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

背景：VA维护内部系统和加强综合 2019年6月的《外部网络（使命）法》大大扩大了退伍军人被推荐的机会。 在退伍军人健康管理局（VHA）之外进行复杂的心脏手术。然而，在这方面， VA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， 在乎因此，增加VHA以外的转介可能会降低退伍军人经历 心脏手术得到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有资格根据《使命法案》获得 对于退伍军人、他们的退伍军人提供者和退伍军人来说， 业务领导人充分了解退伍军人在获得护理方面的选择的后果， 护理质量、护理结果和医疗保健成本。VA社区护理计划的总费用为 因此，退伍军人事务部必须最大限度地利用用于社区护理的资金的价值。 创新：拟议的研究将扩展先前的研究，比较VA和社区护理的提供， 主要心脏手术，特别关注《使命法案》的影响，该法案有可能 大幅度增加退伍军人在VA以外接受护理的人数。我们的研究将提供新的见解， 退伍军人如何在VA和非VA提供者之间做出选择， 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 潜在的机会，VA和非VA提供者之间更好的护理协调可以改善两者 通过消除服务中的差距和减少服务的重复来提供护理的价值。 具体目的：本研究的主要目的是：（a）量化VA和非VA使用的变化 心脏手术和介入心脏病学服务产生的使命法案，重点是如何 获得护理受到影响;（B）衡量《使命法案》实施对退伍军人比率的影响 从高质量医院获得心脏手术和介入心脏病学护理，并比较风险- 在VA医院接受心脏手术或通过 （c）评估《使命法》实施后的效果; 对VA和退伍军人的介入心脏病学和心脏外科护理费用进行了分析。 方法：本研究将利用我们的研究团队在VA和非VA方面的大量专业知识 临床、管理和成本数据集。我们将联合收割机的数据从VA的心脏手术和介入 心脏病学国家登记处，其中包含VA中的医疗保健利用、成本和结局数据 企业数据仓库，以及VA的社区护理数据集，如计划完整性工具 数据库我们将重点关注接受（1）经皮冠状动脉介入治疗，（2）冠状动脉 旁路移植术，（3）外科瓣膜置换术，或（4）经导管主动脉瓣置换术。这些是 在退伍军人中最常见的主要心脏手术中， 死亡率和发病率以及相关的高医疗保健费用。我们将评估使命的影响 关于退伍军人获得这些程序的法案，医院提供的心血管护理质量 执行这些程序，护理的结果，以及VA和退伍军人的成本。 实施/后续步骤：该项目的总体目标是证明质量的重要性 在卫生系统之间做出选择的结果信息，并确定VA的机会 领导改善护理协调，优化临床结果，并降低社区护理成本 程序.我们的研究团队将与退伍军人事务部社区办公室的业务合作伙伴密切合作 护理和退伍军人事务部的国家外科办公室，以塑造退伍军人事务部社区护理计划的未来运作。

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.