County-level Predictors of Growth in Community-based Primary Care Use Among Veterans

Gordon, Sarah H.; Beilstein‐Wedel, Erin; Rosen, Amy K.; Zheng, Tianyu; Kelley, A. Taylor; Cook, James; Zahakos, Sarah S; Vanneman, Megan E.

doi:10.1097/mlr.0000000000001555

Cited by 11 publications

(22 citation statements)

References 22 publications

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“…Similarly, rural VA patients with a new diagnosis of depression, anxiety, or posttraumatic stress disorder in 2004 were less likely to receive psychotherapy than urban VA patients, 24 but a follow-up study indicated the disparity began to close between 2007 and 2010. 25 With regard to expansion of VA-paid care in the community, there were several recent studies in a special issue of Medical Care that compared changes to access for rural versus urban patients and showed that access and timeliness generally improved for rural patients who received both VA-delivered or VA-paid care between 2015 and 2018, 26,27 but none of that work was focused specifically on mental health care. 28 Thus, there is no longitudinal study that examines changes in access to mental health services for rural VA patients following implementation of the UMHSP and subsequent expansion of VA-paid care in the community.…”

Section: Introductionmentioning

confidence: 99%

Evaluating policies to improve access to mental health services in rural areas

Shiner

Gottlieb

Rice

et al. 2022

The Journal of Rural Health

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Purpose:The United States Department of Veterans Affairs (VA) has gradually implemented policies to increase access to mental health care outside of VA medical centers. Most notably, this included requirements to offer mental health services at VAadministered community-based clinics in 2008 and increased access to VA-paid care in the community beginning in 2014. Our objective was to understand how mental health service use patterns changed for rural VA patients during this time. Methods:We developed a longitudinal cohort of all rural patients who used VA services between 2002 and 2019 (N = 3,345,862). We examined individual, health care, and contextual predictors of mental health service use as well as modalities of mental health service use during policy-relevant time periods using descriptive statistics.Findings: Access to mental health services increased with each policy change. The annual percentage of rural VA patients accessing mental health services increased from 11.4% in the earliest years (2002)(2003)(2004) to 19.8% in the latest years (2017)(2018)(2019).The most rapid period of increase followed a requirement for availability of mental health services at VA-administered community clinics. Increasing access to VA-paid care in the community had less effect. By the end of the evaluation, gaps remained in the delivery of care to elderly patients over the age of 75.Conclusions: Rural patients use mental health services when they become available.Access was the highest with a combination of changes to both delivery modalities and payment methods. Continued, and perhaps different efforts are required to address a persistent disparity for older patients.

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Section: Introductionmentioning

confidence: 99%

Evaluating policies to improve access to mental health services in rural areas

Shiner

Gottlieb

Rice

et al. 2022

The Journal of Rural Health

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“…Care leakage from health systems can lead to poor‐quality health care, adverse health outcomes, and high costs for both patients and systems. Past studies found that chronic illness, rurality, longer in‐house wait times, longer distance to in‐house care, unavailability of certain specialties in house, and perceptions of quality are associated with patients seeking out‐of‐system care 2,4,13,30 . Health system administrators have limited control over these factors.…”

Section: Discussionmentioning

confidence: 99%

“…Past studies found that chronic illness, rurality, longer inhouse wait times, longer distance to in-house care, unavailability of certain specialties in house, and perceptions of quality are associated with patients seeking out-of-system care. 2,4,13,30 Health system administrators have limited control over these factors. However, few studies examined the impact of potentially modifiable factors on care leakage from integrated health systems.…”

Section: Discussionmentioning

confidence: 99%

“…Identifying modifiable predictors of care leakage may help health care organizations avoid the adverse consequences of care leakage. Many factors that drive care leakage such as severe health conditions, limited access to in‐house care (e.g., due to rurality or distance), and public health emergencies like COVID are not directly modifiable by health system administrators 4,12,13,14 . However, out‐of‐system emergency department (ED) use may be one modifiable cause of specialty care leakage from health systems.…”

Section: Introductionmentioning

confidence: 99%

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Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals

Palani

Garrido

Tenso

et al. 2023

Academic Emergency Medicine

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Background: Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. Methods: We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit.Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics.Results: A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit.Conclusions: Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit.This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.

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“…13,14 Prior work on CC has typically taken the networks as given and studied the program's association with access to care and compared quality and cost outcomes between VHA and non-VHA physicians. [15][16][17][18][19][20][21] These studies have found that VHA care is typically as good as care from non-VHA physicians, but it is less clear whether policies such as the MISSION Act have improved access. 21 Additionally, some studies have found significant differences in quality and access across facilities and geographic regions.…”

Section: Introductionmentioning

confidence: 99%

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

Eck,

Ho,

Jiang

et al. 2023

Health Services Research

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ObjectiveTo measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size.Data SourcesVHA electronic health records, CC claim data, and National Plan and Provider Enumeration System.Study DesignIn this retrospective cross‐sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market‐year level. Network size was measured as the number of physicians who performed at least one VHA‐purchased screening colonoscopy per 1000 enrollees at baseline.Data ExtractionData were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non‐VHA physician from 2018 to 2021.Principal FindingsFrom 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = −0.12, 95% CI: [−0.18, −0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]).ConclusionsVHA facilities with a higher volume of VHA‐purchased screening colonoscopies and more rural enrollees had more non‐VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

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County-level Predictors of Growth in Community-based Primary Care Use Among Veterans

Abstract: Supplemental Digital Content is available in the text.

Cited by 11 publications

References 22 publications

Evaluating policies to improve access to mental health services in rural areas

Evaluating policies to improve access to mental health services in rural areas

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

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