A Synthesis of the Evidence: Interventions to Improve Veterans' Access to Care
Access to healthcare has been identified as a critical issue, both by VA and the larger medical community. Historically, VA adopted the concept of access as an individual's ability to obtain the healthcare they needed within an appropriate time frame. Recently, VA researchers have begun to develop an updated concept of access that takes into account the impact of new technology and places a greater focus on outcomes beyond increased access. Specifically, the new concept acknowledges post-access outcomes such as satisfaction, symptom levels, and functioning.
Investigators at the VA Evidence-Based Practice Center in Minneapolis conducted a literature review of articles published in peer-reviewed journals from 1990 to June, 2010 to help answer two key questions regarding access to healthcare for Veterans.
Question #1: What is the evidence that variation in Veterans' ability to obtain needed healthcare (i.e., access) contributes to variation in system-level (i.e., utilization, satisfaction) or patient-level outcomes (i.e., quality of life, mortality)?
Associated question: Does the effect of access on system- and/or patient-level outcomes differ by patient, treatment, or setting?
Answer: Investigators identified 23 studies that focused on the association between access and system-level or patient-level outcomes. Most commonly studied was the association between distance from a VA facility and healthcare use, primarily outpatient or mental health services use. Fair to good evidence was found suggesting that increased distance from a VA facility was associated with decreased healthcare use. The greatest decrease was noted for distances up to 60 miles, with little change beyond. Distance, ability to pay for care, and comorbid conditions also influenced the use of inpatient care, including choice of VA or non-VA facilities. For example, many studies reported increased VA care and use of VA care rather than non-VA care by homeless Veterans. In addition, limited evidence was found that increased distance from a VA facility (one study) and longer wait times (one study) were associated with increased mortality.
Question #2: What interventions have been successful in improving access for patient populations with reduced healthcare access? [Interventions were categorized as: Community-Based Outpatient Clinics, Mental Health Integration into Primary Care, Intensive Case Management, Telehealth, Outreach, Co-Payments, and Other.]
Associated questions: Have interventions that have improved healthcare access led to improvements in system-level and patient-level outcomes?
Answer: Investigators identified 26 articles (24 unique studies, including 5 randomized trials) that examined the efficacy of interventions to increase access. The majority of studies that reported satisfaction found that Veterans were more satisfied with care following the different interventions to improve access. Six studies reported patient-level outcomes: three found that improving access did not affect outcomes and one found that Veterans with increased access had worse outcomes. Fair strength of evidence was found that suggests increases in medication co-payments decreased access/adherence to needed medications.
Overall, the data indicate that it is possible to improve access to healthcare, although none of the evidence supporting the efficacy of any one intervention was rated as high-quality. Investigators suggest that future research focus on the quality and appropriateness of care and patient-level outcomes.
To view the full report, go to http://www.hsrd.research.va.gov/publications/esp/.
This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.
Reference: Kehle S, Greer N, Rutks I, and Wilt T. Interventions to Improve Veterans' Access to Care: A Systematic Review of the Evidence. VA-ESP Project #09-009;2011.
To view the full reports, go to http://www.hsrd.research.va.gov/publications/esp/.
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