Utilization and Health Outcomes for Veterans with Expanded Health Care Accessâ¯

扩大医疗保健服务范围的退伍军人的利用和健康结果

• 批准号: 10844340
• 负责人: TODD H WAGNER
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-07-01 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10844340
• 关键词: Affect; Age; Automobile Driving; Budgets; Caring; Censuses; Communities; Community Healthcare; Correlation Studies; Data; Diagnosis; Disease; Elderly; Eligibility Determination; Ensure; Etiology; Evolution; Future; General Population; Health; Health Insurance; Health Personnel; Health Services Accessibility; Health Services Research; Healthcare; Healthcare Systems; Improve Access; Individual; Insurance Coverage; Investments; Link; Location; Machine Learning; Measures; Medicare; Methodology; Methods; Natural experiment; Outcome; Patients; Persons; Policies; Prevalence; Privatization; Procedures; Provider; Publishing; Quality of Care; Records; Research; Research Methodology; Seminal; Services; Subgroup; Surveys; System; Techniques; Testing; Time; Veterans; Wait Time; Work; design; econometrics; evidence base; gaps in access; health care availability; health care service utilization; improved; innovation; mortality; novel; programs; randomized, clinical trials; satisfaction; treatment effect

Background: Improving access to high-quality care is a top priority for VHA. However, access is difficult to measure, especially in the ever-changing U.S. health care landscape. VHA currently focuses on perceived satisfaction measured from survey questions, or wait times measured with administrative data. The wait time metric has received considerable focus in both the Choice and MISSION Acts, yet experts recognize that wait times are imperfect; they are not only challenging to interpret, but they are rarely available from community providers, hindering any VHA to non-VA comparisons. VHA leaders tasked with implementing the Choice and MISSION Acts desire better evidence-based access measures so they can evaluate their program’s impact. Our inability to measure access threatens the future of VHA as a health care provider. Without new metrics that track gaps or improvements in access, VHA is likely to invest in the wrong initiatives, fueling critics who will argue that privatization will fix the programs Significance/Impact: Our objective is to develop new measures of access. These new measures will provide causal information on gaps in VHA services, while also showing the potential impact that expanded access would have on Veterans’ health. Our study leverages natural experiments in the form of arbitrary administrative rules that enable Veterans to access care outside VHA in the forms of Medicare and VA Community Care (VACC). Veterans close to the rule thresholds are similar, yet some gain access based on the rule, while the others do not. We can leverage this information to understand how this added access changes health care utilization and health outcomes. Our results will be useful to national and local VHA leaders as they grapple with how to best improve access with a limited budget. Innovation: It is not feasible to perform a large-scale randomized clinical trial to find the effect of access on utilization and health outcomes. Correlational studies will miss important confounders, and as everyone knows correlation does not equal causation, which is what VHA leaders need most. Instead, we apply novel econometric techniques to take advantage of natural experiments and find the causal effects of increasing access. The results from this approach can then be used as a measure of access for both VHA and non-VA care. This is directly aligned with HSR&D's priorities on access to care, research related to the MISSION Act, and advancing health services research methods across conditions or care settings. Specific Aims: Aim 1: Find the causal impact of Medicare eligibility on Veteran utilization and health, and identify procedures and diagnosis groups that are most affected. Aim 2: Find the causal impact of VACC on Veteran utilization and health, and find the procedures and diagnoses most affected. Aim 3: Identify subgroup analyses that would give crucial information to VHA leaders. Methodology: In Aims 1 and 2, we will apply an econometric technique called regression discontinuity design. We will gather a near complete census of VHA and non-VA records for all recent Veteran VHA users, allowing for precise claims-based measures of utilization, health, and mortality. In Aim 1, this approach leverages the sharp change in Medicare eligibility that occurs at age 65 to find the effect of Medicare on utilization and health. Aim 2 uses the same approach, but instead of age 65, we use the driving distance rules to find the effect of VA Community Care on utilization and health. For these aims we will examine both overall effects and procedure and diagnosis specific effects. In Aim 3, we take a combined approach of working with operational partners and applying machine learning techniques for heterogenous treatment effects to identify and examine metrics and measures that can be used for policy formation. Next Steps and Implementation: By working with operational partners through Aim 3, we will identify opportunities and barriers to implementing measures and metrics derived from our results. This information will be key to setting policy related to VHA’s evolution into a provider and payer of Veteran care while ensuring that Veterans receive high-quality care in both VHA and non-VA settings.

背景：改善获得高质量护理的机会是VHA的重中之重。但是，访问很难 措施，特别是在不断变化的美国卫生保健领域。 VHA目前专注于感知 从调查问题或用管理数据衡量的等待时间衡量的满意度。等待时间 公制在选择和任务行为中都已获得考虑的重点，但专家们认识到等待 时间不完美；它们不仅是解释的挑战，而且很少从社区获得 提供者，阻碍了非VA比较的任何VHA。 VHA领导者的任务是实施选择和 任务行为希望采取更好的循证访问措施，以便他们可以评估其计划的影响。 我们无法衡量访问权限威胁VHA作为医疗保健提供者的未来。没有新指标 VHA可能会投资错误的倡议，从而加剧了批判性，这些迹象的差距或访问方面的改善差距或改进 认为隐私将确定计划的重要性/影响：我们的目标是制定新措施 访问。这些新措施将提供有关VHA服务差距的因果信息，同时也显示 扩大访问权限的潜在影响将对退伍军人的健康产生。我们的研究利用自然 以任意行政规则的形式进行的实验，使退伍军人能够在VHA外访问VHA以外的护理 Medicare和VA社区护理（VACC）的形式。接近规则阈值的退伍军人相似 有些根据规则获得访问权限，而其他规则则没有。我们可以利用这些信息来理解 如何增加访问会改变医疗保健利用率和健康成果。我们的结果对 国家和地方VHA领导人在努力如何通过有限的预算来最大程度地提高访问权限。 创新：执行大规模的随机临床试验以发现访问对 利用和健康结果。相关研究将错过重要的混杂因素，众所周知 相关性并不等于原因，这是VHA领导人最需要的。相反，我们应用小说 计算技术利用自然实验并发现增加的因果 使用权。然后，这种方法的结果可以用作VHA和非VA的访问量度 关心。这与HSR＆D在获得护理的优先级，与《任务法》有关的研究， 并在条件或护理环境中推进卫生服务研究方法。具体目的：目标1： 找到医疗保险资格对退伍军人利用和健康的因果影响，并确定程序和 受影响最大的诊断组。目标2：找到疫苗对退伍军人利用的因果影响和 健康，找到最受影响的程序和诊断。 AIM 3：确定将会的亚组分析 向VHA领导者提供关键信息。方法论：在目标1和2中，我们将应用一个经济的 技术称为回归不连续设计。我们将收集几乎完整的VHA和NON-VA的人口普查 所有最近的资深VHA用户的记录，允许基于确切的利用率，健康和 死亡。在AIM 1中，这种方法利用了65岁时发生的Medicare资格的急剧变化 找到医疗保险对利用和健康的影响。 AIM 2使用相同的方法，但是我们不再是65岁，而是 使用驾驶距离规则来找到VA社区护理对利用和健康的影响。对于这些目标 我们将检查整体效果，程序和诊断特定效果。在AIM 3中，我们接受 与操作伙伴合作并应用机器学习技术的合并方法 异质治疗效果以识别和检查可用于政策的指标和措施 形成。下一步和实施：通过AIM 3与运营合作伙伴合作，我们将 确定从我们的结果中实现措施和指标的机会和障碍。这 信息将是设定与VHA的演变有关的政策的关键 同时确保退伍军人在VHA和非VA设置中都获得高质量的护理。