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How Do VA's Frontline Cardiovascular Clinicians Engage with Concepts of Healthcare Outcomes and Value in their Clinical Work?

Despite VA's focus on quality, relatively little is known about how VA's frontline clinicians regularly engage with the concepts of healthcare outcomes and value in the conduct of their clinical work. This study assessed VA clinicians' familiarity with and attitudes toward VA's efforts to measure and improve quality-of-care processes, clinical outcomes, and healthcare value at their medical centers. Between October 2017 and July 2018, telephone interviews were conducted with cardiovascular healthcare providers (n=31) at VA medical centers that were previously identified as high- (n=10) or low-performers (n=10) in terms of healthcare value, based on a previous research study comparing cardiovascular outcomes and costs. The 20 VAMCs from which providers were recruited comprised a broadly-based national sample of VA facilities, and were ranked using VA data from 2010-2014. The interviews focused on VA providers' experiences with measures of processes, outcomes, and value (i.e., costs relative to outcomes) of cardiovascular care. Responses were organized into five themes: 1) data collection, 2) feedback, 3) data driving decision-making, 4) special consideration for high-cost care, and 5) endorsement of VA's quality improvement system.


  • Regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process-of-care data (for example, appropriate use of aspirin or beta-blockers) to inform their practice. However, clinical outcomes data (for example, adverse events or 30-day readmissions) were used more rarely, and value-of-care data were almost never used.
  • While two-thirds of participants reported that process data were regularly shared with providers, only about one-third of participants were aware of who was responsible for reviewing, analyzing, and disseminating their facility's outcomes and cost data. In addition, half of the participants stated that they did not receive any feedback on costs of care, and they were not aware whether their facility measured the cost of care in relation to processes and outcomes.
  • Fewer respondents reported clinical outcome measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care.
  • Providers expressed general enthusiasm for VA's quality measurement/improvement efforts, with few criticisms about workload or opportunity costs inherent in clinical performance data collection.


  • This study identifies an opportunity for outcomes and value information to be more frequently measured and more commonly used in routine clinical care settings.


  • The relatively small sample size (n=31) limited the investigators' ability to interpret distinctions between participants from high- and low-performing VAMCs.

This study was funded by HSR&D (IIR 14-077). All authors are part of HSR&D's Center for Health Equity Research & Promotion (CHERP) located in Pittsburgh and Philadelphia, PA.

PubMed Logo Segal A, Rodriguez K, Shea J, Hruska K, Walker L, and Groeneveld P. Quality and Value of Health Care in the Veterans Health Administration: A Qualitative Study. Journal of the American Heart Association. May 7, 2019;8(9):e011672.

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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.

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