Evidence-based Synthesis Program 

(ESP)

I iI nterventions to Improve 

Veterans’ Access to Care

A Systematic Review of the Evid

Shannon M. Kehle, PhD

Nancy Greer PhD Nancy Greer, PhD

Center for Chronic Disease Outcomes Rese

Minneapolis VA Health Care System

May 11, 2011
Evidence-based Synthesis Program 

(ESP)

Ak ld c

knowledgements

Co-Authors/Collaborators

I d li R tk

Expert Panel/Reviewe

o In

d

uli

s

R

utk

s J h F t PhD

o Timothy J. Wilt, MD, MPH

o

J

o

hn 

For

tney, PhD

o Maurilio Garcia-Malo Bonnie Wakefield, P
Evidence-based Synthesis Program 

(ESP)

Di l sc osure

This report is based on research conducted by the Evidence-basSynthesis Program (ESP) Center located at the Minneapolis VA Synthesis Program (ESP) Center located at the Minneapolis VA 

System, Minneapolis, MN, funded by the Department of VeteranVeterans Health Administration, Office of Research and DevelopHealth Services Research and Development. The findings and c

in this document are those of the author(s) who are responsible contents; the findings and conclusions do not necessarily represviews of the Department of Veterans Affairs or the United Stategovernment Therefore no statement in this article should be cgovernment. Therefore, no statement in this article should be c

as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g.em

py , , , p p 

lo

yment, consultancies, honoraria, stock ownershi

p or o

ptio

testimony, grants or patents received or pending, or royalties) twith material presented in the report.
Evidence-based Synthesis Program 

(ESP)

VA Evidence-b d h i( 

base

d Synt

hesis 

(ES

Program Overview

• S d b VA Offi f R&D d HSR&D Sponsore

d

by VA Office o

f R&D an

d HSR&D.

• Established to provide timely and accurate 

syntheses/reviews of healthcare topics identified b

cli i i d li li

nicians, managers an

d poli

c

y-mak th 

kers, as they wo

improve the health and healthcare of Veterans. 

• Builds on staff and expertise already in place at the 

Evidence-b d i ( )d i d

base

d Practice Centers 

(EPC

)

designate

d

Four of these EPCs are also ESP Centers: 

o Durham VA Medical Center; VA Greater Los Angeles He

System; Portland VA Medical Center; and Minneapolis VCenter.
Evidence-based Synthesis Program 

(ESP)

• P id id th i t t li i l 

Provides evidence syntheses on impor

tan

t cli

nical 

topics relevant to Veterans, and these reports help:

o develop clinical policies informed by evidence, 

o the implementation of effective services to improve 

the implementation of effective services to improve 

outcomes and to support VA clinical practice guideperformance measures, and 

o guide the direction for future research to address g

guide the direction for future research to address g

clinical knowledge.

• Broad topic nomination process – e.g. VACO, VISNs

facilitated by ESP Coordinating Center (Portland) thfacilitated by ESP Coordinating Center (Portland) th

online process: 

http://www.hsrd.research.va.gov/publications/esp/TopicNomin
Evidence-based Synthesis Program 

(ESP)

• St i C itt ti h d 

Steering 

Committee representing researc

h an

d ope

(PCS, OQP, ONS, and VISN) provides oversight and program direction.

• T h i l Ad i P l (TAP) Tec

h

nical Ad

visory 

Panel (TAP)

o Recruited for each topic to provide content expertio Guides topic development; refines the key questiono Reviews data/draft report Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews and comments on draft report

•

Fi l d b i d di 

inal reports poste

d on VA HSR&D we

b

site an

d diss

widely through the VA. 

http://www.hsrd.research.va.gov/publications/esp/reports.
Evidence-based Synthesis Program 

(ESP)

Current Report

I i I V ’A Interventions to Improve 

Veterans’ A

to Care

A Systematic Review of the Eviden

(January, 2011)

Full

-length report available on ESP website: length report available on ESP website:

http://www.hsrd.research.va.gov/publications/esp/reports.
Evidence-based Synthesis Program 

(ESP)

Back dgroun

d

• Access & Downstream Outcomes

o

VA’s new conceptualization of access distinguishes 

from downstream outcomes (e.g. satisfaction, qualand functioning).

o It i i t t t i th i t f i d It is impor

tan

t

to examine the impact o

f improve

d 

these downstream outcomes.

• Goal of the Review

o R i k l d di th li k b t 

Review 

knowle

dge regarding the li

n

k

b

e

tween acce

healthcare and system-level and patient-level outco

o Given VA's commitment to improving access, exam

effect of interventions designed to improve access effect of interventions designed to improve access 

and downstream outcomes
Evidence-based Synthesis Program 

(ESP)

Back

ground 

– Conce

ptual Mode
Evidence-based Synthesis Program 

(ESP)

K Q ti ey 

Questions

• Key Question 1

• What is the evidence that variation in veterans’ ability 

needed health care (i.e., access) contributes to variatiosystem level (e g utilization satisfaction) or patient lesystem level (e.g., utilization, satisfaction) or patient le

quality of life, functional ability, mortality) outcomes?

• Does the effect of access on system and/or patient leve

Does the effect of access on system and/or patient lev

outcomes differ by patient (e.g., demographics, overall illness severity), treatment (e.g., mental health, physicor settin

g ( g , , , y, ) (e.

g., rural, urban, community, VA

) characte
Evidence-based Synthesis Program 

(ESP)

K Q ti ey 

Questions

• Key Question 2

o What is the evidence that variation in veterans’ ability 

What interventions have been successful in improving patient populations with reduced health care access? patient populations with reduced health care access?

o Have interventions that have improved health care acc

improvements in system level and patient level outcomimprovements in system level and patient level outcom
Evidence-based Synthesis Program 

(ESP)

Method

• The topic was nominated by the Planning Committee for the 

The topic was nominated by the Planning Committee for the 

VA HSR&D Access SOTA Conference 

• TEP members collaborated to identify and refine the key qu

• S h d MEDLINE (OVID) CINAHL d Searc

h

e

d MEDLINE (OVID), CINAHL, an

d P INFO sycINFO f t d

or s

t

ud

published from 1990 to June, 2010

• MEDLINE search terms: Health Services Accessibility, acces

V t U it d St t D t t f V t Aff i d V

e

terans, 

U

nite

d Sta

tes 

Depar

tmen

t o

f

V

e

teran Affairs, an

d

Hospitals, Veterans 

• Also searched the reference lists of articles identified for inc
Evidence-based Synthesis Program 

(ESP)

Method

• Exclusion Criteria: Not English language Exclusion Criteria: Not English language

1. Not United States veteran population2. Not published from 1990 to June 20103. Not about access to health care Not about access to health care4. Not about outcomes of interest5. Not peer-reviewed (including meeting abstracts and presentations)

• Constructed evidence tables with patient characteristics, ou

and study quality for each study included

• Pooled anal

y gy 

ses were not feasible due to hetero

geneity in s

design and outcomes
Evidence-based Synthesis Program 

(ESP)

Method

• RCTs and cohort studies were assigned a rating of good fa

RCTs and cohort studies were assigned

a rating of good, fa

poor using the United States Preventive Services Task Forc

• Observational studies were rated in the domains of: 

o pa ticipant selection (app op iate ec itment of s bjects esponse 

pa

rticipant selection (app

rop

riate recruitment of

s

ubjects, response r

representativeness)

o outcomes assessment (valid and reliable measures, no differential or 

high loss to follow-up)

o analysis (potential confounders equally distributed or adjusted for in 

• If all three were rated as adequate, the study received an 

rating of fair. All other observational studies were rated as 

• Draft report reviewed by TEP and peer reviewers
Evidence-based Synthesis Program 

(ESP)
Evidence-based Synthesis Program 

(ESP)

K Q ti ey 

Questions

• Key Question 1. Key Question 1. What is the evidence that var

What is the evidence that var

veterans’ ability to obtain needed health care (i.e

access) contributes to variation in system access) contributes to variation in system

-level (

level (

utilization, satisfaction) or patient-level (e.g., qua

life, functional ability, mortality) outcomes? 
Evidence-based Synthesis Program 

(ESP)

K Q ti 1 Key 

Question 

1

 23 studies (22 datasets) 23 studies (22 datasets) 9 cohort, 14 cross-sectional 4 good quality, 13 fair quality, 6 poor qu Sample sizes: 109 to >3 million Sample sizes: 109 to >3 million
Evidence-based Synthesis Program 

(ESP)

K Q ti 1 Key 

Question 

1 - S t ys

tem-l lO t evel O

u

tco

Outpatient services: Outpatient services: Decreased use as distance increased Other factors: age, comorbid conditions

health status, cost, VA financial support, sohealth status, cost, VA financial support, so

support
Evidence-based Synthesis Program 

(ESP)

K Q ti 1 Key 

Question 

1

– S t ys

tem-l lO t evel O

u

tco

In

patient services:

 Increased admission and readmission w

increased distance and comorbidity

 Increased admission for ACSCs if longer 

wait time wait time

 VA or non VA or non

-VA care choice associated wit

VA care choice associated wit

distance and health condition
Evidence-based Synthesis Program 

(ESP)

K Q ti 1 Key 

Question 

1

– P ti t a en

t

-l lO t evel O

u

tco

 Mortality

– associated with distance from associated with distance from

admitting hospital, age, and comorbid cond

 Quality of life, self-reported health – limiinformation
Evidence-based Synthesis Program 

(ESP)

K Q ti 1 Key 

Question 

1 - C li onc usions



The maj y orit of studies focused on distan

from a VA facility and utilization of VA servi Few studies included patient-level outcom Future research should include other ele

Future research should include other ele

of access to care and other outcome measu
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

o What interventions have been successful in improving 

patient popul h d dh lh ? lations wit

h re

duce

d

healt

h care access?

o Have interventions that have improved health care acc

improvements in system level and patient level outcomimprovements in system level and patient level outcom
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

• We identified 26 articles (24 unique studies); 5 R• During abstraction, we found that the articles rep

five distinct types of interventions

o Community Based Outpatient Clinic (CBOCs)o Primary ( )g Care Mental Health 

(PCMH

) Inte

gration

o Intensive Case Managemento Telemedicineo Copaymentso Others
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2 - CBOCS

• Opening of satellite primary care clinics• 6 articles (5 unique studies); no RCTs, but four p

post-implementation articles

• 3 fair quality; two poor quality 3 fair quality; two poor quality• Sample sizes large – one study VA-wide• Access Outcomes

o All six articles showed CBOCS were associated with imp

All six articles showed CBOCS were associated with imp

access

o Four articles showed improvements in objective measu

more veterans in care decreased travel time more veterans in care, decreased travel time, decrease

decrease

time).

o Two showed Veterans were satisfied with access
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2 - CBOCS

• System-Level Outcomes

o Five studies reported system-level outcomeso More primary care visitso Better satisfaction with care / fewer problemso Mi d fi di di i l ili i Mixe

d fi

ndings regarding specialty care utilization

• No studies reported patient-level outcomes
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– PCMH I t ti PCMH In

t

e

grati

• Colocation of primary care and mental health ser• 6 articles (5 unique studies); two RCTs• One good quality; two fair quality; two poor qua• Two studies examined the integration of PC into 

Two studies examined the integration of PC into 

clinics; two examined the integration of MH into clinics; and one study (two articles) examined th

integ ation of MH PC and homeless se ices integ

ration of MH, PC, and homeless services

• Access Outcomes

o All studies showed improved access (e.g. shorter wait t

b tt ti f ti t ) b

etter sati

sfaction, more ve

terans seen

)
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– PCMH I t ti PCMH In

t

e

grati

• System-Level Outcomes

o All studies reported system-level outcomeso More likely to receive “optimal care” for depressiono More primary care visitso M i ore preventative careo Fewer ER visits

• Patient

-le el o tcomes le

vel

o

utcomes

o Three studies report patient-level outcomeso Findings mixed

3⁄4 Two found no differences Two found no differences3⁄4 One found better SF-36 physical component scores
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– It i C M 

In

tensive 

Case 

Mana

• High intensity care coordination to increase access 

services for veterans with high levels of health care 

• 2 articles; one RCT• One good quality; one poor quality One good quality; one poor quality• Access Outcomes

o One study found that over 56% of veterans got a referra

One study found that over 56% of veterans got

a referra

o One study reported shortened time between hospital disc

primary care visit & better satisfaction
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– It i C M 

In

tensive 

Case 

Mana

• System-Level Outcomes

o One study reported system-level outcomeso More likely to have at least one GMC visit and more GMC 

six months

o M lik l h h i l d i i d 

More lik

ely to 

have 

hospital rea

d

missions an

d spent mor

inpatient

• Patient

-le el o tcomes le

vel

o

utcomes

o One study report patient-level outcomeso No difference between groups
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– T l di i T

elemedi

cine

• Conducting encounters via telephone or interactive 

conferencing

• 4 articles; one RCT• Two fair quality; two poor quality Two fair quality; two poor quality• Two studies examined using telemedicine to help p

communicate with existing providers; two studies ethe se of telemedicine to cons lt ith off the use of telemedicine to cons

ult with off-site spe

site spe

• Access Outcomes

o Three studies reported veterans were satisfied with telemo O t d f d t l di i lt d i One s

t

u

dy 

foun

d

telemedi

cine resulte

d in more care-coor

initiated primary care visits
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– T l di i T

elemedi

cine

• System-Level Outcomes

o All four studies reported system-level outcomeso Two studies reported veterans were satisfied with care / 

process

o T f d diff b Two 

foun

d no differences 

between groups

• Patient-level outcomes

o Od i ne stu

dy report patient-l l eve outcomes

o Reported better mental health component summary sco

Health Related Quality of Life scale
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C t opaymen

t

s

• Change in medication copayments• 4 articles; no RCTs, all cohort studies• Four fair quality• All large samples including two VA All large samples, including two VA

-wide studies wide studies

• Access Outcomes

o All four studies found that higher copayments resulted in 

All four studies found that higher copayments resulted in 

to medications (e.g. worse adherence, lower refill rates)
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C t opaymen

t

s

• System-Level Outcomes

o One study reported system-level outcomeso Among Veterans with schizophrenia, the group with cop

were more likely to have a psychiatric admission

• No studies reported patient-level outcomes
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– Oth I t ti Other In

terventi

• Four studies reported on other interventions (one 

each)

o Outreach (providing information on how to access care)

quality RCT

o Presence of a specialized rehabilitation unit with a hospi

quality

o Implementation of a health liver program with a substan

cli i li li

nic; poor quality

o Implementation of a mobile care clinic; poor quality
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C li onc usions

•Access to healthcare can be improved through struorganizational interventions•Evidence was strongest (4 fair studies) for interven

Evidence was strongest (4 fair studies) for interven

regarding medication copayments

oIncreasing medication copayments negatively impacted adoCopayment increase led to increased levels of psychiatric Copayment increase led to increased levels of psychiatric

hospitalization

oUnclear whether decreasing copayments would improve a

increase access.
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C li onc usions

•The implementation of CBOCs and PCMH integratiopromising strategies •Five studies found a positive association between t

Five studies found

a positive association between t

opening of CBOCs and access to primary care

oWhile none of the CBOC articles were RCTs, four were fair cohort designs with large sample cohort designs with large sampleoDownstream outcomes, other than primary care utilization

clear
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C li onc usions

•Five studies found a positive association between Pintegration and access. 

oOne fair quality, one good quality RCToImproved access & improved preventative careoSome evidence of improved patient-level outcomesoLess intensive models of PCMH implemented within CBOC

significant positive impact on access

oPCMH i i h i h h 

PCMH integration s

how promise, 

however, more researc

h 

the models of integration is needed
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C li onc usions

•19 of the 24 unique studies reported system 19 of the 24 unique studies reported system

-level o

level o

•Two most frequently reported system-level outcom

sati f ti ith d b f i 

ti

sfaction with care an

d num

ber o

f primary care v

oLarge majority of studies found veterans were satisfied wi

following the intervention

oAll but one of the studies that reported utilization found th

All but one of the studies that reported utilization found th

intervention was associated with increased primary care ut

oFindings regarding the use of specialty care and hospitalizmixed. 
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– C li onc usions

•Only six of the 24 unique studies reported patient Only six of the 24 unique studies reported patient

-

outcomes. 

oThree reported no significant impact of access on outcomeoTwo reported improved functioning (physical and mental h

Two reported improved functioning (physical and mental h

oOne had mixed findings

•No conclusions can be made regarding patient No conclusions can be made regarding patient

-leve

outcomes
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– Li it ti Li

mit

ations

•We identified a number of well designed studies th

We identified

a number of well designed studies th

examined access interventions that were not includebecause they did not include data regarding access 

•Given the small number of high quality studies and relatively small number of studies in support of a spintervention, all findings require further validation
Evidence-based Synthesis Program 

(ESP)

K Q ti 2 Key 

Question 

2

– Ft R 

u

ture 

Researc

•When studying interventions hypothesized to impro

When studying interventions hypothesized to impro

access, measures of access need to be collected and compared across groups

•E i h th d i t ld 

Examine wh

ether a 

decrease in copaymen

ts would 

access to needed medications; compare cost to otheinterventions

•Examine the quality of care that comes with increaaccess; Are Veterans getting access to high quality, based care? based care?•Go beyond utilization as an outcome
Evidence-based Synthesis Program 

(ESP)

Dii i scussion & 

Questions

If you have further questions If you have further questions, 

feel free to contact:

Sh K hl PhD Shannon 

K

ehle, PhD

612-467-1564

Shannon.Kehle@va.gov

The full report and The full report and cyberseminar cyberseminar presentation is available on the E

presentation is available on the E

http://www.hsrd.research.va.gov/publications/esp/