Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act

Abstract

BACKGROUND:To address concerns about access to care, the Veterans Access, Choice, and Accountability Act of 2014 was enacted to make care available in the community when Veterans Health Administration (VA) care was unavailable or not timely. This paper examined VA referrals for diagnostic sleep studies from federal fiscal year (FY) 2015-2018. DESIGN: Sleep studies completed between FY2015 and 2018 for Veterans tested within VA facilities (VAF) or referred to VA community care (VACC) providers were identified using VA administrative data files. Sleep studies were divided into laboratory and home studies. KEY RESULTS: The number of sleep studies conducted increased over time; the proportion of home studies increased in VAF (32 to 47%). Veterans were more likely to be referred for a sleep study to VACC if they lived in a rural or highly rural area (ORs = 1.47 and 1.55, respectively), and had public or public and private insurance (ORs = 2.01 and 1.35), and were less likely to be referred to VACC if they were age 65+ (OR = 0.72) and were in the highest utilization risk based on Nosos score (OR = 0.78). Regression analysis of sleep study type revealed that lab studies were much more likely for VACC referrals (OR = 3.16), for persons living in rural areas (OR = 1.21), with higher comorbidity scores (OR = 1.28) and for ages 44-54, 55 to 64, and 65+ (ORs = 1.12, 1.28, 1.45, respectively) compared to younger Veterans. Veterans with some or full VA copayments (ORs = 0.91 and 0.86, respectively), and overweight Veterans (OR = 0.94) were less likely to have lab studies. CONCLUSIONS: The number of sleep studies performed on Veterans increased from 2015 to 2018. Access to sleep studies improved through a combination of providing care through the Veteran Choice Program, predominantly used by rural Veterans, and increased use of home sleep studies by VA.

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans’ experience with the VA TeleSleep program

“…Among patients who did access community care for testing, lack of follow up and poor continuity of care was an important factor influencing preference for VA, previously identified as a factor influencing satisfaction with outsourced care among both patients and providers [ 32 , 33 ]. Our findings further reinforce the need to improve coordination between VA and the community to mitigate potential satisfaction and patient safety issues [ 3 , 32 ].…”

“…In this qualitative evaluation of Veteran experience with the national VA TeleSleep program, Veterans reported high levels of satisfaction across multiple domains. Since implementation in 2017, the TeleSleep initiative has facilitated an increase in the number of Veterans diagnosed with OSA and in the number of encounters for sleep related disorders [ 3 ]. This study provides insight into Veterans’ experiences with TeleSleep and identifies factors affecting participation.…”

“…The convenience of an integrated health care system and affordability of VA services were important factors shaping preference. Previous research has shown increased access to sleep testing through both home testing and community-care, particularly among rural Veterans [ 3 ]. Our findings provide insight into Veteran preferences for location of care, specifically, the availability of home testing as another reason for preferring VA over community care.…”

“…Obstructive sleep apnea (OSA) is a highly prevalent chronic medical condition among Veterans enrolled in the Veterans Health Administration (VA) [ 1 ]. Between 2013 and 2018, utilization of VA sleep services increased an average of 16% per year [ 2 , 3 ]. In 2018 alone, over 1 million Veterans received sleep apnea care from VA [ 2 ], exceeding capacity of VA sleep programs and exacerbating long wait times.…”

Partnership Forum

“…Further analyses showed that in-person testing studies were much more likely for VCP referrals, for persons living in rural areas, those with higher comorbidity scores, and for older Veterans (age 44 and over) compared with younger Veterans. 15 During the Partnership Forum, we shared our current work in progress. This work suggests that Veterans’ care coordination needs will likely differ for those seeking primary care than those seeking specialty services in the community due to different risk profiles and social determinants.…”