Delivery system emergency department capacity and its effect on nonsystem service utilization.

BACKGROUND: Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. OBJECTIVE: The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. METHODS: We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019. We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status). RESULTS: After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p < 0.001. CONCLUSIONS: Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network.

Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD.

OBJECTIVE: This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD). METHODS: Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity. RESULTS: Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01). CONCLUSIONS: Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

Integrated Health Record Viewers and Reduction in Duplicate Medical Imaging: Retrospective Observational Analysis.

BACKGROUND: Health information exchange and multiplatform health record viewers support more informed medical decisions, improve quality of care, and reduce the risk of adverse outcomes due to fragmentation and discontinuity in care during transition of care. An example of a multiplatform health record viewer is the VA/DoD Joint Longitudinal Viewer (JLV), which supports the Department of Veterans Affairs (VA) and Department of Defense (DoD) health care providers with read-only access to patient medical records integrated from multiple sources. JLV is intended to support more informed medical decisions such as reducing duplicate medical imaging when previous image study results may meet current clinical needs. OBJECTIVE: We estimated the impact of provider usage of JLV on duplicate imaging for service members transitioning from the DoD to the VA health care system. METHODS: We conducted a retrospective cross-sectional study in fiscal year 2018 to examine the relationship between providers' use of JLV and the likelihood of ordering duplicate images. Our sample included recently separated service members who had a VA primary care visit in fiscal year 2018 within 90 days of a DoD imaging study. Patients who received at least one imaging study at VA within 90 days of a DoD imaging study of the same imaging mode and on the same body part are considered to have received potentially duplicate imaging studies. We use a logistic regression model with "JLV provider" (providers with 1 or more JLV audits in the prior 6 months) as the independent variable to estimate the relationship between JLV use and ordering of duplicate images. Control variables included provider image ordering rates in the prior 6 months, provider type, patient demographics (age, race, gender), and clinical characteristics (Elixhauser comorbidity score). RESULTS: Providers known to utilize JLV in the prior 6 months order fewer duplicate images relative to providers not utilizing JLV for similar visits over time (odds ratio 0.44, 95% CI 0.24-0.78; P=.005). This effect is robust across multiple specifications of linear and logistic regression models. The provider's practice pattern of ordering image studies and the patient's health status are powerful confounders. CONCLUSIONS: This study provides evidence that adoption of a longitudinal viewer of health records from multiple electronic health record systems is associated with a reduced likelihood of ordering duplicate images. Investments in health information exchange systems may be effective ways to improve the quality of care and reduce adverse outcomes for patients experiencing fragmentation and discontinuity of care.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Overcoming Challenges to Evidence-Based Policy Development in a Large, Integrated Delivery System.

OBJECTIVE: To describe a new Veterans Health Administration (VHA) program to foster the learning health system paradigm by rigorously evaluating health care initiatives and to report key lessons learned in designing those evaluations. PRINCIPAL FINDINGS: The VHA's Quality Enhancement Research Initiative and its Health Services Research and Development Service are cooperating on several large, randomized program evaluations aimed at improving the care veterans receive and the efficiency with which it is delivered. The evaluations we describe involve collaborative design, outcomes assessment, and implementation science through partnerships between VHA operations and researchers. We review key factors to assess before committing to an evaluation. In addition to traditional design issues (such as ensuring adequate power and availability of data), these include others that are easily overlooked: the stability of intervention financing, means of controlling and commitment to adhering to randomized roll-out, degree of buy-in from key implementation staff, and feasibility of managing multiple veto points for interventions that span several programs, among others. CONCLUSIONS: Successful program implementation and rigorous evaluation require resources, specialized expertise, and careful planning. If the learning health system model is to be sustained, organizations will need dedicated programs to prioritize resources and continuously adapt evaluation designs.

Consult Coordination Affects Patient Experience.

OBJECTIVES: The Medicare accountable care organization (ACO) program financially rewards ACOs for providing high-quality healthcare, and also factors in the patient experience of care. This study examined whether administrative measures of wait times for specialist consults are associated with self-reported patient satisfaction. STUDY DESIGN: Analyses used administrative and survey data from a clinically integrated healthcare system similar to an ACO. METHODS: Veterans Health Administration (VHA) data from 2012 was obtained. Administrative access metrics included the number of days between the creation of the consult request and: 1) first action taken on the consult, 2) scheduling of the consult, and 3) completion of the consult. The Survey of Healthcare Experiences of Patients-which is modeled after the Consumer Assessment of Healthcare Providers and Systems family of survey instruments used by ACOs to measure patient experience-provided the outcome measures. Outcomes included general VHA satisfaction measures and satisfaction with timeliness of care, including wait times for specialists and treatments. Logistic regression models predicted the likelihood of patients reporting being satisfied on each outcome. Models were risk adjusted for demographics, self-reported health, and healthcare use. RESULTS: Longer waits for the scheduling of consults and completed consults were found to be significantly associated with decreased patient satisfaction. CONCLUSIONS: Because patients often report high levels of powerlessness and uncertainty while waiting for consultation, these wait times are an important patient-centered access metric for ACOs to consider. ACOs should have systems and tools in place to streamline the specialist consult referral process and increase care coordination.