Veteran Socioeconomic Status: Development and Validation of a Novel Measure to Support a Learning Healthcare System

背景几十年的研究表明，受教育程度低和收入低的人健康状况较差， 获得更少的所需服务，并且通常具有更差的医疗保健结果，即使在患有 全民覆盖。尽管弗吉尼亚州作为一个安全网提供者的作用和公平的承诺，有限的证据， 现有研究表明，较高的社会经济地位（SES）与VA的较好结局相关， 其他地方患者SES也可能影响卫生系统的性能。但这很难追踪，因为 与其他卫生系统一样，退伍军人事务部不定期收集有关收入或其他社会经济状况的信息。 目前，研究和VA分析使用基于VA优先级组或 人口普查数据仅仅是个体SES的粗略近似值。需要有一个更好的衡量标准。 具体目标。本试点研究申请的目的是评估以下方面的潜在价值和局限性 一个新的可用的数据源作为个人层面的代理措施的社会经济地位。次全军 职业能力倾向成套测验（英语：Vocational Aptitude Battery，ASVAB）是一系列在征兵时对新兵进行的测验。 考虑到反映一个人认知能力的能力倾向测试分数与后来的测试分数之间的密切相关性， 生活教育程度，收入和财富，退伍军人的ASVAB结果可能有助于捕获元素 SES的研究，性能测量和其他用途。这项试验性研究的目的是：（1）研究 VA人口覆盖率，代表性和ASVAB数据的质量;（2）使用两种不同的分析方法 子样本和两个收入数据源，a）检查退伍军人的ASVAB分数之间的关系 （b）评估其在入伍时的收入和目前的收入，以及B）评估其代表性。 （3）确定ASVAB分数是否增加了 在解释当前健康和健康行为（功能）的选定措施中的个体差异方面的价值 糖尿病患者的限制、合并症负担、血红蛋白A1 c和吸烟状况）。 意义拟议的研究与HSR&D和VHA的优先事项保持一致：开发新的 成为一个高性能，不断学习的医疗保健系统的测量方法， 医疗保健公平和健康差距，以及改善退伍军人获得护理的机会。更好的个人层面的SES 一项衡量标准在VA中有多种重要用途，包括改进绩效衡量标准， 考虑患者SES和模型的预测能力， 期望、未来的访问和能力。 创新这项研究是高度创新的，因为它创造性地解决了研究的一个主要障碍， 和业绩衡量，以及评估和监测保健服务的公平性， 结局：缺乏患者SES的信息。这项研究利用了一项有希望的新数据 资源ASVAB分数，以前没有评估用于支持退伍军人以后的生活。 方法.人口是2010-2017年使用VA医疗服务的退伍军人。这将是一个回顾 研究使用现有的VA，美国社区调查，和国防部ASVAB数据。老兵 收入数据将来自退伍军人登记者健康和医疗保健年度调查以及退伍军人事务部的 健康资格中心（HEC）。将进行描述性和多变量回归分析。 预期成果。该项目将提供对数据的优势和局限性的理解， 评估可用样本中测量的ASVAB-收入关系是否在 更广泛的VA人群和ASVAB数据将为当前的测量方法提供附加值。 下一步。根据这项工作的结果，我们计划提交一份研究者发起的研究提案 (IIR)根据ASVAB评分制定和评估SES指数，并评估其风险调整价值 在性能测量中。

Background. Decades of research indicates people with less education and lower income have worse health, receive fewer needed services, and often have poorer healthcare outcomes, even in populations with universal coverage. Despite VA's role as a safety-net provider and commitment to equity, the limited evidence available suggests that higher socioeconomic status (SES) is associated with better outcomes in VA, as elsewhere. Patient SES may also influence health system performance. But this is difficult to track because the VA, like other health systems, does not routinely collect information on income or other SES measures. Currently, research studies and VA analyses use indirect proxy measures based on VA priority group or census data that are only rough approximations of individual SES. There is a need for a better measure. Specific Aims. The objective of this pilot study application is to evaluate the potential value and limitations of a newly available data source as an individual-level proxy for measures of SES. The Armed Services Vocational Aptitude Battery (ASVAB) is a series of tests administered to military enlistees at recruitment. Given the close correlation between aptitude test scores, which reflect a person's cognitive ability, and later life educational attainment, income, and wealth, Veterans' ASVAB results may be useful in capturing elements of SES for research, performance measurement, and other uses. The aims of this pilot study are: (1) Examine the VA population coverage, representativeness, and quality of the ASVAB data; (2) Using two distinct analytic subsamples and two income data sources, a) examine relationships between Veterans' ASVAB scores measured at enlistment and their present-day income, and b) assess the representativeness of the subsamples in regard to ASVAB-income relationships; and (3) determine whether ASVAB scores have added value in explaining individual variation in selected measures of current health and health behaviors (functional limitations, comorbidity burden, hemoglobin A1c in those with diabetes, and smoking status). Significance. The proposed research is well-aligned with HSR&D and VHA priorities: developing new measurement approaches for becoming a high-performing, continuously learning healthcare system, healthcare equity & health disparities, and improving Veterans' access to care. A better individual-level SES measure would have multiple important uses in VA, including in improving performance measurement to take patient SES into account and the predictive ability of models determining resource allocation, productivity expectations, and future access and capacity. Innovation. This study is highly innovative because it creatively addresses a major barrier to research, quality and performance measurement, and assessment and monitoring of equity in healthcare access and outcomes: lack of information on patient SES. The study does so by taking advantage of a promising new data resource—ASVAB scores—that was not previously evaluated for use to support Veterans later in life. Methods. The population is Veterans using VA healthcare services in 2010-2017. This will be a retrospective study using existing VA, American Community Survey, and Department of Defense ASVAB data. Veteran income data will come from the Annual Survey of Veteran Enrollees' Health and Healthcare and the VA's Health Eligibility Center (HEC). Descriptive and multivariable regression analyses will be conducted. Expected Results. This project will provide an understanding of the strengths and limitations of the data and evidence to assess whether the ASVAB-income relationships measured in available samples will hold in the broader VA population and ASVAB data will provide value-added to current measurement approaches. Next Step(s). Based on the results of this work, we plan to submit an Investigator-Initiated Research proposal (IIR) to develop and evaluate an SES index based on ASVAB scores and assess its value for risk adjustment in performance measurement.