Abstract

1 Background: Specialty care deserts—the absence of specialists in geographic regions—have led to an access 2 crisis for the VA. In addition to increasing wait times and causing delays in care, these access needs drive many 3 Veterans to seek care outside VA, resulting in fragmented care, increased risks for hospitalization and hospital 4 readmission, and higher costs. In response, VA has launched the Clinical Resource Hub (CRH) program, which 5 seeks to deliver virtual care from “hub” to “spoke” sites in VA. VISN 21 has begun implementing this model in 6 cardiology at several spoke sites, but little is known about how care utilization and quality within the program. 7 Significance/Impact: This work seeks to better understand the effects of a virtual model of specialty care, in 8 this case cardiology care, on Veterans’ care access and quality. In addition, it aligns closely with several VA and 9 HSR&D priorities, chiefly access to care, virtual care/telehealth, and advancing the goals of the MISSION Act. 10 Innovation: The CRH program and the virtual care model at its core have yet to be studied in depth, and there 11 is no research in progress regarding specialty CRH despite strong interest at the national VA level in 12 understanding how specialty CRH is used and associated outcomes. Given that virtual cardiology care was very 13 limited prior to the COVID-19 pandemic, cardiology CRH is particularly novel. Hence, this project would add to 14 the limited body of research examining virtual cardiology care in the VA. In addition, the proposed work seeks to 15 evaluate this virtual care model at a time of unprecedented choice for Veterans between in-person and virtual 16 care, and limited data on how best to integrate these modalities. 17 Specific Aims: The proposed CDA will offer mentorship and training for me to pursue the following aims: 18 Aim 1. Evaluate quality of cardiology care associated with CRH implementation with administrative data. 19 I will use adjusted difference-in-difference event studies to compare cardiology quality metric achievement for 20 patients who received cardiology care via CRH versus those who received conventional VA-based cardiology care. 21 Aim 2. Assess Veteran perceptions of quality of cardiology care delivered via CRH. 22 I will interview Veterans participating in the CRH program and their caregivers regarding their experiences and 23 perceptions of quality of CRH cardiology care and elicit suggestions for key metrics to focus on for improvement. 24 Aim 3. Construct intervention to track and improve access to high-quality, equitable care through CRH. 25 Building on finding from Aims 1 and 2, I will interview clinicians and employ a facilitated deliberative process with 26 an expert advisory group to construct and pilot an intervention to improve quality. 27 Methodology: In Aim 1, I will use a difference-in-difference event study design to assess the impact of the program 28 on a battery of validated and/or guideline-based quality of cardiology care metrics. In Aim 2, guided by the Fortney 29 model of care access and quality, I will conduct semi-structured interviews of Veterans and caregivers receiving 30 care through the VISN 21 CRH program to understand their experiences with the CRH program and what outcomes 31 they recommend to include in a quality improvement intervention. In Aim 3, I will interview clinicians (Aim 3.1) and 32 conduct a facilitated deliberation process (Aim 3.2) to inform the construction of an intervention (proactive panel 33 management using a clinical dashboard tool) to track and improve quality of care and pilot the intervention. 34 Next Steps/Implementation: To continue moving this research into practice to improve health outcomes for 35 Veterans, I will extend the analysis of cardiology quality of care to compare cardiology care in the community to 36 CRH care. In addition, I will assess the effect of the intervention constructed in Aim 3 on patient outcomes and 37 clinician satisfaction via a hybrid implementation-effectiveness trial. I will continue to work with operational partners 38 to ensure cardiology CRH is improving access to high-quality cardiology care for Veterans. This project supports 39 my goal of becoming an independent VA health services researcher and leader in optimizing cardiovascular 40 disease care access, value, and equity for Veterans through virtual care innovations and implementation.

NIH Reporter Project Information: https://reporter.nih.gov/project-details/10999287


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