The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care

Perlin, Johnathan B; Kolodner, Robert M.; Roswell, Robert H.

doi:10.12927/hcpap..17381

Cited by 173 publications

(184 citation statements)

References 11 publications

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“…The Veterans Affairs (VA) is the largest integrated health care system in the United States that provided health care to more than 4.9 million subjects with a budget of $25 billion in 2003 [10]. As the veteran population is male predominant and arthritis is the fifth most common medical condition in veterans [11]; this population is well suited for studies of SpA.…”

Section: Introductionmentioning

confidence: 99%

Health care utilization in patients with spondyloarthropathies

Singh¹,

Strand²

2008

Rheumatology

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Objective. To study health care utilization in veterans with SpAs. Methods. In a postal survey of 70 508 veterans in Veterans Integrated Service Network (VISN)-13 from 1 October 1996 to 31 March 1998, demographics, smoking status and performance of activities of daily living (ADLs) were queried. Databases provided ICD-9 codes for AS, PsA and ReA; comorbidities; demographics; and health care utilization post-survey in respondents. Multivariable linear/logistic regression compared out-and inpatient health care utilization in SpA vs non-SpA, and its predictors in SpA. Results. A total of 1001 veteran respondents had diagnoses of SpA: AS, n ¼ 154; PsA, n ¼ 814; ReA, n ¼ 33. Veterans with AS, PsA and ReA, respectively, had significantly higher adjusted annual medical specialty (2.8, 3.6 and 3 vs 1.5; P < 0.0001), surgical care (3.3, 2.7 and 3.2 vs 1.9; P < 0.0001) and primary care visits (3.4, 3.0 and 2.3 vs 2.7, P ¼ 0.024). Multivariable-adjusted analyses showed that more ADL limitations and higher comorbidity were associated with higher in-and outpatient health care utilization in PsA and none of the predictors were significantly associated with utilization in AS. Conclusions. After adjustment for differences in demographics and comorbidities, more outpatient health resource utilization was observed in SpA patients. Further studies should focus on what leads to this increase in utilization, and whether any modifiable factors can be introduced to reduce health care utilization in PsA patients.

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Section: Introductionmentioning

confidence: 99%

Health care utilization in patients with spondyloarthropathies

Singh¹,

Strand²

2008

Rheumatology

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“…12,13 Smoking prevalence is 29%, very similar to the 30% prevalence seen among VA users nationwide. 5 During the study period, all providers used an electronic medical record, 14,15 which included clinical reminders for tobacco use. 15 Smoking cessation has been a nationally mandated VA guideline since 1996, with facilities held accountable for screening and advising rates.…”

Section: Design Study Settingmentioning

confidence: 99%

“…5 During the study period, all providers used an electronic medical record, 14,15 which included clinical reminders for tobacco use. 15 Smoking cessation has been a nationally mandated VA guideline since 1996, with facilities held accountable for screening and advising rates. 15,16 Sepulveda has an active Smoking Cessation Clinic (SCC), 17 providing pharmacotherapy and interdisciplinary counseling during 6-7 visits over 2 months.…”

Section: Design Study Settingmentioning

confidence: 99%

Effectiveness of an On-Call Counselor at Increasing Smoking Treatment

et al. 2007

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BACKGROUND: Smoking cessation programs are very effective, but little is known about how to get smokers to attend these programs. OBJECTIVE:To evaluate whether an "on-call" counselor increased smoking cessation program referrals and attendance. DESIGN:We randomly assigned 1 of 2 primary care teams at the Sepulveda VA Ambulatory Care Center to intervention and the other to usual care. The intervention team had access to an on-call counselor who provided counseling and care coordination. Social marketing efforts included educational outreach, provider feedback, and financial incentives. MEASUREMENTS:Baseline telephone interviews with a sample of 482 smokers were conducted, covering smoking history, health status, and smoking cessation treatments. Follow-up surveys were conducted at midintervention (n=251) and post-intervention (n=251).RESULTS: Two hundred ninety-six patients were referred to the on-call counselor, who counseled each patient in person and provided follow-up calls. The counselor referred 45% to the on-site program, and 27% to telephone counseling; of these, half followed through on the referral; 28% declined referral. Patients on the intervention team were more likely to report being counseled about smoking (68% vs 56%; odds ratio [OR] 1.7, CI 1.0-2.9) and referred to a cessation program (38% vs 23%; OR 2.1, CI 1.2-3.6); having attended the program (11% vs 4%; OR 3.6, CI 1.2-10.5); and receiving a prescription for bupropion (17% vs 8%) (OR 2.3, CI 1.1-5.1). The effect was not sustained after the case management period. CONCLUSIONS:Having access to an on-call counselor with case management increased rates of smoking cessation counseling, referral, and treatment. The intervention could be reproduced by other health care systems.

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“…At the time, performance-based bonuses could amount to 10 % of VA Network Directors' annual salaries. [14][15][16] In addition, financial incentives were often provided to managers and clinicians at VA facilities, at the discretion of Network Directors, based upon the results of the performance contract. 15 To qualify for the CoC measure denominator, patients needed to attend three visits at a VA specialty SUD treatment program within 30 days.…”

Section: Introductionmentioning

confidence: 99%

Are Improvements in Measured Performance Driven by Better Treatment or “Denominator Management”?

et al. 2016

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BACKGROUND: Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators. OBJECTIVE: In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-ofcare quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion. DESIGN: Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes. PARTICIPANTS: All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. MAIN MEASURES: The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact. KEY RESULTS: Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001). CONCLUSIONS: These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of Bshadow measures^to monitor and reduce undesirable denominator management.

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The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care

Cited by 173 publications

References 11 publications

Health care utilization in patients with spondyloarthropathies

Health care utilization in patients with spondyloarthropathies

Effectiveness of an On-Call Counselor at Increasing Smoking Treatment

Are Improvements in Measured Performance Driven by Better Treatment or “Denominator Management”?

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