BACKGROUND/RATIONALE:
Emergency care is a critical but understudied part of the continuum of health care services offered to Veterans by the VA. While the VA is committed to providing timely and high-quality emergency care, surprisingly little is known about Veteran access to acute care or about the quality of care provided. Variations in VA emergency care resources are not well understood and prevent Veterans from making informed choices. Moreover, eligibility for non-VA ED care is confusing, complex and can translate to delays in treatment and poor outcomes. VA estimates that current VA users get, on average, only about 38% of their ED visits from VA, yet no study to date has examined emergency care Veterans receive in non-VA settings. While use of non-VA EDs may sometimes be appropriate, there are other times when the ED care could have been provided at the VA and use of the non-VA ED may result in duplicative care and delays. This dual use matters to the VA because, like an Accountable Care Organization, the VA is still responsible for the overall health of the Veteran and often the expenses even when Veterans receive care outside of the VA.

OBJECTIVE(S):
Objectives of this proposal are: (1) To create survey items that facilitate a comprehensive inventory of VA ED resources and capabilities; (2) to calculate VA and non-VA ED utilization rates and identify the patient, facility, and community-level predictors of VA ED use and VA reliance; and (3) to characterize Veterans' preferences, resources and contextual factors that influence ED setting choice (i.e. VA, non-VA).

METHODS:
We will build on pilot work and convene an advisory panel to create and add survey items to the next ED survey to assess VA ED resources and capabilities and determine how they vary (e.g. region, rurality, complexity). Using an innovative linkage method, we will use VA, Medicare, and California data to examine ED use across groups. Further, we will assess the patient, facility, and community level predictors of Veterans' choice of delivery system and VA reliance. All analyses will be conducted for three cohorts: a national accountable veteran population (Veterans 65+), residents of California (Veterans 65+), and residents of California (Veterans 18-64). Finally, we will conduct semi-structured interviews with Veterans to better understand why Veterans choose to receive their ED care inside or outside the VA.

FINDINGS/RESULTS:
We will determine capabilities of VA EDs nationwide and examine the impact of these factors on VA ED use and reliance. Further by analyzing data and speaking with Veterans, we will better understand where and why Veterans access the acute care system (in both VA and non-VA settings) and will identify barriers in access amendable to future intervention and policy changes.

IMPACT:
Access to ED care for Veterans is poorly understood, fragmented, costly and confusing to Veterans. New VA EM leadership is committed to using our results to make impactful changes in emergency care organization, care provision and resource allocation. Using novel data sources and linkages, and Veteran perspectives, for the first time we can study the complexities of VA and non-VA use of acute care services.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002362-01A2
Link: https://reporter.nih.gov/project-details/9502819

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PUBLICATIONS:

Journal Articles

1. Azevedo KJ, Gray CP, Gale RC, Urech TH, Ramirez JC, Wong EP, Lerner B, Charns MP, Vashi AA. Facilitators and barriers to the Lean Enterprise Transformation program at the Veterans Health Administration. Health care management review. 2021 Oct 1; 46(4):308-318. [view]
2. Vashi AA, Urech T, Carr B, Greene L, Warsavage T, Hsia R, Asch SM. Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization. JAMA Network Open. 2019 Aug 2; 2(8):e198642. [view]
3. Tran LD, Rose L, Urech T, Dalton A, Wu S, Vashi AA. Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System. Annals of surgery. 2021 Jul 1; 274(1):45-49. [view]

DRA: Health Systems
DRE: TRL - Applied/Translational, Treatment - Observational, Treatment - Implementation
Keywords: Care Coordination, Gap Analysis, Organizational Structure, Practice Patterns/Trends
MeSH Terms: none