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IIR 22-011 – HSR Study

IIR 22-011
Improving Value through Comprehensive Episodes of Emergency Care for Veterans
Keith E Kocher, MD MPH
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Anita Vashi MD MPH MHS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: April 2024 - March 2028


Background: Through the Choice Act of 2014 and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018, the Veterans Affairs (VA) health system has substantially expanded its role as a purchaser of care with greatly increased opportunities for Veterans to receive care outside VA and in the community. Emergency department (ED) visits and related hospitalizations now represent the largest provision of community-based care, costing over $4 billion to VA in fiscal year 2021— more than 5 times greater than the next category of community care—and with nearly 50% more ED use compared to the previous year, but with uncertain return on that spending. Significance: Current approaches are inadequate for understanding the overall value of ED care for Veterans. Episode of care models, however, a central strategy for measuring population level utilization and quality associated with the full treatment of an illness, are a promising method for characterizing Veteran ED care both in the community and VA with the goal of identifying sources of variability and opportunities for improvement. Yet these models are not available for ED care or for emergency conditions and concerns common to Veterans. Innovation & Impact: Our proposed research represents a departure from the status quo and previous attempts to understand differences in ED practice patterns for Veterans receiving care. Our study will unlock critical insight and substantially move the field forward by evaluating differences in resource use, quality, and care fragmentation patterns indicating opportunities for improvement in emergency care delivery that ultimately shorten the standard cycle of meaningful and successful interventions for widespread adoption within VA. Specific Aims: (1) To define a set of highly promising ED-based episodes of care for common conditions experienced by Veterans; (2) To assess resource use and quality in ED-based episodes of care beginning in the VA vs community setting; (3) To evaluate care fragmentation within ED-based episodes of care in the VA vs community setting. Methodology: Using the national VA datamart, we will define care episodes beginning with the ED visit for several important Veteran conditions: congestive heart failure, chest pain, chronic obstructive pulmonary disease, pneumonia, and suicidality. Employing a technical expert panel with a modified Delphi method, we will determine inclusion and exclusion criteria, standardize risk-adjustment methods, and establish the validity of these episode definitions. Then, using national VA and non-VA Community Care data and the methodologies developed in Aim 1, we will apply ED-based care episodes and test for differences in patient utilization and quality. Finally, we will test for associations between Veteran resource use and quality as developed in Aim 2 with indicators of care fragmentation, an important opportunity for intervention, in Aim 3. Next Steps/Implementation: Discoveries derived from this proposed study will directly address the critical knowledge gap facing VA operational leaders in understanding the value of ED purchased community care relative to VA ED care. Once this project has proven the concept of ED-based episodes of care, these findings can inform VA administrative decisions to systematically reveal opportunities for improvement and spotlight high value targets of intervention. Ultimately, Veterans will derive the greatest benefit as we accelerate our understanding of innovative strategies to maximize the quality and safety of ED care practices.

External Links for this Project

NIH Reporter

Grant Number: I01HX003601-01A2

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None at this time.

DRA: Health Systems, Cardiovascular Disease
DRE: TRL - Applied/Translational
Keywords: Models of Care
MeSH Terms: None at this time.

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