Relationship Between Perioperative Outcomes Used for Profiling Hospital Noncardiac Surgical Quality.

BACKGROUND: Risk-adjusted morbidity and mortality are commonly used by national surgical quality improvement (QI) programs to measure hospital-level surgical quality. However, the degree of hospital-level correlation between mortality, morbidity, and other perioperative outcomes (like reoperation) collected by contemporary surgical QI programs has not been well-characterized. MATERIALS AND METHODS: Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) data (2015-2016) were used to evaluate hospital-level correlation in performance between risk-adjusted 30-d mortality, morbidity, major morbidity, reoperation, and 2 composite outcomes (1- mortality, major morbidity, or reoperation; 2- mortality or major morbidity) after noncardiac surgery. Correlation between outcomes rates was evaluated using Pearson's correlation coefficient. Correlation between hospital risk-adjusted performance rankings was evaluated using Spearman's correlation. RESULTS: Based on a median of 232 [IQR 95-331] quarterly surgical cases abstracted by VASQIP, statistical power for identifying 30-d mortality outlier hospitals was estimated between 3.3% for an observed-to-expected ratio of 1.1 and 45.7% for 3.0. Among 230,247 Veterans who underwent a noncardiac operation at 137 VA hospitals, there were moderate hospital-level correlations between various risk-adjusted outcome rates (highest r = 0.40, mortality and composite 1; lowest r = 0.32, mortality and morbidity). When hospitals were ranked based on performance, there was low-to-moderate correlation between rankings on the various outcomes (highest ρ = 0.47, mortality and composite 1; lowest ρ = 0.37, mortality and major morbidity). CONCLUSIONS: Modest hospital-level correlations between perioperative outcomes suggests it may be difficult to identify high (or low) performing hospitals using a single measure. Additionally, while composites of currently measured outcomes may be an efficient way to improve analytic sample size (relative to evaluations based on any individual outcome), further work is needed to understand whether they provide a more robust and accurate picture of hospital quality or whether evaluating performance across a portfolio of individual measures is most effective for driving QI.

Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines?

BACKGROUND: The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution. METHODS: A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications. RESULTS: The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care). CONCLUSION: Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.

"We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care.

Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women's groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.

Implementation of a pharmacist-led transitional care clinic.

PURPOSE: To describe a pharmacist-led transitional care clinic (TCC) for high-risk patients who were recently hospitalized or seen in the emergency department (ED). SUMMARY: The Memphis Veterans Affairs Medical Center (VAMC) established a pharmacist-led face-to-face and telephone follow-up TCC to improve posthospitalization follow-up care through medication optimization and disease state management, particularly for veterans with high-risk disease states such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). The clinic's clinical pharmacy specialists (CPSs) ordered diagnostic and laboratory tests, performed physical assessments, and consulted other providers and specialty services in addition to performing medication reconciliation, compliance assessment, and evaluation of adverse drug events. TCC patients were typically seen within 2 weeks of discharge and subsequently referred back to their primary care provider or a specialty care provider for continued management. A retrospective review of 2016 TCC data found that 7.8% of patients seen in the TCC were readmitted within 30 days of discharge; readmission rates for COPD and HF were reduced to 13% and 10%, respectively, compared to hospital-wide readmission rates of 17% and 24%. A separate observational analysis found that 30-day readmissions for COPD and HF were reduced in TCC patients, with pharmacists documenting an average of 6.2 interventions and 3.3 medication-related problems per patient. To reduce clinic appointment no-shows, the CPSs worked with inpatient providers and schedulers to emphasize to patients the importance of clinic attendance; also, TCC services were expanded to include telehealth appointments to increase access for rural and/or homebound patients. CONCLUSION: A pharmacist-led TCC effectively reduced readmissions and prevented medication-related problems for high-risk patients who were hospitalized or seen in the ED.

Virtual Colorectal Cancer Surveillance: Bringing Scope Rate to Target.

BACKGROUND: Although endoscopy is recommended at 1 year after colorectal cancer (CRC) resection to detect locally recurrent CRC, earlier work at our Veterans Affairs (VA) facility demonstrated that 35% of patients achieve this metric. STUDY DESIGN: The interdisciplinary team used quality improvement methods to standardize processes and implement a gastroenterology-managed virtual surveillance clinic. The intervention clinic was implemented in August 2014. Veterans who underwent resection for stage I to III CRC at a single VA facility from January 2010 to December 2017 were included, with those undergoing resection between January 2010 and July 2014 considered pre-intervention and those undergoing resection between August 2014 and December 2017 considered post-intervention. The primary endpoint was the proportion of eligible patients for whom endoscopy was completed within 1 year of resection. Secondary outcomes were the proportion of patients who completed endoscopy within 18 months of resection or at any time post-resection and time to surveillance endoscopy. RESULTS: A total of 186 patients underwent resection for stage I to III CRC from 2010 to 2017; of these, 160 (86%) were eligible for endoscopy at 1-year post-resection (98 pre-intervention and 62 post-intervention). In the pre-intervention period, 30 of 98 patients (30.6%) underwent surveillance endoscopy within 1 year vs 31 of 62 (50.0%) post-intervention (p = 0.031). When evaluated at 18 months after resection, 56 of 98 patients (57.1%) in the pre-intervention group vs 52 of 62 (83.9%) in the post-intervention group underwent surveillance endoscopy (p = 0.001). Median time from resection to endoscopy decreased during the study period, from 1.19 years pre-intervention (interquartile range 0.93 to 1.74 years) to 1.0 years post-intervention (interquartile range 0.93 to 1.09 years) (p = 0.006). CONCLUSIONS: Implementation of a virtual surveillance clinic with standardized processes was associated with increased guideline-concordant endoscopic surveillance after CRC resection.

VA-Radiation Oncology Quality Surveillance Program.

PURPOSE: We sought to develop a quality surveillance program for approximately 15,000 US veterans treated at the 40 radiation oncology facilities at the Veterans Affairs (VA) hospitals each year. METHODS AND MATERIALS: State-of-the-art technologies were used with the goal to improve clinical outcomes while providing the best possible care to veterans. To measure quality of care and service rendered to veterans, the Veterans Health Administration established the VA Radiation Oncology Quality Surveillance program. The program carries forward the American College of Radiology Quality Research in Radiation Oncology project methodology of assessing the wide variation in practice pattern and quality of care in radiation therapy by developing clinical quality measures (QM) used as quality indices. These QM data provide feedback to physicians by identifying areas for improvement in the process of care and identifying the adoption of evidence-based recommendations for radiation therapy. RESULTS: Disease-site expert panels organized by the American Society for Radiation Oncology (ASTRO) defined quality measures and established scoring criteria for prostate cancer (intermediate and high risk), non-small cell lung cancer (IIIA/B stage), and small cell lung cancer (limited stage) case presentations. Data elements for 1567 patients from the 40 VA radiation oncology practices were abstracted from the electronic medical records and treatment management and planning systems. Overall, the 1567 assessed cases passed 82.4% of all QM. Pass rates for QM for the 773 lung and 794 prostate cases were 78.0% and 87.2%, respectively. Marked variations, however, were noted in the pass rates for QM when tumor site, clinical pathway, or performing centers were separately examined. CONCLUSIONS: The peer-review protected VA-Radiation Oncology Surveillance program based on clinical quality measures allows providers to compare their clinical practice to peers and to make meaningful adjustments in their personal patterns of care unobtrusively.

The VA and Non-VA Experience of Tracking Good Care.

The VA Mission Act of 2018 allows for choice of health care for 9 million veterans in their community, but deciding where the best care is requires transparency. Recent reports questioning the transparency of reporting health care outcomes in the Department of Veterans Affairs (VA), the largest US health care organization, pointed to flaws in how VA tracks and improves performance, and posed questions about the validity and transparency of using popular hospital ratings systems to define good care. To explore this further, the authors examined 3 widely referenced public health care ranking models - U.S. News America's Best Hospitals, Truven Health Analytics, and Hospital Compare - and the VA model. Upon examination, the authors find that metrics used across the 4 models are neither comparable nor transparent. Between 6%-46% reporting deficiencies were found in reporting of hospital metrics in non-VA hospitals, which reduces transparency for the public. In contrast, VA reporting is 100%. Comparing VA health care and Hospital Compare quality outcomes showed similar or better outcomes for VA for the same metrics of quality and for comparable health care costs. VA inpatient satisfaction falls significantly short of the private sector, but no individual VA outcome measure was found to contribute significantly to inpatient satisfaction. However, overall inpatient satisfaction increased over time with higher global hospital ranking in both VA and non-VA health care. Encouraging use of uniform rating models and reporting of metrics from all hospitals would improve transparency of current health care reporting to the consumer.

Implementation of Evidence-Based Recommendations for Preventive Services in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. To date, there has been scant research on how VHA adopts clinical preventive services guidelines and how U.S. Preventive Services Task Force recommendations factor into the process. METHODS: Researchers conducted semistructured interviews with eight VHA leaders to examine how they adopt, disseminate, and measure adherence to recommendations. Interviews were recorded, transcribed, and aggregated into a database to enable sorting and synthesis. Themes were identified across the key informant interviews. RESULTS: The development of VHA clinical prevention guidelines is coordinated by the National Center for Health Promotion and Disease Prevention. A VHA Advisory Committee discusses and votes to approve or disapprove each guideline. Several factors can impact the ability of a veterans affairs medical center to implement a guideline, such as local system capacity and priorities for quality improvement. Methods to promote implementation include electronic reminders, educational events, and a robust performance measurement system. CONCLUSIONS: Provision of evidence-based clinical preventive services is an important part of VHA's effort to provide high-quality care for Veterans. Recent achievements in lung cancer, colorectal cancer, and Hepatitis C screening highlight VHA's successful approach to implementation of preventive services guidance.

Quality information disclosure and health insurance demand: evidence from VA hospital report cards.

This study examines the effect of public reporting of quality information on the demand for public insurance. In particular, we examine the effect of the introduction of Veterans Affairs (VA) hospital quality report cards in 2008. Using data from the Current Population Survey in 2005-2015, we find that new information about the quality of a VA hospital had a significant effect on VA coverage among veterans living in the same Metropolitan Statistical Area (MSA). Despite the significant effect on VA coverage, the quality report did not have a spillover effect on veterans' labor supply. Moreover, updated quality information released in later years, which was presented in a less straightforward form, led to no additional changes in VA coverage. These findings suggest that quality reports for public insurance programs can be used as a policy lever to facilitate take up decision among potential beneficiaries.

Women Veterans' Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care.

BACKGROUND: In the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings. METHODS: Semistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans' experiences with VA specialty care providers, including their perceptions of gender bias. RESULTS: Four major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved. CONCLUSIONS: This study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases.

Diffusion of Excellence: Accelerating the Spread of Clinical Innovation and Best Practices across the Nation's Largest Health System.

The time it takes for clinical innovation and evidence-based practices to reach patients remains a major challenge for the health care sector. In 2015, the Veterans Health Administration (VHA) launched the Diffusion of Excellence Initiative aimed at aligning organizational resources with early-stage to midstage promising practices and innovations to replicate, scale, and eventually spread those with greatest potential for impact and positive outcomes. Using a 5-step systematic approach refined over time, frontline VHA staff have submitted more than 1676 practices since the initiative's inception, 47 of which have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated more than 412 times in Veterans Affairs hospitals across the country, improving care for more than 100,000 veterans and approximately $22.6 million in cost avoidance for the VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) and rapid availability of intranasal naloxone have saved veterans' lives. Several practices are now being implemented across the country, and the Diffusion of Excellence Initiative is playing a pivotal role as the VHA works to modernize its health care system. This initiative serves as a promising model for other health care systems seeking to accelerate the spread and adoption of clinical innovation and evidence-based practices.

Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult Conversations About Opioid Prescribing.

BACKGROUND: Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention. OBJECTIVE: This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain. DESIGN: Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients. PARTICIPANTS: Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain. APPROACH: Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion. KEY RESULTS: We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization. CONCLUSION: Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter.

Accuracy of Administrative Coding to Identify Reduced and Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Coding of systolic function in heart failure is important, but the accuracy is uncertain. METHODS AND RESULTS: We used data from a chart review of VA heart failure hospitalizations from 2006 to 2013. Trained abstractors determined the documented diagnosis of heart failure and the left ventricular ejection fraction (LVEF). We compared this LVEF with the primary and secondary International Classification of Disease, 9th edition, codes for heart failure for the same hospitalization. Among 43,044 hospitalizations for heart failure, the primary discharge diagnosis was coded as systolic heart failure in 18%, diastolic heart failure in 17%, and other heart failure codes in 65%. For an LVEF <40%, a systolic heart failure code had a sensitivity of 29% and a positive predictive value of 76%. The code for systolic heart failure was used more frequently over time, with sensitivity increasing from 16% to 37% but at the expense of the positive predictive value, which decreased from 80% to 74%. The overall area under the receiver operating characteristic curve for the relationship between LVEF and the systolic heart failure code was 0.71. Using LVEF >50% to define diastolic heart failure led to a sensitivity of 29% for a diastolic heart failure code, with a positive predictive value of 78%. In multivariate analysis, a systolic heart failure code had an odds ratio for 1-year mortality of 1.1 (95% confidence interval 1.03-1.17) compared to not having a systolic heart failure code. CONCLUSIONS: Coding for systolic and diastolic heart failure is associated with LVEF, but the accuracy is too poor to substitute for the documented LVEF in performance measurement.

Adverse drug reactions in the Veterans Affairs healthcare system: Frequency, severity, and causative medications analyzed by patient age.

PURPOSE: Adverse drug events (ADEs) in the U.S. Department of Veterans Affairs (VA) were evaluated, and differences in age group report rates and reported medications in different age groups were assessed. METHODS: We utilized the VA Adverse Drug Event Reporting System (ADERS) to assess 10-year age groups regarding ADE reporting rates, event severity, and associated reported medications. Data were derived from 484,351 ADE reports from 395,703 patients included in VA ADERS from 2009 through 2016. RESULTS: Reported rates of ADEs per 10,000 unique users demonstrated a nonlinear relationship with age, peaking in the group aged 60-69 years (148.6 reports/10,000 unique users) and declining thereafter. However, the percentage of adverse events reported as severe consistently rose with age group (3% in patients age 20-29 years versus 6% in patients older than 90 years). The types of medications reported as causative agents shifted over time from predominantly mental health and pain medications in younger veterans (e.g., age 20-29 years) to medications for chronic diseases in older cohorts (e.g., age 60-69 years). CONCLUSION: An analysis of VA ADE reports revealed a nonlinear relationship between age and events, with events peaking at age 60-69 years. Rates of severe ADEs increased in older age groups. Drugs commonly associated with ADEs tended to be those primarily used for mental health and pain treatment in younger patients and those used to address chronic disease states in older patients.

Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers.

Importance: Concerns have been raised about the adequacy of health care access among patients cared for within the United States Department of Veterans Affairs (VA) health care system. Objectives: To determine wait times for new patients receiving care at VA medical centers and compare wait times in the VA medical centers with wait times in the private sector (PS). Design, Setting, and Participants: A retrospective, repeated cross-sectional study was conducted of new appointment wait times for primary care, dermatology, cardiology, or orthopedics at VA medical centers in 15 major metropolitan areas in 2014 and 2017. Comparison data from the PS came from a published survey that used a secret shopper survey approach. Secondary analyses evaluated the change in overall and unique patients seen in the entire VA system and patient satisfaction survey measures of care access between 2014 and 2017. Main Outcomes and Measures: The outcome of interest was patient wait time. Wait times in the VA were determined directly from patient scheduling. Wait times in the PS were as reported in Merritt Hawkins surveys using the secret shopper method. Results: Compared with the PS, overall mean VA wait times for new appointments in 2014 were similar (mean [SD] wait time, 18.7 [7.9] days PS vs 22.5 [7.3] days VA; P = .20). Department of Veterans Affairs wait times in 2014 were similar to those in the PS across specialties and regions. In 2017, overall wait times for new appointments in the VA were shorter than in the PS (mean [SD], 17.7 [5.9] vs 29.8 [16.6] days; P < .001). This was true in primary care (mean [SD], 20.0 [10.4] vs 40.7 [35.0] days; P = .005), dermatology (mean [SD], 15.6 [12.2] vs 32.6 [16.5] days; P < .001), and cardiology (mean [SD], 15.3 [12.6] vs 22.8 [10.1] days; P = .04). Wait times for orthopedics remained longer in the VA than the PS (mean [SD], 20.9 [13.3] vs 12.4 [5.5] days; P = .01), although wait time improved significantly between 2014 and 2017 in the VA for orthopedics while wait times in the PS did not change (change in mean wait times, increased 1.5 days vs decreased 5.4 days; P = .02). Secondary analysis demonstrated an increase in the number of unique patients seen and appointment encounters in the VA between 2014 and 2017 (4 996 564 to 5 118 446, and 16 476 461 to 17 331 538, respectively), and patient satisfaction measures of access also improved (satisfaction scores increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, P < .05). Conclusions and Relevance: Although wait times in the VA and PS appeared to be similar in 2014, there have been interval improvements in VA wait times since then, while wait times in the PS appear to be static. These findings suggest that access to care within the VA has improved over time.

Hospitals lead by poor example: An assessment of snacks, soda, and junk food availability in Veterans Affairs hospitals.

OBJECTIVE: The Veterans Health Administration is the largest integrated health care system fully funded through the US government; however, compliance with government dietary recommendations within Veterans Affairs (VA) hospitals is not well known. The aim of this study was to determine which foods are available at VA hospitals and whether these foods comply with government recommendations. METHODS: Process verification for a Freedom of Information Act request was used to assess government-run inpatient and outpatient VA hospital facilities by accessing the location, quantity, and contents of vending machines. These foods and beverages were then quantified and compared with the US Department of Agriculture Dietary Guidelines for Americans 2015-2020 (eighth edition). RESULTS: Of the beverages supplied, 49% contained >55 g of sugar, supplying >10% of daily calories in added sugar in a single serving. Of all beverages, 50% contained >50 g of added sugar (range 17-77 g per bottle/can). The 65 available food items were comprised of 28% candy, 14% potato chips/puffed corn snacks, 11% pastries/frosted baked goods, 11% crackles/pretzels, and 8% nuts/trail mix, and the remainder consisted of jerky, pork rinds, gum, and popcorn. Nuts/trail mix and granola-items meeting nutritional guidelines-comprised five and three options in total, respectfully. CONCLUSIONS: All VA Hospitals contain vending machines providing a majority of soda, candy, and junk foods that directly conflict with healthy food choice recommendations from US governing health bodies. Few sources meeting US dietary guidelines are available in vending machines at these government-run facilities, which serve as poor examples for patients who are attempting to follow a healthy diet.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.