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CRE 12-008 – HSR&D Study

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CRE 12-008
Evaluation of Quality and Coordination of Outsourced Care for Women Veterans
Lori Anne Bastian MD MPH
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: March 2013 - September 2017

BACKGROUND/RATIONALE:
While the number of women Veterans utilizing VA care is rising, many specialized, gender-specific services (e.g. mammography and prenatal care) are not available within the VA. In these instances, federal law enables the VA to pay for Veterans' care at outside facilities when the VA does not offer needed care or on an emergency basis when travel to a VA site would not be feasible. Despite increasing numbers of women Veterans relying on outsourced care for gender-specific services, little is known about the quality of non-VA care, perceptions and experiences of women Veterans who utilize such care, or the experiences of VA providers coordinating care.

OBJECTIVE(S):
The purpose of our study is to understand providers' and fee basis managers' strategies for provision, coordination, and quality oversight of outsourced care, and to assess perceptions and experiences with non-VA care among women Veterans. Follow-up of abnormal mammograms will be used as a case example in Aim 3 for evaluating gender-specific non-VA care.

- Aim #1: To understand providers' and fee basis managers' strategies for provision, coordination, and quality oversight of non-VA care.
- Aim #2: To understand perceptions and experiences with non-VA care among women Veterans.
- Aim #3: Evaluate the quality of gender-specific services for women Veterans using a case example mapped to VHA Handbook priorities (e.g., Do VA facilities utilizing non-VA care for mammography meet key quality standards compared to VA facilities providing in-house mammograms?)

METHODS:
Aims 1 and 2 will use a qualitative approach to examine perceptions and experiences with non-VA care access, provision, and coordination. Specifically, we will use the Women's Health Evaluation Initiative Database (WHEI) to ascertain the top 24 VA sites nationally for non-VA care referrals for women Veterans and to identify women Veterans from each of those facilities that received non-VA care over the past two fiscal years (FY10-FY12). Veterans will be sent letters to participate and we will conduct telephone interviews with a random sample of 6-8 women Veterans from each facility. We will interview women's health providers and fee basis managers from the 24 facilities to understand their perceptions and experiences with non-VA care. We will transcribe interviews and develop a top-level codebook with both women Veterans and VA staff to examine perceptions, experiences, and recommendations for improving non-VA care.
Aim 3 is a retrospective electronic medical chart review. We will use VINCI to pull administrative data including CDW, DSS, TIU text notes, Vital Status, and CAPRI/VistAWeb access to identify women (ages 40-74) at 8 sites with either non-VA or on-site mammograms in FY12. For FY12, we use chart reviews to evaluate whether: (1) results of mammograms were appropriately acknowledged in the patient's medical record, and (2) identified abnormal mammograms received appropriate and timely follow-up. We define abnormal mammogram results, using the existing Breast Imaging Reporting and Data System Atlas (BI-RADS) scoring system, as BI-RADS categories of 0 (indeterminate), 4 (suspicious for cancer), and 5 (highly suspicious for cancer) and we will also examine medical follow-up for BI-RADS 3 (probably benign).
Once we have confirmed the accuracy of FY12 CDW data, using chart reviews, we will use the terminology and coding we learned from FY12 to pull mammography records and subsequent follow-up imaging from FY13-FY16 using electronic CDW data only.

FINDINGS/RESULTS:
A total of 150 Women Veterans completed phone call interviews about their experience with non-VA care from 13 sites (Aim 2). We completed 15 provider interviews (Aim 1). Four major themes arose in the study: (1) Women Veterans felt responsible for their own care coordination with Veterans Choice Program (VCP) providers; (2) VCP care results are not shared with women Veterans or their VA providers in a timely manner; (3) Mounting unpaid VCP bills led many women to go into 'collections', and (4) Women's perceptions of VA and non-VA care quality varied substantially. In Aim 3, we have identified 34,918 completed mammogram requests between FY12-FY16. Median follow-up time for abnormal mammograms was 11.4 days for on-site mammography compared to 10 days for non-VA mammography; yet, there was also variability between the 8 sites as well. BI-RADS scores were missing in 10% of electronic records and BI-RADS 0 scores ranged from 10-15% depending on year and site. In our chart reviews of FY12 data, we found on-site mammography was more likely to report BI-RADS scores, document patient notification, and notify women more quickly of abnormal results than non-VA sites. On the other hand, non-VA sites were more likely to meet guidelines for timely follow-up (90% of women receive follow-up testing in 30 days).

IMPACT:
Decisions regarding use of non-VA care (including fee basis and contract care) are made and monitored almost entirely within each VA facility (i.e., virtually no centralized oversight). Given that the use of non-VA care is increasing within the VA system due to the Choice Act, understanding the provision, coordination, and perceived quality of this type of care is of utmost importance as the VA continues to understand how to provide the best comprehensive health care for women Veterans.

PUBLICATIONS:

Journal Articles

  1. Mattocks KM, Yano EM, Brown A, Casares J, Bastian L. Examining Women Veteran's Experiences, Perceptions, and Challenges With the Veterans Choice Program. Medical care. 2018 Jul 1; 56(7):557-560.
  2. Mattocks KM, Mengeling M, Sadler A, Baldor R, Bastian L. The Veterans Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs. Medical care. 2017 Jul 1; 55 Suppl 7 Suppl 1:S71-S75.
  3. Bastian LA, Mattocks KM, Rosen AK, Hamilton AB, Bean-Mayberry B, Sadler AG, Klap RS, Yano EM. Informing policy to deliver comprehensive care for women veterans. Medical care. 2015 Apr 1; 53(4 Suppl 1):S1-4.
  4. deKleijn M, Lagro-Janssen AL, Canelo I, Yano EM. Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel. Medical care. 2015 Apr 1; 53(4 Suppl 1):S156-64.
  5. Yano EM. A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE. Medical care. 2015 Apr 1; 53(4 Suppl 1):S10-4.
  6. Mattocks KM, Frayne S, Phibbs CS, Yano EM, Zephyrin L, Shryock H, Haskell S, Katon J, Sullivan JC, Weinreb L, Ulbricht C, Bastian LA. Five-year trends in women veterans' use of VA maternity benefits, 2008-2012. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2014 Jan 1; 24(1):e37-42.
Online News Media Articles

  1. Yano EM. VA researchers, clinicians and policymakers partner to help women Veterans. VAntage Point: Official Blog of the U.S. Department of Veterans Affairs [Internet]. 2015 Apr 7. Available from: http://www.blogs.va.gov/VAntage/18744/va-researchers-clinicians-and-policymakers-partner-to-help-women-veterans/.
Reports

  1. Frayne SM, Phibbs CS, Friedman SA, Saechao F, Berg E, Balasubramanian V, Bi X, Iqbal S, Mattocks K, Haskell S, Zephyrin L, Whitehead E, Hayes PM. Sourcebook, women veterans in the Veterans Health Administration (VHA), Volume 2. Sociodemographics and Use of VHA and Non-VA Care (Fee). Washington, DC: Women Veterans Health Strategic Health Care Group, Veterans Health Administration, Department of Veterans Affairs; 2012 Oct 1. 72 p.
Government Briefings

  1. Yano EM. VA's Research Efforts on Women Veterans. Panelist Briefing at Capitol Hill Lunch and Learn Event on Women Veterans. In Response to "Women Veterans: The Journey Ahead," a Report from Disabled American Veterans (DAV): Briefing before the members and staffers of the US Congress; 2018 Sep 12; Capitol Hill Visitor Center, Washington DC.
  2. Yano EM. Advances in Women Veterans Research: Briefing before the National Association of State Women Veteran Coordinators; 2018 Jun 25; Alexandria, VA.
  3. Yano EM. VA Research Day on the Hill: Briefing before the members and staffers of the US Congress; 2018 Jun 19; Washington, DC.
  4. Haskell S, Yano EM. Veterans Health Research: A Focus on Women: Briefing before the US Congress; 2016 Feb 22; Washington, DC.
Conference Presentations

  1. DeRycke EC, Bastian LA. Smoking status and pain levels among OEF/OIF/OND Veterans. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2015 Apr 15; San Antonio, TX.
  2. Bastian LA. Mammography Care Coordination and Tracking: Current VA Practices and Applications. Poster session presented at: National Women’s Health Field Leaders Training; 2014 Sep 17; Orlando, FL.


DRA: Health Systems
DRE: Diagnosis, Prevention
Keywords: Care Coordination, Models of Care, Organizational Structure, Outcomes - Patient, Outcomes - System, Patient Preferences, Quality of Care, Rural
MeSH Terms: none