Evaluating the VA Make-or-Buy Decision in Emergency Care

评估 VA 在紧急护理中的自制或外购决策

• 批准号: 10331741
• 负责人: David Chimin Chan
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-01-01 至 2024-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10331741
• 关键词: Accident and Emergency department; Address; Adopted; Affect; Age; Ambulances; Caring; Characteristics; Communities; Contracts; Data; Decision Making; Diagnosis; Direct Costs; Economics; Elderly; Emergency Care; Emergency Medicine; Emergency Situation; Emergency department visit; Emergency medical service; Face; Goals; Guidelines; Health; Health Care Costs; Health Services Accessibility; Homelessness; Intervention; Investments; Knowledge; Link; Literature; Location; Mediating; Mental Health; Methods; Natural experiment; Outcome; Outpatients; Patients; Physicians; Play; Policies; Process Measure; Provider; Quality of Care; Quasi-experiment; Randomized; Records; Research; Resources; Savings; Site; Source; Teaching Hospitals; Testing; Trauma; Traumatic Brain Injury; Triage; Variant; Veterans; Work; base; care coordination; care costs; comorbidity; complex chronic conditions; cost; cost outcomes; demographics; health care delivery; health difference; improved; low socioeconomic status; mortality; policy implication; prevent; randomized trial; residence; response

Background: In response to concerns about access to and quality of care at VA facilities, the VA has begun to redirect resources toward financing care for Veterans outside of the VA. However, the quality and cost of care for Veterans that will result from this “make-or-buy” decision remain a scientific unknown, with significant policy implications for how the VA can optimize Veteran health. Quality and cost of care are particularly influenced by emergency services, with 13% of care and more than $800 million in yearly costs directed outside the VA. Objective: Our objective is to identify how quality and cost of care for Veterans are affected by its provision inside or outside the VA. Studying the quality and costs of VA vs. non-VA care faces the fundamental concern that patients who receive care at VA facilities may have different levels of underlying health than do those who receive care outside the VA. Without understanding the consequences of VA vs. non-VA emergency care on quality and cost, VA policymakers will be unable to direct Veterans to the best care location, nor will they understand mechanisms behind quality and cost differences between VA vs. non-VA care. Finally, a lack of knowledge about the effects of VA vs. non-VA care, and about how Veterans access care, prevents policymakers from predicting quality and cost outcomes for Veterans from policy interventions redirecting Veterans to non-VA care. Methods: In Aim 1, we will adopt a quasi-experimental approach, based on instrumental variables (IVs), to study the effect of the care source on health, utilization, and spending. In preliminary results, we find that VA EDs reduce elderly Veteran mortality by 50%, or five percentage points. In Aim 2, we will assess the factors altering the effect of VA vs. non-VA care, evaluating mechanisms behind the effect. For example, we will investigate whether the VA performs better for Veterans with certain conditions or demographics, such as a mental health diagnosis or low socioeconomic status. We will assess whether the capacity of local VA options plays a key role in determining outcomes, and whether coordination of care mediates improved VA outcomes. In Aim 3, we will evaluate how Veteran use VA and non-VA ED alternatives, and we will use these results and those in Aims 1 and 2 to simulate quality and cost outcomes under policies for expanding VA capacity, contracting with non-VA options, and redirecting Veterans to care depending on their characteristics and on local options. Expected Outcome: Based on our preliminary results, we expect there to be important differences in health outcomes and spending between VA and non-VA emergency care. We therefore expect that policymakers can save thousands of Veteran lives and can improve health outcomes by making decisions based on this research. The effect of VA care likely differs across Veterans and local conditions. Accordingly, we expect there to be large additional gains in health and spending outcomes that result from tailoring policies related to this important make-or-buy decision. Finally, by understanding how outcomes differ across settings and Veteran types, we expect to contribute to a general understanding about which components of health care delivery are most critical to achieving excellence. In partnership with the Offices of Policy and Planning, Community Care, and Emergency Medicine, we anticipate that our findings will be disseminated widely and will be applied directly to VA decisions and guidelines.

背景：为了应对人们对退伍军人管理局设施的可及性和护理质量的担忧，退伍军人管理局已开始 将资源重新定向为退伍军人事务部以外的退伍军人提供资金。然而，护理的质量和成本 对于退伍军人来说，这种“制造或购买”的决定仍然是一个科学的未知数， 对VA如何优化退伍军人健康的影响。护理的质量和成本尤其受到以下因素的影响： 紧急服务，13%的护理和超过8亿美元的年度费用直接在弗吉尼亚州以外。 目标：我们的目标是确定退伍军人护理的质量和成本如何受到其提供的影响 不管是退伍军人事务部内部还是外部研究VA与非VA护理的质量和成本面临着根本的问题 在退伍军人管理局机构接受护理的患者可能与那些 在VA之外接受护理。如果不了解VA与非VA紧急护理的后果， 质量和成本，退伍军人管理局的政策制定者将无法直接退伍军人到最好的护理地点，他们也不会 了解VA与非VA护理之间的质量和成本差异背后的机制。最后，缺乏 了解VA与非VA护理的影响，以及退伍军人如何获得护理， 政策制定者从预测退伍军人的质量和成本结果，从政策干预， 退伍军人到非退伍军人护理。 方法：在目标1中，我们将采用基于工具变量（IV）的准实验方法， 研究护理来源对健康、利用和支出的影响。在初步结果中，我们发现，VA 急诊室将老年退伍军人的死亡率降低了50%，即5个百分点。在目标2中，我们将评估 改变VA与非VA护理的效果，评估效果背后的机制。比如我们会 调查VA是否对具有某些条件或人口统计学特征的退伍军人表现更好，例如 精神健康诊断或社会经济地位低下。我们将评估当地VA选项的容量 在确定结果以及护理协调是否介导VA结果改善方面起着关键作用。 在目标3中，我们将评估退伍军人如何使用VA和非VA艾德替代品，我们将使用这些结果， 目标1和目标2中的目标，以模拟在扩大VA能力的政策下的质量和成本结果， 与非VA选项签订合同，并根据他们的特点和 本地选项。 预期结果：根据我们的初步结果，我们预计在健康方面会有重要的差异。 VA和非VA紧急护理之间的结果和支出。因此，我们预计政策制定者能够 拯救成千上万的退伍军人的生命，并可以通过基于此做出决定来改善健康状况。 research. VA护理的效果可能因退伍军人和当地条件而异。因此，我们期望 有大量的额外收益，在健康和支出的结果，导致定制政策， 这个重要的自制或购买的决定最后，通过了解不同环境下的结果如何不同， 退伍军人类型，我们希望有助于对医疗保健的哪些组成部分的一般理解 交付是实现卓越的关键。与政策和规划办公室合作， 社区护理和急诊医学，我们预计我们的研究结果将广泛传播，并将 直接应用于VA决策和指导方针。