VHA has the most extensive tracking and reporting system of any health care system in the country. However, Veterans are increasingly receiving care by non-VHA providers, creating challenges for this tracking and monitoring system. VHA must develop methods to identify, prioritize, and track care in both VHA and non-VHA settings in order to ensure Veterans continue to receive appropriate care.
Providing appropriate health care means ensuring that patients get the care they need while avoiding care that is unnecessary or harmful. Previously, there was focus on increasing the use of necessary services. Today, there is growing national interest in identifying and reducing overuse - care that exposes patients to services that are not beneficial or may cause harm and which may take scarce resources away from those who would benefit from them. The appropriateness of this care extends not just to clinical processes but also to care experiences (e.g., access, continuity, coordination).
1. Identify and prioritize measures of underuse and overuse relevant to the Veterans Choice Act (VCA) [Aim 1]
2. Assess the use of existing and non-VHA data sources to evaluate quality of care for VCA users [Aim 2a/2b]
3. Identify areas of importance to Veterans with respect to access, continuity, and coordination [Aim 3]
Aim 1: In this aim, we assembled an expert council comprised of national VHA clinical and policy leaders to identify clinical areas most important to current and future VCA participants. Council members identified fifteen clinical areas and then prioritized these based on improvement opportunity and feasibility of measurement. Project staff conducted a rapid, high-level environmental scan to identify measures, guidelines, and recommendations related to the top eight clinical areas. Using a modified Delphi panel process, council members rated the measures, guidelines, and recommendations on validity/importance, feasibility of measurement, and improvement opportunity.
Aim 2a: To better understand the accuracy of medications in VA automated data (i.e., in CDW - including VHA and non-VHA medication fields), we conducted a brief phone survey with 100 VHA patients with diabetes who had an outpatient visit between 10/1/14-3/31/15 either within VHA or outside VHA as part of VCA. Additionally, non-VHA scanned records from 260 patients with diabetes who had a VCA or fee-basis outpatient encounter for diabetes care between 10/1/14-6/30/15 were reviewed to assess the feasibility of using those scanned records to evaluate the quality of care that Veterans are receiving in the community. Medications on these scanned records were compared with medications in CDW.
Aim 2b: In this aim, we developed a script and tested an interactive voice response (IVR) approach for collecting treatment outcomes to allow outcome-based quality measurement of Veterans' depression care. One hundred patients, from VISN 11, with newly diagnosed depression were mailed an invitation to participate. Baseline calls, via IVR, were made to those who did not opt out.
Aim 3: To identify measures of patient satisfaction with care coordination and access, we completed a review of existing survey items. Domains found to be most relevant to the VCA were used to inform questions for an interview guide. Ten semi-structured patient interviews were conducted to determine if domains emerged that were not well covered by existing survey items. The final list of domains was used to inform the content of a day-long deliberative consensus-oriented session. Twenty-three Veterans participated in the session to identify factors that likely influence their desire to use non-VHA care and factors that lead to greater satisfaction with access, continuity, and care coordination.
Aim 1: The eight clinical areas prioritized by the expert council included [diagnosis, treatment, and/or screening/surveillance] for: Back pain, Cardiac testing, Diabetes, GI procedures, Headaches, Hepatitis C, Prostate Cancer, and PTSD. Within these areas, 29 measures/guidelines/recommendations [8 VHA measures/guidelines; 7 NQF-endorsed measures; 11 Choosing Wisely recommendations; 3 other] were rated as highly valid/important for patients receiving care in the community.
Aim 2a: 22% of phone survey respondents reported taking medications prescribed by a non-VHA provider that were not in the CDW (VHA or non-VHA medication fields). Comparing the medications found on the non-VHA scanned records with medications in CDW revealed that 15% of patients had at least one diabetes medication on a scanned record that wasn't in CDW. The percentage was the same for statins (15%) and higher for blood pressure medications (25%).
Aim 2b: Thirty-five patients provided baseline depression data via IVR. Respondents reported a mean PHQ-9 (Patient Health Questionnaire depression scale) score of 11.9; scores ranged from 0 (no depressive symptoms) to 27 (severely depressed).
Aim 3: During the interviews, two new care coordination domains emerged: 1) Burden that falls on the patient and family to ensure care coordination; 2) Effort required and resulting stress to determine financial responsibility. During the deliberative sessions, Veterans recommended that "condition severity" be a criterion for deciding whether Veterans should get care in the community; this included consideration of clinical necessity for getting care in the community and burden taken on by the Veteran to get care at VHA. After deliberation, Veterans favored funds to strengthen VHA (building) rather than increasing payment for care in the community (buying).
The approach developed in Aim 1 to identify and prioritize quality measures for VCA could be used by VHA for identifying and prioritizing other quality measures. Additionally, for those areas where an improvement opportunity is confirmed, the measures/recommendations could soon be implemented as quality tracking measures for Veterans receiving care in the community.
Our findings from Aim 2 suggest that in order to accurately evaluate quality of care for Veterans receiving care in the community non-VHA prescribed medications need to be better documented in CDW. Additionally, this aim demonstrated that it is feasible to use IVR to collect outcomes from patients receiving care in the community; with slight modifications to increase the response rate (e.g., an initial live person contact), the IVR technology could be adapted for operational use across VHA for essentially any patient-reported outcome.
The information gathered in Aim 3 could be used by VHA to guide development of new survey measures related to care coordination and access.
- Quinn M, Robinson C, Forman J, Krein SL, Rosland AM. Survey Instruments to Assess Patient Experiences With Access and Coordination Across Health Care Settings: Available and Needed Measures. Medical care. 2017 Jul 1; 55 Suppl 7 Suppl 1:S84-S91.
HSR&D or QUERI Articles
- Saini SD, Hofer TP, Kerr EA. Measuring Quality of Care in the Era of Veterans' Choice. HSR&D FORUM. 2016 Aug 1.
- Rosland A. VCA Patient-Centered Access and Coordination Measures Tool. Ann Arbor, MI: VA Center for Clinical Management Research; 2015 Nov 1.