Resource‐constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018.

Aims The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all‐cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD). Design Secondary analysis of a stepped‐wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020. Setting and Participants United States VHA facilities were randomized to case review the top 1 or 5% of high‐risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post‐hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation. Measurements All‐cause mortality and opioid‐related, drug‐related, suicide‐related and other SAEs within 90 days of OUD diagnosis. Findings Mandated case review increased the odds of 90‐day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all‐cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients. Conclusions Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all‐cause mortality following expansion of a case review mandate for high‐risk patients prescribed opioids.

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