a VA primary care clinic was 44.5 miles. The most common types of distance barriers discussed pertained to patient health, functioning, and financial or time resources. Other barriers frequently cited included challenges associated with travel, such as limited transportation and cost/expense. Veterans perceived the same travel distance as more burdensome when seeking care for regular services available locally (e.g. laboratory, podiatry), when compared with specialty care (e.g., cardiology, neurology). Many older Veterans who were able to drive viewed distance more as a ‘way of life’ than a ‘barrier.’ However, given that 44% of Veterans are >65 years old, travel distance is likely to become increasingly salient as a barrier in this aging population. Date: November 1, 2011 Access to Healthcare and Framework for Reducing Hospital Readmissions This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies. Date: October 26, 2011 VA Travel Reimbursement Increases Outpatient Visits This study examined the effects of a February 2008 policy change to increase Veterans’ mileage reimbursement rate (from 11 cents per mile to 28.5 cents per mile) on utilization of outpatient, inpatient, and pharmacy services in the 10.5 months before the reimbursement rate increase and the 10.5 months after the rate increase. Findings showed that after the reimbursement rate increase, eligible Veterans at all distances were 7% more likely to have at least one VA outpatient visit and had 3% more outpatient visits compared to Veterans who were not eligible for the travel reimbursement. The increased reimbursement was associated with slightly larger increases in outpatient costs to provide care to Veterans who lived farther away from VA facilities compared to those who lived closer. The odds of having a prescription filled at a VA pharmacy increased by at least 4% for Veterans across all distance definitions, with patients living farther than 50 miles away experiencing the largest increase at 9%. The reimbursement rate also was associated with a significant increase in pharmacy costs to provide medications to Veterans living farther than 50 and 75 miles from a VA facility. Inpatient visits remained generally unaffected, and there was no significant increase in cost. Date: August 24, 2011 Veterans in Favor of Internet-Provided HIV Screening Information This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. Date: August 15, 2011 Updated Literature Review Examines Research and Findings on Women Veterans’ Health Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and quality of care interventions/outcomes for physical and mental conditions affecting women Veterans. Date: July 6, 2011 Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004 This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT. Date: June 16, 2011 Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems. Date: June 7, 2011 Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide. Date: April 4, 2011 Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators. Date: January 17, 2011 Electronic Health Information’s Effect on Clinical Workflow This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety. Date: December 1, 2010 Increasing Access to VA Primary Care via Community Clinics May Alter Veterans’ Use of Healthcare This study examined trends in primary care, specialty care, and mental health services use in VA and Medicare among Medicare-eligible Veterans who obtained community-based primary care or hospital-based primary care. Findings show that VA primary care patients who were eligible for Medicare used significant primary care and specialty care outside of VA, but not mental health care. Community-based VA patients used less VA care and more Medicare services, suggesting possible unintended fragmentation of care. Hospital-based VA patients were more likely than community-based patients to obtain primary care and specialty care only at VA. Dual use of VA and Medicare specialty care was the most common care pattern and the most fragmented among both community and hospital-based patients. Mental healthcare services were not fragmented, as most patients used VA only for these services. Use of Medicare only for outpatient primary and specialty care increased over the 4-year study, while use of VA only for these services decreased. Date: October 1, 2010 VA Increases Prescriptions for Smoking Cessation Medications among Veterans Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum). Date: September 24, 2010 VHA Policymakers May Need to Consider Additional Classification Schemes when Planning Care for “Rural” Veterans To better understand the issues confronting Veterans living in rural settings, VHA developed a three-category classification system that designates locations throughout the U.S. as Urban, Rural, or Highly Rural. To understand the policy implications of the VA classification system, this study compared VA’s categories to three Office of Management and Budget (OMB) and four Rural-Urban Commuting Area (RUCA, developed by the University of Washington and the USDA) geographical categories. Findings show that although the three classification schemes differ considerably in the number of VHA healthcare enrollees designated as Rural residents, they all show that the proportions of rural Veterans among enrollees are substantial. VHA’s Rural category (36% of its enrollees) is broadly defined and includes up to 3 to 5 times the enrollees included in the middle RUCA or OMB categories. VHA’s Highly Rural and Urban categories are defined more narrowly than in the other schemes, suggesting that VHA’s categories may more accurately reflect specifically urban or remotely rural populations. Of Veterans enrolled in VA healthcare, roughly 1 in 60 is a Highly Rural resident. If policymakers rely solely on either the RUCA or OMB category scheme, they might conclude that access standards have been met for the majority of VHA enrollees. However, the VHA scheme indicates that access standards have not been met for Veterans living in highly rural settings. Thus, authors suggest that policymakers supplement analyses of Rural Veterans’ healthcare needs with more detailed breakdowns from other classification systems. Date: September 1, 2010 Patient-Centered Medical Homes Could Reduce Medical Errors The patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care, including what is likely the leading type of error – diagnostic error (i.e., missed, delayed, or wrong diagnosis). Integral to the PCMH concept are electronic medical records (EHRs), which can enhance access to data and advanced decision support to reduce diagnostic error. However, as currently envisioned, many PCMH models may not address other systems and cognitive problems that cause diagnostic errors. In this Commentary, authors recommend five “rights” for reducing diagnostic errors in future patient-centered medical homes within and outside VA. The five “Rights” include: Right Teamwork, Right Information Management, Right Measurement and Monitoring, Right Patient Empowerment, and Right Safety Culture. Date: July 28, 2010 Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means. Date: July 1, 2010 Study Examines the State of Colorectal Cancer and Finds Cause for Optimism, Particularly within the VA Healthcare System In contrast to the health disparities that are evident in the community, when colorectal cancer (CRC) outcomes were studied within an equal-access, integrated healthcare system, such as VA, racial disparities were markedly decreased or absent. The type of screening test used in the US has varied over the last decade, but colonoscopy is becoming the dominant modality. However, VA relies primarily on fecal occult blood tests (FOBT). From 1998 to 2003, the proportion of screened Veterans undergoing FOBT within VA increased from 82% to 90% compared to that of Veterans receiving screening colonoscopies, which decreased from 6% to 5%. From the perspective of population-based screening, VA is actually more successful than the general population at screening, and has CRC screening rates well above the national average. Date: June 1, 2010 Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and access to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems. Date: June 1, 2010 Majority of OEF/OIF Veterans Interested in Interventions/Information to Help with Community Readjustment An estimated 40% of OEF/OIF combat Veterans who used VA medical services perceived some to extreme overall difficulty readjusting to civilian life within the past 30 days. Between 25% and 56% of the participants had some to extreme difficulty in specific areas related to social functioning, productivity, community involvement, and self-care. For example, 31% reported more alcohol and drug use, and 57% reported more anger control problems since returning from Iraq or Afghanistan. Almost all Veterans (96%) expressed interest in services to help them readjust to civilian life. Veterans with probable PTSD (n=291) reported more reintegration problems and expressed interest in more kinds of services for these problems than did Veterans without probable PTSD (n=463). The most commonly preferred ways to receive reintegration services or information were at a VA facility, through the mail, and via the Internet. Almost all OEF/OIF Veterans in this study had access to the Internet and used it regularly. Date: June 1, 2010 Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality. Date: May 11, 2010 Predictors of Veterans’ Use of Mental Health Services Findings show that being older, female, having greater clinical need, lack of enabling resources (e.g., employment, stable housing, social support), and fewer problems with access to treatment significantly predicted increased mental health services use over the three-month follow-up period. Results also show that fewer outpatient mental health visits did not adversely affect clinical outcomes. Findings support VA’s ongoing commitment to provide special programs and initiatives focused on easing access to mental health services, vocational rehabilitation, and housing assistance. Date: April 1, 2010 VA Care for Obese Veterans Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications. Date: February 24, 2010 VA Provides Broader Variety of Assistive Technologies for Veterans with Stroke at Lower Cost Findings from this study suggest that VA provides a broader variety of assistive technology devices (ATDs) at a lower cost than Medicare. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items, and slightly lower than Medicare for capped rental payments. More than half of the ATDs provided by VA were ADL-related, compared to only 11% provided by Medicare. Findings also showed that 39% of the cohort had not received an ATD of any kind, while 56% received ATDs from VA only, 3% received ATDs from both systems, and 1% received an ATD from Medicare only. Analyses suggest that VA policy in providing ATDs is driven by Veterans’ needs, whereas Medicare policy may be driven, in part, by cost-containment needs associated with increases in fraudulent claims. Date: February 1, 2010 Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist. Date: January 26, 2010 Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention. Date: December 1, 2009 Veterans’ Age and Disability Status Associated with Choice of Medicare Plans Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care. Date: November 1, 2009 Use of Medicare and VA Healthcare among Veterans with Dementia This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities. Date: October 1, 2009 Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily. Date: October 1, 2009 Geographic Access to Rehabilitation for OEF/OIF Veterans This study sought to ascertain specific geographic areas where the need for VHA rehabilitation services appears greatest and potential access gaps may exist. Findings show that VA provides access to rehabilitation care for the majority of traumatically injured OEF/OIF Veterans; however, more than 10% of Veterans may have potential access barriers due to excessive travel time. For the combined cohort, the median distance to Level I, Level II, and Level III facilities was 411 miles, 121 miles, and 64 miles respectively, and the median distance to the closest VA facility was 22 miles. Clark County, Nevada, and El Paso County, Texas had the highest number of patients with potential access gaps due to excessive travel times. Date: October 1, 2009 Focus Groups Recommend Strategies to Decrease Missed Test Results This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome. Date: September 1, 2009 Demands on VHA for Post-Deployment Healthcare Needs of OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases). Date: September 1, 2009 Healthcare Utilization among American Indian and Alaska Native Veterans Findings show that like other VA healthcare users, American Indian and Alaska Native (AIAN) patients had the same three most frequent diagnoses associated with healthcare encounters: post-traumatic stress disorder, hypertension, and diabetes. VHA-Indian Health Service (IHS) dual-users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VA. Many dual-users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping healthcare services in VA and IHS. Therefore, authors suggest that strategies to improve outcomes among the AIAN Veteran population should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Date: June 1, 2009 Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care. Date: May 1, 2009 Diffusion of New Drug Therapy for PTSD Lessens with Distance This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas. Date: April 1, 2009 Access to Healthcare among Veterans with Bipolar Disorder Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness. Date: April 1, 2009 Teledermatology – Promising Technique for Improving Access to Care In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists. Date: April 1, 2009 Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression. Date: March 1, 2009 Physicians May Need More Education about Long-Term Care Options for Veterans The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals. Date: February 1, 2009 Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use. Date: January 27, 2009 Transparency Standards for Diabetes Performance Measures The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence. Date: January 14, 2009 Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of quality assessment. Date: January 1, 2009 Barriers to Bone Density Testing for Patients with Spinal Cord Injury Several barriers to routine bone mineral density assessment among the SCI population were identified, e.g., scanner design that limits accessibility, and increased scanning time that requires additional staff. To help lessen these barriers, investigators recommend several changes, such as: installing ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the screening room, increasing staff during scans, and partnering with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury. Date: January 1, 2009 Controlling Medicare Costs: Study Suggests VA-Administered Drug-Only Benefit for Veterans Enrolled in Medicare This article discusses the role of interest groups in drug-plan policy differences between Medicare and VA. Authors suggest a partnership between Medicare and VA that could provide access to the VA drug benefit to a large number of Medicare-enrolled veterans who do not currently have it. Date: December 1, 2008 Program Improves Access to Mental Health Care for Veterans This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources. Date: November 1, 2008 Factors Associated with VA Employee Participation in Quality Improvement Program to Reduce Patient Wait Times Perceived group norms and attitudes were related to greater individual participation in the Advanced Clinic Access program, but perceived behavioral control was not found to be significant to participation. Overall, survey respondents typically engaged in just under half of the change behaviors. Employees with greater responsibility (e.g., nurse practitioners, RNs, and physicians) participated in more activities compared to other clinic employees. Team size, academic affiliation, and job satisfaction were not significant predictors of participation. Date: November 1, 2008 Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals Regardless of where they live (rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas. Date: October 1, 2008 Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas. Date: September 10, 2008 Psychotherapy Administered via Telephone Reduces Depression Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy. Date: September 1, 2008
What is included in Publication Briefs? HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations. ^ top

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