Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex.

Importance: Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective: To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants: This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures: The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results: Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance: In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Reexamining Differences Between Black and White Veterans in Hospital Mortality and Other Outcomes in Veterans Affairs and Other Hospitals.

OBJECTIVES: To examine Black-White patient differences in mortality and other hospital outcomes among Veterans treated in Veterans Affairs (VA) and non-VA hospitals. BACKGROUND: Lower hospital mortality has been documented in older Black patients relative to White patients, yet the mechanisms have not been determined. Comparing other hospital outcomes and multiple hospital systems may help inform the reasons for these differences. METHODS: Repeated cross-sectional analysis of hospitalization records was conducted for Veterans discharged in VA and non-VA hospitals from January 1, 2013 to December 31, 2017 in 11 states. Hospital outcomes included 30-day mortality, 30-day readmissions, inpatient costs, and length of stay. Hospitalizations were for acute myocardial infarction, coronary artery bypass graft surgery, gastrointestinal bleeding, heart failure, pneumonia, and stroke. Differences in outcomes were estimated between Black and White patients for VA and non-VA hospitals and age groups younger than 65 years or 65 years and older in regression models adjusting for patient and hospital factors. RESULTS: There were a total of 459,574 study patients. Older Black patients had lower adjusted mortality for acute myocardial infarction, gastrointestinal bleeding, heart failure, and pneumonia. Adjusted probability of readmission was higher and adjusted mean length of stay and costs were greater for older Black patients relative to White patients in non-VA hospitals for several conditions. Fewer differences were observed in younger patients and in VA hospitals. CONCLUSION: While older Black patients had lower mortality, other outcomes compared poorly with White patients. Differences were not fully explained by observable patient and hospital factors although social determinants may contribute to these differences.

Comparing Outcomes in Patients Undergoing Colectomy at Veteran Affairs Hospitals and Non-Veteran Affairs Hospitals: A Multiinstitutional Study.

INTRODUCTION: The Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. METHODS: After institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. RESULTS: VASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) CONCLUSIONS: Despite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals.

Hospital and Patient Factors Affecting Veterans' Hospital Choice.

Veterans enrolled in the Veterans Affairs (VA) health care system gained greater access to non-VA care beginning in 2014. We examined hospital and Veteran characteristics associated with hospital choice. We conducted a longitudinal study of elective hospitalizations 2011 to 2017 in 11 states and modeled patients' choice of VA hospital, large non-VA hospital, or small non-VA hospital in conditional logit models. Patients had higher odds of choosing a hospital with an academic affiliation, better patient experience rating, location closer to them, and a more common hospital type. Patients who were male, racial/ethnic minorities, had higher VA enrollment priority, and had a mental health comorbidity were more likely than other patients to choose a VA hospital than a non-VA hospital. Our findings suggest that patients respond to certain hospital attributes. VA hospitals may need to maintain or achieve high levels of quality and patient experience to attract or retain patients in the future.

Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals.

INTRODUCTION: Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals. METHODS: We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals. RESULTS: A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001). CONCLUSIONS: Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.

Comparing Quality of Surgical Care Between the US Department of Veterans Affairs and Non-Veterans Affairs Settings: A Systematic Review.

In response to concerns about healthcare access and long wait times within the Veterans Health Administration (VA), Congress passed the Choice Act of 2014 and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 to create a program for patients to receive care in non-VA sites of care, paid by VA. Questions remain about the quality of surgical care between these sites in specific and between VA and non-VA care in general. This review synthesizes recent evidence comparing surgical care between VA and non-VA delivered care across the domains of quality and safety, access, patient experience, and comparative cost/efficiency (2015 to 2021). Eighteen studies met the inclusion criteria. Of 13 studies reporting quality and safety outcomes, 11 reported that quality and safety of VA surgical care were as good as or better than non-VA sites of care. Six studies of access did not have a preponderance of evidence favoring care in either setting. One study of patient experience reported VA care as about equal to non-VA care. All 4 studies of cost/efficiency outcomes favored non-VA care. Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.

What is the impact of veterans affairs rotations in oral and maxillofacial surgery residency?

PURPOSE: Oral and maxillofacial surgery (OMS) residencies commonly affiliate with Veterans Affairs Medical Centers (VAMC) to extend care for veterans. This study quantifies the surgical experience of residents at the Corporal Michael J. Crescenz (CMC) VAMC in Philadelphia, Pennsylvania and determines the number of programs affiliated with VA Medical Centers, to enumerate the educational benefits and improve veteran healthcare. METHODS: The dental project manager logs from 2012 through 2021 of the CMC VAMC operating room were analyzed, and cases were categorized into 12 groups. The implant cases from 2012 through 2021 were quantified. Program affiliations were determined using a VA Office of Academic Affiliation report. RESULTS: There were 1359 procedures (760 cases) performed. Dentoalveolar (n = 967) was the most common category, and extractions (n = 384) were the most common procedure. The least cases and procedures were performed in 2012 (n = 14; n = 23). The most cases were performed in 2019 (n = 137), and the most procedures were performed in 2019 and 2021 (n = 255). There were 3133 implants placed. There are 40 OMS programs affiliated with VA Medical Centers; more dual degree (n = 24) than single degree (n = 16) programs having an affiliation. CONCLUSION: The CMC VAMC offers robust dentoalveolar experience and is increasing in surgical volume, representing the expected needs of an aging veteran population. An increasing budget and millions of eligible veterans indicates VA medical centers nationally will continue to provide valuable surgical experiences.

Payer shifting after expansions in access to private care among veterans.

OBJECTIVE: To investigate whether expanded access to Veterans Affairs (VA)-purchased care increased overall utilization or induced a shift from other payers to VA for emergency care among VA enrollees. DATA SOURCES AND STUDY SETTING: This study included all emergency department (ED) encounters in 2019 from hospitals in the state of New York. STUDY DESIGN: We conducted a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June 2019. DATA COLLECTION/EXTRACTION METHODS: We included all ED visits with individuals aged 30 or older at the time of the encounter. Individuals were considered eligible for the policy change if they were enrolled with VA at the beginning of 2019. PRINCIPAL FINDINGS: Of the 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were made by VA enrollees. Of these, 44.9% of visits were paid by Medicare, 32.8% occurred in VA facilities, and 7% were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = 0.45). CONCLUSIONS: Leveraging a novel dataset, we demonstrate that MISSION Act implementation coincided with a shift in the financing of non-VA ED visits from Medicare to VA without any increase in overall ED utilization. These findings have important implications for VA health care financing and delivery.

Robotic General Surgery Trends in the Veterans Health Administration, Community Practice, and Academic Centers From 2013 to 2021.

This cross-sectional study compares trends in use of robotic surgery for general surgical procedures among the Veterans Health Administration (VHA), community practice, and academic health centers from 2013 to 2021.

Variation in Resident Operative Autonomy at Veterans Affairs Hospitals.

This cohort study examines resident involvement in the care of US veterans who underwent noncardiac surgery.

Comparison of the Impact of COVID-19 on Veterans Affairs and Non-federal Hospitals: a Survey of Infection Prevention Specialists.

BACKGROUND: As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock. OBJECTIVE: To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic. DESIGN: Cross-sectional national survey administered April 2021 through May 2022. PARTICIPANTS: Lead infection preventionists from VA and non-federal hospitals across the US. MAIN MEASURES: Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital's COVID response. KEY RESULTS: The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, p<.001) and intensive care unit (24 vs. 16, p<.001) beds. VA hospitals were more likely to report no shortages of personal protective equipment or medical supplies during the pandemic (17% vs. 9%, p=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, p<.001) compared with non-federal hospitals. Non-federal hospitals more frequently experienced increased loss of staff due to resignations (76% vs. 53%, p=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p<0.001). CONCLUSIONS: In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA's structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks.

Accuracy of vancomycin AUC values estimated with trough-only data in a veteran population.

PURPOSE: The purpose of this study was to evaluate the accuracy and precision of estimating area under the curve (AUC) values using only vancomycin trough concentrations versus both peak and trough values derived from applying 4 different volume of distribution (Vd) models in a veteran population. METHODS: This retrospective, observational study was performed from July 2021 to April 2022 using data from 5 Veterans Affairs hospitals across the US. AUC values for a total of 259 veterans were included in the analysis, with 10 excluded after pooling of data. Trough-only AUC values were calculated with 1-compartment intermittent infusion equations (Sawchuk-Zaske equations) using age- and weight-adjusted Vd values derived from an online calculator (VancoPK) or fixed Vd values specified by 3 comparator models. RESULTS: The mean population peak-trough AUC was 496 (range, 266-886). Of the 4 Vd models evaluated, the VancoPK model was the most accurate and precise, yielding a mean trough-only AUC of 491, with a correlation of 0.925; the root mean square error was 41, meaning that approximately 95% of the trough-only AUCs were within 82 points of values calculated using AUC peak-trough couplets. CONCLUSION: A trough-only AUC estimation approach has many advantages over a peak-trough approach. The equation Vd = 0.29 (age) + 0.33 (actual BW in kg) + 11 provided accurate and precise AUC estimates with trough-only data when applied to pharmacokinetic equations in a veteran population.

Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

BACKGROUND: Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery. METHODS: Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes. RESULTS: 618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001). CONCLUSION: Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.

Factors Associated With Severe COVID-19 Among Vaccinated Adults Treated in US Veterans Affairs Hospitals.

Importance: With a large proportion of the US adult population vaccinated against SARS-CoV-2, it is important to identify who remains at risk of severe infection despite vaccination. Objective: To characterize risk factors for severe COVID-19 disease in a vaccinated population. Design, Setting, and Participants: This nationwide, retrospective cohort study included US veterans who received a SARS-CoV-2 vaccination series and later developed laboratory-confirmed SARS-CoV-2 infection and were treated at US Department of Veterans Affairs (VA) hospitals. Data were collected from December 15, 2020, through February 28, 2022. Exposures: Demographic characteristics, comorbidities, immunocompromised status, and vaccination-related variables. Main Outcomes and Measures: Development of severe vs nonsevere SARS-CoV-2 infection. Severe disease was defined as hospitalization within 14 days of a positive SARS-CoV-2 diagnostic test and either blood oxygen level of less than 94%, receipt of supplemental oxygen or dexamethasone, mechanical ventilation, or death within 28 days. Association between severe disease and exposures was estimated using logistic regression models. Results: Among 110 760 patients with infections following vaccination (97 614 [88.1%] men, mean [SD] age at vaccination, 60.8 [15.3] years; 26 953 [24.3%] Black, 11 259 [10.2%] Hispanic, and 71 665 [64.7%] White), 10 612 (9.6%) had severe COVID-19. The strongest association with risk of severe disease after vaccination was age, which increased among patients aged 50 years or older with an adjusted odds ratio (aOR) of 1.42 (CI, 1.40-1.44) per 5-year increase in age, such that patients aged 80 years or older had an aOR of 16.58 (CI, 13.49-20.37) relative to patients aged 45 to 50 years. Immunocompromising conditions, including receipt of different classes of immunosuppressive medications (eg, leukocyte inhibitor: aOR, 2.80; 95% CI, 2.39-3.28) or cytotoxic chemotherapy (aOR, 2.71; CI, 2.27-3.24) prior to breakthrough infection, or leukemias or lymphomas (aOR, 1.87; CI, 1.61-2.17) and chronic conditions associated with end-organ disease, such as heart failure (aOR, 1.74; CI, 1.61-1.88), dementia (aOR, 2.01; CI, 1.83-2.20), and chronic kidney disease (aOR, 1.59; CI, 1.49-1.69), were also associated with increased risk. Receipt of an additional (ie, booster) dose of vaccine was associated with reduced odds of severe disease (aOR, 0.50; CI, 0.44-0.57). Conclusions and Relevance: In this nationwide, retrospective cohort of predominantly male US Veterans, we identified risk factors associated with severe disease despite vaccination. Findings could be used to inform outreach efforts for booster vaccinations and to inform clinical decision-making about patients most likely to benefit from preexposure prophylaxis and antiviral therapy.