IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTSWe conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and(3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi 2 ). Compared with the 87 clinics in the lowest decile of the Pi 2 , the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCEThe extent of PCMH implementation, as measured by the Pi 2 , was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

Objective A third of Americans are obese and an increasing number opt for bariatric surgery. This study estimates the cost-effectiveness of common bariatric surgical procedures from a healthcare system perspective. Methods We evaluated the three most common bariatric surgical procedures in the US: laparoscopic gastric bypass (LRYGB), conventional (open) Roux en Y gastric bypass (ORYGB), and laparoscopic adjustable gastric banding (LAGB) compared to no surgery. The reference case was defined as a 53-year old female with BMI of 44 kg/m2. We developed a two-part model using a deterministic approach for the first 5-year period post-surgery and separate empirical forecasts for the natural history of body mass index (BMI), costs and outcomes in the remaining years. We used a combination of datasets including Medicare and MarketScanR together with estimates from the literature to populate the model. Results Bariatric surgery produced additional life expectancy (80 to 81 years) compared to no surgery (78 years). The incremental cost-effectiveness ratios (ICERs) of the surgical procedures were $6600 per QALY gained for LRYGB, $6200 for LAGB, and $17,300 for ORYGB (3% discount rate for cost and QALYs). ICERs varied according to choice of BMI forecasting method and clinically plausible variation in parameter estimates. In most scenarios, the ICER did not exceed a threshold of $50,000 per QALY gained. Conclusion Gastric bypass and banding procedures are likely to be cost-effective for obese patients compared to nonsurgical treatment at conventional cost-effectiveness thresholds.

Purpose Interactive clinical video telemedicine (CVT) has the potential to benefit health care systems and patients by improving access, lowering costs, and more efficiently distributing providers. However, there is a gap in current knowledge around the demand for and potential uses of CVT in large integrated health care systems. Methods We conducted an observational study using Veterans Health Administration (VHA) administrative databases to analyze trends in CVT utilization, and types of care received, among 7.65 million veterans during fiscal years (FY) 2009‐2015 (October 1, 2008‐September 30, 2015). Trends were stratified by veteran rurality and analyzed using linear regression. Among 4.95 million veterans in FY2015, we used logistic regression to identify characteristics associated with CVT utilization for any care, mental health care, and major specialties. Findings Over 6 years, the annual CVT utilization grew from 30 to 124 encounters per 1,000 veterans (>300% increase), with faster growth among rural veterans than urban veterans. Over the study period, ≥50% of all CVT‐delivered care was mental health care. In FY2015, 3.2% of urban and 7.2% of rural veterans utilized CVT for nearly 725,000 clinical encounters. Rural residence, younger age, longer driving distance to VHA facilities, one or more comorbidities, and higher rates of traditional, non‐video utilization were independently associated with higher odds of CVT use. Conclusions CVT utilization in VHA has increased quickly and exceeds published rates in the private health care market. The availability of CVT has likely increased access to VHA care for rural veterans, especially for mental health care.

The Veterans Health Administration (VHA) has historically served a disproportionately male patient population with lower income and greater rates of mental illness than non-VHA populations. The generalizability of research based on VHA enrollees is unknown because the overlap between VHA and non-VHA populations has never been empirically examined. This study used 2013 National Health Interview Survey data to examine the extent to which VHA enrollees had similar demographic and health characteristics as individuals with Medicaid, Medicare, or private insurance coverage, based on propensity score models. A majority of male VHA enrollees were similar to Medicare beneficiaries suggesting greater generalizability of VHA studies than commonly hypothesized. Overlap declined when comparing with Medicaid enrollees or privately insured individuals, suggesting more limited generalizability of VHA studies to these populations.

BACKGROUND: Heterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time. OBJECTIVE: To characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout. DESIGN: Longitudinal study of the VA All Employee Survey during 2013-2017. PARTICIPANTS: Self-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide. MAIN MEASURES: We identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories. KEY RESULTS: We identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site. CONCLUSIONS: VA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings.

Objective To examine whether nurse practitioner (NP)‐assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)‐assigned patients. Data Sources Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. Study Design We applied a difference‐in‐difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. Principal Findings Compared to MD‐assigned patients, NP‐assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. Conclusions Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost‐effective approach to addressing anticipated shortages of primary care physicians.

BackgroundMany previous studies estimating the relationship between body mass index (BMI) and mortality impose assumptions regarding the functional form for BMI and result in conflicting findings. This study investigated a flexible data driven modelling approach to determine the nonlinear and asymmetric functional form for BMI used to examine the relationship between mortality and obesity. This approach was then compared against other commonly used regression models.MethodsThis study used data from the National Health Interview Survey, between 1997 and 2000. Respondents were linked to the National Death Index with mortality follow-up through 2005. We estimated 5-year all-cause mortality for adults over age 18 using the logistic regression model adjusting for BMI, age and smoking status. All analyses were stratified by sex. The multivariable fractional polynomials (MFP) procedure was employed to determine the best fitting functional form for BMI and evaluated against the model that includes linear and quadratic terms for BMI and the model that groups BMI into standard weight status categories using a deviance difference test. Estimated BMI-mortality curves across models were then compared graphically.ResultsThe best fitting adjustment model contained the powers -1 and -2 for BMI. The relationship between 5-year mortality and BMI when estimated using the MFP approach exhibited a J-shaped pattern for women and a U-shaped pattern for men. A deviance difference test showed a statistically significant improvement in model fit compared to other BMI functions. We found important differences between the MFP model and other commonly used models with regard to the shape and nadir of the BMI-mortality curve and mortality estimates.ConclusionsThe MFP approach provides a robust alternative to categorization or conventional linear-quadratic models for BMI, which limit the number of curve shapes. The approach is potentially useful in estimating the relationship between the full spectrum of BMI values and other health outcomes, or costs.