Leveraging a natural experiment to identify the effects of VA community care programs on health care quality, equity, and Veteran experiences

利用自然实验来确定 VA 社区护理计划对医疗保健质量、公平性和退伍军人体验的影响

• 批准号: 10595577
• 负责人: Walid F. Gellad
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-04-01 至 2026-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10595577
• 关键词: Address; Admission activity; Adverse effects; Affect; Ambulatory Care; Attention; Automobile Driving; Caring; Clinical; Communities; Community Healthcare; Complement; Continuity of Patient Care; Data; Dimensions; Disparity; Drug Interactions; Eligibility Determination; Equitable healthcare; Equity; Funding; Health; Health Care Surveys; Health Services Accessibility; Health system; Healthcare; Hospitalization; Improve Access; Length of Stay; Link; Low income; Managed Care; Medical; Medicare; Methodology; Methods; Natural experiment; Outcome; Outpatients; Patient Care; Patients; Pharmaceutical Preparations; Policies; Process; Process Measure; Provider; Qualitative Research; Quasi-experiment; Recommendation; Reporting; Research; Research Priority; Risk; Safety; Services; Subgroup; Substance Use Disorder; Support Groups; Support System; Surveys; System; Testing; Therapeutic; Time; Translating; Travel; United States Department of Veterans Affairs; Variant; Veterans; Veterans Health Administration; Vulnerable Populations; Work; adverse outcome; analytical method; care coordination; care fragmentation; care recipients; complex chronic conditions; data tools; data warehouse; design; econometrics; ethnic minority; experience; follow-up; health care cost/financing; health care delivery; health care quality; health equity; improved; innovation; medical vulnerability; military veteran; patient safety; pharmacy benefit; programs; provider communication; racial minority; satisfaction; severe mental illness; social; social vulnerability

Background: The Veterans Choice Program and MISSION Act have transformed how VA delivers care by expanding Veterans’ eligibility to receive VA-funded care from community providers. The effects of this change on the quality and equity of care are unknown. Understanding these effects is critical, given the importance of these programs to VA and the complexity of managing care for Veterans across different health systems. To address this evidence gap, we will use a quasi-experimental regression discontinuity (RD) design and examine outcomes in medically and socially vulnerable subgroups to determine the impact of Choice and MISSION on quality and equity of Veterans’ health care. To further examine impacts on vulnerable groups, we will analyze disparities in ratings of community care from VA’s Survey of Healthcare Experiences of Patients (SHEP). Significance: This proposal addresses cross-cutting HSR&D research priorities, including evaluating the quality and equity of care for Veterans in the context of a key legislative priority for VA: the MISSION Act. We will examine how the effects of receiving community care, and patient experiences with community care, differ in vulnerable populations, addressing VA priorities related to equity. The project constitutes an advancement in the rigor of research while directly informing ongoing and high priority clinical initiatives within VA. Innovation and Impact: Our project is innovative because it uses an RD design to provide causal evidence about the effects of community care on the quality and equity of outpatient care and prescribing. The project is also innovative and impactful in its attention to subpopulations of socially and medically vulnerable Veterans, including analyses of disparities in community care patient experiences from national survey data. By working closely with operational partners and a Veterans Advisory Board, we will impact VA policy by translating findings into actionable recommendations to improve community care, particularly for vulnerable groups. Specific Aims: (1) Identify the effects of receiving outpatient community care through Choice and MISSION on quality and equity. (2) Identify the effects of community care on the quality and equity of prescribing. (3) Compare Veterans’ experiences with community care in vulnerable and other Veteran populations. Methodology: We will use an RD design and analyses of both administrative and VA survey data to assess the effects of Choice (all program years) and MISSION (2019-2022) on the quality and equity of Veterans’ health care. Aims 1-2 will use a quasi-experimental RD design that compares Veterans just above vs. below distance and travel time eligibility thresholds for VA community care in Choice and MISSION. We will study effects of community care use on quality overall and, to evaluate implications for equity, in vulnerable subpopulations defined by the presence of serious mental illness or substance use disorders, complex chronic conditions, low income, and racial/ethnic minority status. Outcome variables in Aim 1 focus on outpatient processes of care (e.g., continuity of care) and outcomes linked to care coordination (e.g., admissions for ambulatory care-sensitive conditions). Outcome variables in Aim 2 focus on prescribing safety and quality (e.g., drug-drug interactions), therapeutic duplication, and refill non-adherence. These analyses use VA Corporate Data Warehouse, Planning Systems Support Group, Medicare, and Program Integrity Tool data. In Aim 3, we will analyze national data from the VA SHEP Community Care survey (conducted among community care recipients) to compare patient-reported experiences with community care among Veterans in vulnerable populations vs. other Veterans. Outcome variables in Aim 3 include 5 domains of Veterans’ experiences with care coordination, provider communication, and timely access in VA community care. Next Steps/Implementation: Through close partnerships with the Office of Community Care, Pharmacy Benefits Management, Office of Health Equity, and a Veterans Advisory Board, we will rapidly disseminate our findings and translate them into actionable recommendations to improve quality and equity in community care.

背景：退伍军人选择计划和使命法案改变了退伍军人管理局提供医疗服务的方式 扩大退伍军人从社区提供者获得退伍军人管理局资助的护理的资格。这一变化的影响 关于护理的质量和公平性，目前尚不清楚。鉴于这些影响的重要性，理解这些影响至关重要 这些方案为退伍军人和跨不同医疗系统管理退伍军人护理的复杂性提供了帮助。至 为了解决这一证据差距，我们将使用准实验回归不连续性(RD)设计并检验 医疗和社会弱势群体的结果，以确定选择和使命对其的影响 退伍军人医疗保健的质量和公平。为了进一步考察对弱势群体的影响，我们将分析 从退伍军人事务部的患者医疗体验调查(SHEP)中得出的社区护理评级的差异。 意义：这项建议涉及交叉的HSR&D研究优先事项，包括评估 退伍军人护理的质量和公平--退伍军人事务部的一项关键立法优先事项：《使命法》。我们 将研究接受社区护理的效果与患者接受社区护理的体验有何不同 在弱势群体中，解决退伍军人管理局与公平有关的优先事项。该项目是在 研究的严谨性，同时直接为退伍军人事务部正在进行的高度优先的临床计划提供信息。 创新和影响：我们的项目是创新的，因为它使用了RD设计来提供因果证据 关于社区护理对门诊护理和处方质量和公平性的影响。该项目是 在关注社会和医疗弱势退伍军人亚群方面也具有创新性和影响力， 包括从全国调查数据中分析社区护理患者体验的差异。通过工作 我们将与运营合作伙伴和退伍军人顾问委员会密切合作，通过以下方式影响退伍军人政策 将调查结果转化为可操作的建议，以改善社区护理，特别是对弱势群体的护理。 具体目标：(1)通过选择和使命确定接受门诊社区护理的影响 质量和公平。(2)确定社区护理对处方质量和公平性的影响。(3) 将退伍军人的经历与弱势群体和其他退伍军人群体的社区护理进行比较。 方法：我们将使用研发设计以及对行政和退伍军人管理局调查数据的分析来评估 选择(所有计划年)和使命(2019-2022年)对退伍军人质量和公平性的影响 医疗保健。AIMS 1-2将使用准试验性RD设计，将上面的退伍军人与下面的退伍军人进行比较 选择和使命中退伍军人社区护理的距离和旅行时间资格阈值。我们会研究 社区护理使用对整体质量的影响，以及评估对公平的影响，在弱势群体中 由存在严重精神疾病或物质使用障碍、复杂的慢性 条件、低收入和种族/少数民族地位。AIM 1中的结果变量侧重于门诊患者 护理过程(例如，护理的连续性)和与护理协调有关的结果(例如，收治 门诊护理--敏感情况)。AIM 2的结果变量侧重于开出安全性和质量处方 (例如，药物-药物相互作用)、治疗复制和再灌装不依从性。这些分析使用VA 企业数据仓库、规划系统支持小组、医疗保险和计划完整性工具数据。在……里面 目标3，我们将分析退伍军人事务部社区关怀调查(在 社区护理接受者)将患者报告的经历与#年退伍军人的社区护理进行比较 弱势群体与其他退伍军人的对比。目标3中的结果变量包括退伍军人的5个领域 在退伍军人管理局社区护理中具有护理协调、提供者沟通和及时获取的经验。 下一步/执行：通过与社区护理、药房办公室密切合作 福利管理、健康公平办公室和退伍军人咨询委员会，我们将迅速传播我们的 并将其转化为可操作的建议，以提高社区护理的质量和公平性。