Assessing Quality of VA and Community Care in the MISSION Era

背景：为了改善退伍军人获得及时服务的目标，《使命法案》正在改变 VA从一个紧密集成的系统到一个更加“分散”的系统， 现在由社区提供者提供访问。使用VA购买的社区护理（VA-CC）可以 改善退伍军人的获得，但也可能增加护理的分散，可能导致延误， 冗余和不太协调的治疗计划。虽然之前的多项研究表明， VA相对于社区护理（CC）的优势，我们对碎片化将如何 影响护理的及时性和质量，特别是对于癌症护理等高风险情况。 意义：分散的护理是癌症患者面临的一个常见、严重和紧迫的问题。这 一项研究，这是响应几个HSR&D研究的优先事项，将审查癌症护理的质量后， 选择和使命的机构，协调VA-CC的努力是否成功， 维持可衡量的质量，以及将其护理分为以下两类的患者的质量风险程度： 系统.我们的VA合作伙伴和退伍军人可以使用结果来了解质量的变化和缺陷。 创新与影响：该项目侧重于护理系统以及质量的潜在风险和收益 当政策激励跨系统移动时，并制定可用于监控的措施 并有针对性地努力改变实践，提高退伍军人在所有环境中接受的癌症护理质量。 主要产品：1）VA提供的和VA购买的CC的癌症护理质量报告; 2） 与VA签订合同的社区中的供应商相对于地理上邻近的供应商的质量 3）一套准备实施的癌症质量措施和确定为 （4）一套需要进一步测试和发展的措施; 和5）方法，以加强在VA和非VA设置的执行。 具体目标：1。调整和扩展一套旨在评估癌症的声明和基于登记的措施 在VA内使用的美国国家卫生系统的护理质量; 2.比较退伍军人癌症护理的质量 从在综合系统中接受癌症护理的人到在综合系统中接受更分散护理的人， 系统，并检查关键预测变量之间的测量性能差异;以及3.进行 利益相关者专家小组（SEP）推荐一套癌症绩效衡量标准，用于跟踪 VA和/或非VA环境中的癌症护理以及近期实施议程。 方法：我们将在VA数据中实施先前设计的基于索赔的癌症护理措施 并扩展度量集（具有附加的前列腺癌度量）。我们将比较质量措施 64岁以上退伍军人的表现：1）仅接受VA提供的护理vs.接受任何VA购买的CC;以及 2）主要依赖VA护理与依赖VA和医疗保险。(Data对于这些分析 包括：VA CDW、VA PIT/购买的护理和VA-CMS。）我们还将使用CMS数据检查质量 所有64岁以上的患者在与VA签订合同的情况下， 为在同一医院转诊区域内非合同诊所就诊的患者提供社区癌症护理。 最后，我们将检查关键患者和系统预测变量之间的测量性能差异。 通过利益攸关方专家小组，我们将确定措施的优先次序，评估现有措施的差距， 填补这些差距的潜在措施，并建议执行办法。 下一步/执行：通过咨询理事会和利益攸关方专家小组的工作， 涉及VA和非VA专家，我们将创建一个多步骤的过程， 研究产品。通过让决策者参与决策过程， 可执行和可持续。

Background: With the goal of improving Veteran access to timely services, the MISSION Act is shifting the VA from a tightly integrated system to one that is more “dis-integrated,” with a substantial number of specialty visits now provided by community providers. The use of VA-purchased community care (VA-CC) could improve access for Veterans, but could also increase fragmentation of care, potentially resulting in delays, redundancies, and less coordinated treatment plans. While multiple previous studies have shown a quality advantage for VA relative to community care (CC), we have little understanding of how fragmentation will impact timeliness and quality of care, especially for high-risk conditions such as cancer care. Significance: Fragmented care is a common, serious, and urgent problem for individuals with cancer. This study, which is responsive to several HSR&D research priorities, will examine the quality of cancer care after the institution of CHOICE and MISSION, whether the efforts to coordinate VA-CC are successful in maintaining measured quality, and the degree of risk to quality for patients who divide their care between systems. Results can be used by our VA partners and Veterans to understand variation and deficits in quality. Innovation & Impact: This project focuses on systems of care and the potential risks and benefits to quality when policy incentivizes movement across systems, and develops measures that can be used for monitoring and targeting efforts to change practice and improve cancer care quality received by Veterans in all settings. Key products: 1) a report of cancer care quality across VA-delivered and VA-purchased CC; 2) an assessment of quality for providers in the community who contract with VA relative to geographically proximate providers who do not; 3) a set of cancer quality measures ready for implementation and new measures identified as appropriate targets for future implementation; 4) a set of measures requiring further testing and development; and 5) approaches to enhance implementation in VA and non-VA settings. Specific Aims: 1. Adapt and extend a set of claims and registry-based measures designed to assess cancer care quality in national US health systems for use within VA; 2. Compare the quality of cancer care for Veterans who receive their cancer care within an integrated system to those receiving more fragmented care across systems, and examine differences in measure performance across key predictor variables; and 3. Conduct a Stakeholder Expert Panel (SEP) to recommend a cancer performance measurement set for tracking quality of cancer care in VA and/or non-VA settings and an agenda for near term implementation. Methodology: We will operationalize previously designed claims-based measures of cancer care in VA data and extend the measure set (with additional prostate cancer measures). We will compare quality measure performance for Veterans over 64: 1) Receiving VA-delivered care only vs. receiving any VA-purchased CC; and those 2) Predominantly reliant on VA care vs. reliant on both VA and Medicare. (Data for these analyses includes: VA CDW, VA PIT/purchased care, and VA-CMS.) We will also examine, using CMS data, if quality measure performance is similar for all patients over 64 attending practices under contract with VA to provide community cancer care to patients attending non-contracted practices within the same hospital referral region. Finally, we will examine differences in measure performance across key patient and system predictor variables. Through a Stakeholder Expert Panel, we will prioritize measures, assess gaps in the current measure set and potential measures to fill those gaps, and recommend approaches for implementation. Next Steps/Implementation: Through the work of the Advisory Council and Stakeholder Expert Panel, which involve both VA and non-VA experts, we will create a multi-step process for dissemination of the research products. By engaging policy makers in the process of decision making, the results will be more implementable and sustainable.