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IIR 21-036 – HSR Study

IIR 21-036
Leveraging a natural experiment to identify the effects of VA community care programs on health care quality, equity, and Veteran experiences
Walid F. Gellad, MD MPH
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Eric Roberts PhD
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: April 2022 - June 2026


Background: The Veterans Choice Program and MISSION Act have transformed how VA delivers care by expanding Veterans’ eligibility to receive VA-funded care from community providers. The effects of this change on the quality and equity of care are unknown. Understanding these effects is critical, given the importance of these programs to VA and the complexity of managing care for Veterans across different health systems. To address this evidence gap, we will use a quasi-experimental regression discontinuity (RD) design and examine outcomes in medically and socially vulnerable subgroups to determine the impact of Choice and MISSION on quality and equity of Veterans’ health care. To further examine impacts on vulnerable groups, we will analyze disparities in ratings of community care from VA’s Survey of Healthcare Experiences of Patients (SHEP). Significance: This proposal addresses cross-cutting HSR&D research priorities, including evaluating the quality and equity of care for Veterans in the context of a key legislative priority for VA: the MISSION Act. We will examine how the effects of receiving community care, and patient experiences with community care, differ in vulnerable populations, addressing VA priorities related to equity. The project constitutes an advancement in the rigor of research while directly informing ongoing and high priority clinical initiatives within VA. Innovation and Impact: Our project is innovative because it uses an RD design to provide causal evidence about the effects of community care on the quality and equity of outpatient care and prescribing. The project is also innovative and impactful in its attention to subpopulations of socially and medically vulnerable Veterans, including analyses of disparities in community care patient experiences from national survey data. By working closely with operational partners and a Veterans Advisory Board, we will impact VA policy by translating findings into actionable recommendations to improve community care, particularly for vulnerable groups. Specific Aims: (1) Identify the effects of receiving outpatient community care through Choice and MISSION on quality and equity. (2) Identify the effects of community care on the quality and equity of prescribing. (3) Compare Veterans’ experiences with community care in vulnerable and other Veteran populations. Methodology: We will use an RD design and analyses of both administrative and VA survey data to assess the effects of Choice (all program years) and MISSION (2019-2022) on the quality and equity of Veterans’ health care. Aims 1-2 will use a quasi-experimental RD design that compares Veterans just above vs. below distance and travel time eligibility thresholds for VA community care in Choice and MISSION. We will study effects of community care use on quality overall and, to evaluate implications for equity, in vulnerable subpopulations defined by the presence of serious mental illness or substance use disorders, complex chronic conditions, low income, and racial/ethnic minority status. Outcome variables in Aim 1 focus on outpatient processes of care (e.g., continuity of care) and outcomes linked to care coordination (e.g., admissions for ambulatory care-sensitive conditions). Outcome variables in Aim 2 focus on prescribing safety and quality (e.g., drug-drug interactions), therapeutic duplication, and refill non-adherence. These analyses use VA Corporate Data Warehouse, Planning Systems Support Group, Medicare, and Program Integrity Tool data. In Aim 3, we will analyze national data from the VA SHEP Community Care survey (conducted among community care recipients) to compare patient-reported experiences with community care among Veterans in vulnerable populations vs. other Veterans. Outcome variables in Aim 3 include 5 domains of Veterans’ experiences with care coordination, provider communication, and timely access in VA community care. Next Steps/Implementation: Through close partnerships with the Office of Community Care, Pharmacy Benefits Management, Office of Health Equity, and a Veterans Advisory Board, we will rapidly disseminate our findings and translate them into actionable recommendations to improve quality and equity in community care.

External Links for this Project

NIH Reporter

Grant Number: I01HX003457-01A1

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None at this time.

DRA: Health Systems
DRE: TRL - Applied/Translational
Keywords: Disparities, Outcomes - Patient, Socioeconomic Factors
MeSH Terms: None at this time.

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