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2019 HSR&D/QUERI National Conference Abstract

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1054 — Potential Overuse of In-Laboratory Sleep Studies in the VA Community Care Program

Lead/Presenter: Lucas Donovan,  COIN - Seattle/Denver
All Authors: Donovan LM (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle), Coggeshall SS (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle), Spece LJ (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Griffith MF (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Palen BN (VA Puget Sound Health Care System; University of Washington, Seattle) Parsons EC (VA Puget Sound Health Care System; University of Washington, Seattle) Todd-Stenberg JA (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Glorioso TJ (Center of Innovation for Veteran-Centered & Value-Driven Care, Denver) Carey EP (Center of Innovation for Veteran-Centered & Value-Driven Care, Denver) Feemster LC (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Zeliadt SB (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle) Kirsh S (Office of Veterans Access to Care) Au DH (Center of Innovation for Veteran-Centered & Value-Driven Care, Seattle)

Objectives:
In 2014, VA introduced the Choice program in response to an access crisis. Although VA had an existing Fee-Basis process that had established relationships to provide community services for Veterans, Choice was managed by third party administrators who did not have historical relationships with VA. Evaluation of the Choice program raised questions not only on the effectiveness and quality of care, but also the value of care provided in the community. While testing for sleep apnea historically relied on in-laboratory polysomnography, home sleep testing is preferred by Veterans, provides equivalent outcomes but at substantially reduced cost (~74% lower costs per test). We sought to compare use of home sleep testing by VA, Fee-Basis and Choice sleep providers.

Methods:
We identified Veterans without contraindications to home sleep studies who completed sleep testing. We chose to examine the period between 2015 and 2016, which corresponded with the transition period from Fee-Basis to Choice for sleep referrals. We identified performance of home testing versus in-laboratory polysomnography using CPT codes. and compared relative use of home testing between VA, Fee-Basis and Choice providers. We used multiple logistic regression to adjust for potential confounders (demographics, comorbidities, and distance from VA Medical Centers). We estimated differences in sleep testing costs using Medicare reimbursement rates.

Results:
We identified 157,676 Veterans who underwent sleep testing with 71.8% having studies within VA, 19.9% with Fee-Basis, and 8.3% through Choice. VA providers consistently utilized home sleep studies (37.7%) over Fee Basis (19.0%) and Choice (4.1%) providers. Results were consistent in multivariable models (Fee-Basis to VA RR 0.50, 95%CI: 0.26-0.75; Choice to VA RR 0.11, 95%CI: 0.05-0.17). Every 100 Veterans referred to Fee-Basis or Choice represented an additional $8,832 (95%CI: $8,587-9,076) and $15,814 (95%CI: $15,603-16,024) costs for VA respectively.

Implications:
Community providers preferentially use sleep testing modalities that generate higher service costs, a practice that appears to have been exacerbated with third party relationships in the Choice program.

Impacts:
As VA engages with new legislation that expands community access, VA will need to not only monitor quality, but also value in community services. VA should develop community payment models that reward high quality value-based practices.