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Health Services Research & Development

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Publication Briefs
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  • Subgroups of High-Risk VA Patients Based on Social Determinants May Help Predict Risk of Future Hospitalization
    The objective of this study was to identify discrete and clinically meaningful subgroups of high-risk Veterans that could help VA better tailor clinical and social services to the distinct needs of these populations. Findings showed that patients’ self-reported social determinants of health (SDH) measures can be used to identify meaningful subgroups that may benefit from tailored interventions to reduce their risk of hospitalization and other adverse events. Five subgroups of high-risk Veterans with different risk for VA hospitalization emerged, those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). After adjusting for covariates, Veterans with ‘multiple SDH vulnerabilities’ were significantly more likely to be hospitalized at 6 months than those with ‘minimal SDH vulnerabilities.’
    Date: May 1, 2021
  • VA’s Progress and Next Steps in Incorporating Social Determinants of Health
    This commentary outlines the recommendations of an inter-professional workgroup of 26 VA and non-VA health services researchers, Veterans who use VA care, as well as leaders from several VA offices and centers, brought together by HSR&D to identify challenges and opportunities for addressing social factors in the VA healthcare system. The breadth of data and the innovative environment bode well for VA to be a major national laboratory, liaison, and leader in navigating the challenges around the integration of social factors into healthcare.
    Date: June 27, 2020
  • Key Organizational Characteristics Associated with Providing Evidence-based, Patient-Centered Medical Care in VAMCs
    Two major trends in healthcare over the past 10 years have been the moves to evidence-based practice (EBP) and patient-centered care (PCC). However, the provision of PCC, with its emphasis on being responsive to individual patient and family preferences, needs, and values can potentially conflict with the delivery of effective and efficient care via standardized processes of EBP. This study assessed the relationship between EBP and PCC by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics, that distinguish medical centers that are able to provide inpatient care that is both evidence-based and patient-centered from those where performance is either mixed or low in both domains. High-performing sites for both EBP and PCC: exhibited organizational cultures of empowerment where EBP and PCC expectations were both emphasized; provided formal and informal institutional supports and structures for PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC. Low-performing sites: exhibited a passive or sometimes punitive culture in which there was a lack of accountability, blaming, and resistance to change and aspired to improve clinical performance and patient-centeredness, but clinicians often felt bound by institutional structures and systems that were bureaucratic and constrained their ability to deliver their preferred type of care.
    Date: June 20, 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
  • Identifying Best Strategies to Implement Patient-Centered Care
    This paper describes a qualitative study of four early Centers of Innovation (VA medical centers considered early leaders in patient-centered care [PCC]) to inform VA leadership about how best to catalyze and sustain change across the system. Investigators identified seven domains that impacted PCC implementation: 1) leadership, 2) patient and family engagement, 3) staff engagement, 4) focus on PCC innovations, 5) alignment of staff roles and priorities, 6) organizational structures and processes, and 7) environment of care. Within each domain, multi-faceted strategies for implementing change were identified. These included efforts by leadership at all levels of the organization who modeled PCC in their interactions – and who fostered willingness to try novel approaches to care among staff. Capturing patients’ voices, obtaining patient perspectives, and finding out what matters most to Veterans and their families also were essential to selecting, planning, and implementing PCC initiatives. Alignment and integration of patient-centered care within the organization, particularly surrounding roles, priorities, and bureaucratic rules, remained major challenges. Findings from this study were used to create policy-level incentives to change by incorporating the seven domains into VA senior executive performance measures.
    Date: March 7, 2018
  • Measures of Patient Care Experiences Reflect Fair Hospital Assessments
    There are concerns about the fairness of using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures to compare healthcare facilities if some have more ”complex” patients that are harder to treat, and it has been argued that clinical variables should be included to adjust for such differences. Therefore, this study compared scores for different types of hospitals after making adjustments using only survey-reported patient characteristics – and then also using more complete clinical and hospital information. Findings showed that comparisons of composite patient-centered care (PCC) scores across types of hospitals that were adjusted only for patient-reported health status and sociodemographics were similar to those that also adjusted for patient clinical characteristics. Thus, study findings do not support concerns that measures of patient care experiences are unfair because commonly used models do not adjust adequately for potentially confounding patient clinical characteristics. The same was true when the various adjusted scores for specific dimensions of patient experience were compared across hospital types.
    Date: July 1, 2014
  • Trends in Healthcare Use and Costs after VA’s Implementation of Patient-Aligned Care Teams
    This study analyzed data for 11 million VA primary care patients treated from FY03 through FY12 to assess how trends in healthcare use and costs changed after the PACT implementation. Findings showed that PACT implementation was associated with modest increases in primary care visits – and with modest decreases in both hospitalizations for conditions like heart failure that might be avoided with better ambulatory care, and outpatient visits with mental health specialists. It is estimated that these changes avoided $596 million in costs compared to the investment in PACT of $774 million, for a potential net loss of $178 million during the study period. The investment in PACT was overwhelmingly attributed to hiring personnel to staff primary care teams. Although PACT has not generated a positive financial return, it is still maturing and trends in costs and use are favorable. Thus, adopting patient-centered care does not appear to have been a major financial risk for VA.
    Date: June 1, 2014

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