Comparing Quality of Care between VA-Delivered and VA-Purchased Care: The Need for Better Risk Adjustment

背景：2018年的使命法案进一步扩大了退伍军人接受护理的机会

Background: The MISSION Act of 2018 further expanded the opportunity for Veterans to receive care in the community. While this may have led to improved access to care, it may also have resulted in decreases in the quality of care that Veterans receive. Significance: This study will be the first to improve existing risk adjustment methods used by VA with an application for VA/Community Care (CC) quality comparisons. As increasing numbers of Veteran enrollees use CC, there is an urgent need to know if the quality of care delivered in the community that is purchased by VA is at least equivalent to the quality of care delivered in VA. We will also examine whether adding social determinants of health (SDOH) to the risk adjustment methods impacts assessments of quality and health disparities. Innovation and Impact: A better understanding of which new data sources and SDOH variables improve risk adjustment methods is needed to enable fairer and more accurate comparisons of VA/CC quality at both the national and local area levels. We will obtain a much richer picture of the conditions and other individual- and community-level factors that affect the risk or disease burden of Veterans by also including data from multi-system use (Medicare and All-Payer Claims Databases). Specific Aims: For federal fiscal years 2020-2022, our specific aims are to: 1) Examine whether adding readily available VA, CC, and pharmacy data and individual- and community-level SDOH variables improve the discrimination and calibration of Gagne (an easily modifiable comorbidity measure); 2) Examine whether adding non-VA system use improves the discrimination and calibration of Gagne; and 3) Compare overall VA/CC quality at the national and local area levels using “Gagne1” (which includes additional VA and SDOH data), “Gagne2” (which includes non-VA system use datasets), and the Nosos risk score (an “off-the-shelf” VA risk adjustment method). We selected two Veteran subgroups to study: Veterans with serious mental illness (SMI) and Veterans undergoing total hip or total knee arthroplasty (THA/TKA). Both of these subgroups are in high-cost, high-volume categories of outsourced CC. Quality of care is defined by 4 health outcomes: emergency department (ED) visits and readmissions for Veterans with SMI, and complications and readmissions after THA/TKA. Methodology: For Aim 1, we will examine the extent to which the coefficients on the Gagne comorbidities change when additional data sources (CC and pharmacy data) are added to VA utilization data and then when SDOH variables are added to predict outcomes. We will also compare discrimination and calibration between Gagne, Gagne1, and Nosos. For Aim 2, we will examine the effect of adding non-VA system use data to Gagne1 and evaluate their effect on model discrimination and calibration of Gagne2. For Aim 3, we will compare overall VA/CC quality at the national and local levels using Gagne1, Gagne2, and Nosos. Next Steps/Implementation: Through collaboration with key operational partners (the Office of Community Care [OCC], Analytics and Performance Integration [API], Office of Health Equity [OHE], Access Office, and Serious Mental Illness Research and Evaluation Center [SMITREC]), we will provide VA leaders and policymakers with equitable comparisons of quality that can be integrated into ongoing development of tools and initiatives that are being implemented nationwide or used to help facilitate practice (which risk adjuster to use) and policy (decisions related to whether to allocate additional resources to VA-provided care or expand use of VA-purchased care). Our findings will also enable more informed staff, clinician, and Veteran shared decision-making about where to receive care.