Impact of the MISSION Act on Quality and Outcomes of Interventional Cardiology and Cardiac Surgery among Veterans

背景：退伍军人事务部维护内部制度和加强整合的实施 2019年6月颁布的《外部网络(传教)法》大大增加了退伍军人被转介的机会 在退伍军人健康管理局(VHA)之外，用于复杂的心脏手术和手术。然而， 退伍军人管理局在介入心脏病学和心脏外科质量方面一直处于全国领先地位。 关心。因此，在退伍军人管理局之外增加转诊可能会降低退伍军人经历 心脏手术得到了最高的护理质量和最好的手术结果。 意义/影响：随着越来越多的退伍军人现在根据《使命法》有资格获得 除退伍军人外的主要心脏手术，对于退伍军人、他们的退伍军人提供者和退伍军人来说至关重要 行动领导人充分了解退伍军人在获得医疗服务方面的选择的后果， 医疗质量、医疗结果和医疗成本。退伍军人事务部社区关怀计划的总成本为 因此，退伍军人管理局必须最大限度地发挥社区护理资金的价值。 创新：拟议的研究将扩展先前比较退伍军人管理局和社区护理提供的研究 主要心脏手术，特别侧重于《使团法》的影响，该法案有可能 大大增加退伍军人在退伍军人管理局以外接受护理的人数。我们的研究将提供新的见解 退伍军人如何通过健康信息更好地在退伍军人管理局和非退伍军人管理局之间做出选择 护理质量和护理结果，从而加强决策过程。我们的成本分析将确定 退伍军人管理局和非退伍军人管理局之间更好的护理协调可以改善两者的潜在机会 通过消除服务差距和减少重复服务来提供护理的价值。 具体目标：本研究的主要目标是：(A)量化退伍军人和非退伍军人的使用变化 《使命法案》所产生的心脏手术和介入心脏病学服务，重点是如何 获得护理的机会受到影响；(B)衡量执行《使团法》对退伍军人比率的影响 从高质量的医院获得心脏手术和介入心脏病护理，并比较风险- 退伍军人在退伍军人医院接受心脏手术或通过 《使团法》实施后的社区护理；(C)评估《使团法》实施的效果-- 对退伍军人和退伍军人的介入心脏病学和心脏外科护理费用的影响。 方法：这项研究将利用我们研究团队在VA和非VA方面的丰富专业知识 临床、管理和成本数据集。我们将结合退伍军人管理局心脏手术和介入治疗的数据 国家心脏病学登记处，卫生保健利用率、费用和结果数据保存在退伍军人管理局 企业数据仓库，以及退伍军人管理局的社区关怀数据集，如计划完整性工具 数据库。我们将关注接受(1)经皮冠状动脉介入治疗，(2)冠状动脉介入治疗的退伍军人 搭桥术，(3)外科瓣膜置换术，(4)经导管主动脉瓣置换术。这些是 退伍军人中最常见的主要心脏手术之一，有很大的风险 死亡率和发病率以及相关的高额保健费用。我们将评估任务的影响 对退伍军人获得这些程序的机会、医院提供的心血管护理质量采取行动 执行这些程序，护理的结果，以及退伍军人和退伍军人的费用。 实施/下一步：项目的首要目标是证明质量的重要性 和结果信息，以在卫生系统之间做出选择，并确定退伍军人管理局的机会 在社区护理中领导改善护理协调、优化临床结果和降低成本 程序。我们的研究团队将与退伍军人事务部社区办公室的运营合作伙伴密切合作 CARE和退伍军人事务部国家外科办公室共同决定退伍军人事务部社区关怀计划未来的运作。

Background: The implementation of the VA’s Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June of 2019 greatly expanded opportunities for Veterans to be referred outside of the Veterans Health Administration (VHA) for complex cardiac procedures and surgeries. However, the VA has been a longstanding national leader in both interventional cardiology and cardiac surgical quality of care. Hence, increased referrals outside of the VHA may reduce the probability that Veterans undergoing cardiac procedures receive the highest care quality and the best procedural outcomes. Significance/Impact: With increasing numbers of Veterans now eligible under the MISSION Act to obtain major cardiac procedures outside VA, it is critically important for Veterans, their VA providers, and VA operational leaders to fully understand the consequences of Veterans' choices in terms of their access to care, quality of care, outcomes of care, and health care costs. The total costs of VA's Community Care program are substantial; it is therefore essential that VA maximizes the value from funds expended on Community Care. Innovation: The proposed research will extend prior studies comparing VA and Community Care provision of major cardiac procedures with a specific focus on the impact of the MISSION Act, which has the potential to vastly expand the number of Veterans receiving care outside VA. Our research will provide novel insight into how Veterans’ choices between VA and non-VA providers could be better informed by information about health care quality and outcomes of care, thus enhancing the decision-making process. Our cost analysis will identify potential opportunities where better care coordination between VA and non-VA providers could improve both the value of care delivered by eliminating gaps in, and reducing duplication of, services. Specific Aims: The primary objectives of this study are to: (a) quantify the changes in use of VA and non-VA cardiac surgery and interventional cardiology services resulting from the MISSION Act, with a focus on how access to care was affected; (b) measure the effects of MISSION Act implementation on the rates Veterans obtain cardiac surgery and interventional cardiology care from high-quality hospitals, and compare the risk- adjusted post-procedure outcomes among Veterans obtaining cardiac procedures in VA hospitals or via Community Care after the MISSION Act was implemented; (c) assess the effect of MISSION Act imple- mentation on the cost of interventional cardiology and cardiac surgical care to both the VA and to Veterans. Methodology: This study will leverage our research team’s substantial expertise with both VA and non-VA clinical, administrative, and cost datasets. We will combine data from VA’s cardiac surgery and interventional cardiology national registries with health care utilization, cost, and outcomes data housed in the VA’s Corporate Data Warehouse, as well as VA’s Community Care datasets such as the Program Integrity Tool database. We will focus on Veterans undergoing (1) percutaneous coronary intervention, (2) coronary artery bypass grafting, (3) surgical valvular replacement, or (4) transcatheter aortic valve replacement. These are among the most common major cardiac procedures performed among veterans, with substantial risk of mortality and morbidity as well as high associated health care costs. We will assess the impact of the MISSION Act on Veterans’ access to these procedures, the quality of cardiovascular care delivered by the hospitals performing these procedures, the outcomes of care, and the costs to both VA and to Veterans. Implementation/Next Steps: The project's overarching goals are to demonstrate the importance of quality and outcomes information in making choices between health systems, and to identify opportunities for VA leadership to improve care coordination, optimize clinical outcomes, and reduce costs in the Community Care program. Our research team will work closely with our Operational Partners in the VA's Office of Community Care and the VA's National Surgery Office to shape the VA Community Care Program’s future operations.