Utilization and Health Outcomes for Veterans with Expanded Health Care Accessâ¯

扩大医疗保健服务范围的退伍军人的利用和健康结果

• 批准号: 10844340
• 负责人: TODD H WAGNER
• 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: 2020-07-01 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10844340
• 关键词: Affect; Age; Automobile Driving; Budgets; Caring; Censuses; Communities; Community Healthcare; Correlation Studies; Data; Diagnosis; Disease; Elderly; Eligibility Determination; Ensure; Etiology; Evolution; Future; General Population; Health; Health Insurance; Health Personnel; Health Services Accessibility; Health Services Research; Healthcare; Healthcare Systems; Improve Access; Individual; Insurance Coverage; Investments; Link; Location; Machine Learning; Measures; Medicare; Methodology; Methods; Natural experiment; Outcome; Patients; Persons; Policies; Prevalence; Privatization; Procedures; Provider; Publishing; Quality of Care; Records; Research; Research Methodology; Seminal; Services; Subgroup; Surveys; System; Techniques; Testing; Time; Veterans; Wait Time; Work; design; econometrics; evidence base; gaps in access; health care availability; health care service utilization; improved; innovation; mortality; novel; programs; randomized, clinical trials; satisfaction; treatment effect

Background: Improving access to high-quality care is a top priority for VHA. However, access is difficult to measure, especially in the ever-changing U.S. health care landscape. VHA currently focuses on perceived satisfaction measured from survey questions, or wait times measured with administrative data. The wait time metric has received considerable focus in both the Choice and MISSION Acts, yet experts recognize that wait times are imperfect; they are not only challenging to interpret, but they are rarely available from community providers, hindering any VHA to non-VA comparisons. VHA leaders tasked with implementing the Choice and MISSION Acts desire better evidence-based access measures so they can evaluate their program’s impact. Our inability to measure access threatens the future of VHA as a health care provider. Without new metrics that track gaps or improvements in access, VHA is likely to invest in the wrong initiatives, fueling critics who will argue that privatization will fix the programs Significance/Impact: Our objective is to develop new measures of access. These new measures will provide causal information on gaps in VHA services, while also showing the potential impact that expanded access would have on Veterans’ health. Our study leverages natural experiments in the form of arbitrary administrative rules that enable Veterans to access care outside VHA in the forms of Medicare and VA Community Care (VACC). Veterans close to the rule thresholds are similar, yet some gain access based on the rule, while the others do not. We can leverage this information to understand how this added access changes health care utilization and health outcomes. Our results will be useful to national and local VHA leaders as they grapple with how to best improve access with a limited budget. Innovation: It is not feasible to perform a large-scale randomized clinical trial to find the effect of access on utilization and health outcomes. Correlational studies will miss important confounders, and as everyone knows correlation does not equal causation, which is what VHA leaders need most. Instead, we apply novel econometric techniques to take advantage of natural experiments and find the causal effects of increasing access. The results from this approach can then be used as a measure of access for both VHA and non-VA care. This is directly aligned with HSR&D's priorities on access to care, research related to the MISSION Act, and advancing health services research methods across conditions or care settings. Specific Aims: Aim 1: Find the causal impact of Medicare eligibility on Veteran utilization and health, and identify procedures and diagnosis groups that are most affected. Aim 2: Find the causal impact of VACC on Veteran utilization and health, and find the procedures and diagnoses most affected. Aim 3: Identify subgroup analyses that would give crucial information to VHA leaders. Methodology: In Aims 1 and 2, we will apply an econometric technique called regression discontinuity design. We will gather a near complete census of VHA and non-VA records for all recent Veteran VHA users, allowing for precise claims-based measures of utilization, health, and mortality. In Aim 1, this approach leverages the sharp change in Medicare eligibility that occurs at age 65 to find the effect of Medicare on utilization and health. Aim 2 uses the same approach, but instead of age 65, we use the driving distance rules to find the effect of VA Community Care on utilization and health. For these aims we will examine both overall effects and procedure and diagnosis specific effects. In Aim 3, we take a combined approach of working with operational partners and applying machine learning techniques for heterogenous treatment effects to identify and examine metrics and measures that can be used for policy formation. Next Steps and Implementation: By working with operational partners through Aim 3, we will identify opportunities and barriers to implementing measures and metrics derived from our results. This information will be key to setting policy related to VHA’s evolution into a provider and payer of Veteran care while ensuring that Veterans receive high-quality care in both VHA and non-VA settings.

背景：改善获得高质量护理的机会是VHA的首要任务。然而，很难进入 特别是在不断变化的美国医疗保健领域。VHA目前专注于感知 从调查问题中衡量满意度，或用行政数据衡量等待时间。等待时间 度量标准在《选择法案》和《使命法案》中都受到了相当大的关注，但专家们认识到， 时代是不完美的;它们不仅难以解释，而且很少能从社区获得 提供者，阻碍任何VHA到非VA比较。VHA领导人负责实施选择， 使命法案希望更好的基于证据的访问措施，使他们能够评估他们的计划的影响。 我们无法衡量访问威胁到VHA作为医疗保健提供者的未来。如果没有新的指标 跟踪访问的差距或改善，VHA可能会投资于错误的举措，助长批评谁会 我认为私有化将解决该计划的重要性/影响：我们的目标是制定新的措施， 的访问。这些新措施将提供有关VHA服务差距的因果信息，同时还显示 扩大准入对退伍军人健康的潜在影响。我们的研究利用自然 以任意行政规则的形式进行的实验，这些规则使退伍军人能够在VHA之外获得护理， 医疗保险和VA社区护理（VACC）。接近规则阈值的退伍军人是相似的，然而， 有些人根据规则获得访问权限，而另一些人则没有。我们可以利用这些信息来了解 这种增加的访问如何改变卫生保健利用和健康结果。我们的研究结果将有助于 国家和地方VHA领导人，因为他们努力解决如何以有限的预算最好地改善访问。 创新：进行大规模随机临床试验来发现接入对 利用和健康结果。相关性研究会遗漏重要的混杂因素， 相关性不等于因果关系，这是VHA领导者最需要的。相反，我们应用新的 经济计量技术，利用自然实验，并找到因果关系的影响，增加 access.这种方法的结果可以用作VHA和非VA的访问措施 在乎这与HSR&D在获得护理、与《使命法案》相关的研究、 以及推进各种条件或护理环境下的卫生服务研究方法。具体目标：目标1： 找出医疗保险资格对退伍军人利用和健康的因果影响，并确定程序和 最受影响的诊断组。目标2：找出VACC对退伍军人利用率的因果影响， 健康，并找到最受影响的程序和诊断。目标3：确定亚组分析， 向VHA领导人提供重要信息。方法：在目标1和2中，我们将采用计量经济学方法， 这就是所谓的回归不连续设计。我们将收集一个接近完整的人口普查VHA和非VA 所有最近VHA用户的记录，允许精确的基于索赔的利用率、健康状况和 mortality.在目标1中，这种方法利用了65岁时医疗保险资格的急剧变化， 发现医疗保险对利用率和健康的影响。目标2使用相同的方法，但不是65岁，我们 运用行车距离法则探讨退伍军人社区照顾服务对使用及健康的影响。为了这些目标 我们将检查整体效果以及程序和诊断的具体效果。在目标3中，我们采取 与运营伙伴合作并应用机器学习技术的综合方法， 不同的治疗效果，以确定和检查可用于政策的指标和措施 阵后续步骤和实施：通过与运营伙伴合作实现目标3，我们将 确定实施从我们的结果中得出的措施和指标的机会和障碍。这 信息将是制定与VHA演变为退伍军人护理提供者和支付者相关政策的关键 同时确保退伍军人在VHA和非VA环境中获得高质量的护理。