27

Interventions to Improve Veterans’ Access to Care Evidence-based Synthesis Program

APPENDIX A. SEARCH STRATEGY

Database: Ovid MEDLINE(R) <1950 to May Week 4 2010>

Search Strategy:

--------------------------------------------------------------------------------

1 exp *Health Services Accessibility/ (34616)

2 limit 1 to (english language and humans and yr=”1990 -Current” and “all adult (19 plus years)” 

and english) (6577)

3 *Veterans/ (4309)

4 *United States Department of Veterans Affairs/ (1252)

5 *Hospitals, Veterans/ (2008)

6 or/3-5 (6992)

7 2 and 6 (75)

8 access.mp. (114750)

9 6 and 8 (287)

10 limit 10 to (english language and humans and yr=”1990 -Current” and “all adult (19 plus 

years)” and english) (182)

11 7 or 10 (209)
28

ans’ Access to Care Evidence-based Synthesis Program

R REVIEW COMMENTS AND AUTHOR RESPONSES

RESPONSE

and methods for this review clearly described? 

t the search strategy:

to access that appears to be addressed in KQ1 was 

umerous other relevant barriers and facilitators to access 

d in KQ1, including price/income, social support, health 

alth systems (e.g., Medicare). These are all implied by 

ure 1, but only distance receives attention. A Medline 

es Accessibility” in Appendix A missed articles that 

ies that I expected to be included in KQ2.

te whether specific types of studies were explicitly 

some reason. There may not have been such exclusion, 

.

n types of interventions discussed in KQ2 would be 

had some other studies in mind and wondered what 

a. Thank you for the suggestion. We revised the KQ1 section to highlight other barriers and facilitators to access. To re-do the search at this point would markedly expand the scope and practice.b. The inclusion and exclusion criteria are outlined in the method section. We attempted to clarify that for KQ1, we included only studies that reported on how a measure of access impacted systemlevel or patient-level outcomes. Further, for KQ2, we included only studies that reported impact of the intervention on a measure of access (objective, subjective, or satisfaction with access).c. We clarified that the types of interventions were not a priori categories used in the search, but rather, we developed after the search as a way to more cohesively present the findings. A brief description of each of the types of interventions is now presented in Table 2.

bias in our synthesis of the evidence? 

above, I expected to see a review of other barriers to 

ponse to KQ1. Not sure if it represents a bias per se.

As noted above, we revised the KQ1 section.

r of studies reviewed in KQ2 that were not and it isn’t 

cluded. Not sure if it represents a bias per se.

xpected to see the following cites: Maciejewski et al. 

 2010..

ase management, I expected to see Bosworth Ann Intern 

9; Piette 2001 (diabetes); Heisler Ann Intern Med 2010; 

y VA researchers

clude papers by Stroupe Medical Care 2007 and Doshi 

Thank you for the suggested references. We have reviewed these citations and have included those that met our inclusion criteria.

 unpublished studies that we may have overlooked?

scussion of 2 Medicare papers), there are a number of 

ks, West, Liu, Morgan) that also address this issue of 

s that should be incorporated.

health applications to improve access, all published 

heVet, telemedicine, nurse case management via 

eviewed and included.

a. We have reviewed the suggested references and included those that met our inclusion criteria.b. We have included studies of e-health applications if they met our inclusion criteria and presented data regarding the impact of the intervention on a measure of access (objective, subjective, or satisfaction with access).
29

ans’ Access to Care Evidence-based Synthesis Program

ortant topic. It is even more important now that the VA 

o all clinics. This mandate makes it even more important 

ature and its limitations.

Thank you.

e much more attention to the quality of studies 

ld like some summary for each section of the types 

buting data to the discussion. There seems to be little 

nd cross-sectional studies as an example ---- no clear 

hors on how the reader should weight the study findings.

We agree and have added information about study type and quality.

distance from the VA” should be considered separately 

nd one is controlled by the patient. It seems to me that 

ient health outcomes and their association with distance 

cal system) are almost meaningless. Unless the studies 

 status, SES, patient choices, etc., the findings are not 

ation of access. It is impossible to know whether patients 

 are similar to those that are closer. Patients choose 

sons some of which could be controlled for if assessed 

 be able to be accounted for in an observational study. 

s studies that attempted to control for other factors, the 

nd weight the studies by their attempts to control for 

n the other hand, waiting times are within the control of 

 to be confounded by patient factors. I feel strongly that 

d be a subsection relating to key questions 1 and 1a. In 

weighting of the studies, these issues should be more 

Thank you for the suggestion. However, in light of the suggestion to include other barriers/facilitators, we modified the response to KQ1 to highlight factors other than distance and wait time. We organized the section by clinical area. We have rated the quality of the included studies and control of potential confounding factors was an important consideration in assigning the quality rating.

ummary of findings at the beginning of a section awkward 

hould come at the end, not the beginning of a section.

We moved the summary of findings to the end of each section.

s fairly strong yet is not discussed much if at all in the 

ly good and important data that could make a difference 

We agree and we added a discussion of the copayment studies to both the conclusions and future research sections.
30

ans’ Access to Care Evidence-based Synthesis Program

ng the literature you found under each subsection. For 

utcomes” section, I think it would be much easier to 

e what you found for these types of studies there rather 

paragraph on page 4 that precedes this section. I would 

17 studies. Were they cross-sectional, prospective or 

 RCTs and what was their quality? I would like to know 

tribute to the section. It might even make sense to divide 

clude both system level and patient level outcomes in one 

ute to both outcomes.

Thank you for the suggestion. We have added information about study design and quality to the text.

miologic thought in the discussion. The issue of more care 

 deserves a little more discussion than it was given. The 

scussed more fully in this regard.

Thank you for the suggestion. We expanded our discussion of the issue as to whether more care equates with better care and reference Weinberger 1996 as an example.
31

ans’ Access to Care Evidence-based Synthesis Program

ENCE TABLES

iation in outcomes associated with variation in access (KQ1)

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

lusion: Responders 

the 1987 Survey of 

terans (SOV) 

Choice of VA over other outpatient options and amount of VA outpatient useDistance, characteristics of closest VA facility, age

1) Likelihood of using VA for outpatient services decreased as distance increased up to 60 miles (little change beyond 60 miles)2) For veterans who choose some outpatient VA services, distance has a smaller additional effect on number of visits

N/A* Effect of distance on number of 

outpatient VA visits is greatest for those >65 yrs

lusion: ≥18 years 

age, first seen 

h at least one of 

sustained fever, 

nvoluntary weight 

s, c) sustained 

rrhea

clusion: cognitive 

pairment

Overall perceived access, temporal access, health related quality of life (HRQOL)Age, gender, race, mode of HIV transmission, education, income, marital status, log of CD4 counts, symptoms

Prevalence of access problems:Cost of care: 49%Office hours: 48%Location: 34%Appt. w/ Specialists: 15%Transportation time>30 min: 55%>1 hour: 17%# days to schedule urgent appt>1 day 50%>2 days 23%Office wait time>1 hour 54%>2 hours 32%

Better overall perceived access to care associated with better HRQOL for 8 of 11 scales including overall quality of life (p<0.001); temporal access scores not significantly associated with HRQOL

Adjusted access scores for VA care significantly (p<0.05) higher† for:a. covering cost of care (vs. uninsured)b. availability of emergency care (vs. uninsured or Medi-Cal)c. availability of hospital care (vs. uninsured)d. office wait time (vs. uninsured or Medi-Cal)VA scores significantly (p<0.05) lower for:a. convenience of contacting provider (vs. uninsured or Medi-Cal)b. transportation time (vs. Medi-Cal)

lusion: discharged 

the community 

m VA inpatient 

ychiatry and bstance abuse 

ograms during 

month period in 

94-95, primary 

ychiatric or bstance abuse 

order and 

condary medical 

orders

Four measures representing access, timeliness, and intensity of outpatient medical services utilizationSystem-facility factors (e.g., region, hospital size, academic emphasis, specialization in mental health care)Predisposing factors (e.g., age, gender, race, marital status, diagnosis of psychiatric or substance abuse)Enabling factors (e.g., compensation, proximity, receipt of psychiatric or substance abuse services within 30 days of discharge)Illness leading to seeking treatment

Proximity to VA clinic, receipt of VA compensation payments, mental health follow-up within 30 days of discharge, and psychiatric diagnosis associated (p<0.01) with receipt of medical-surgical follow-up within 6 month post-discharge, receipt of medical services within 30 days post-discharge, number of days from discharge until first medical visit (among those with a visit), and number of visits in 6 month post-discharge

N/A N/A
32

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

lusion: non

titutionalized, 

ntified by random it dialing and 

m lists of patients 

rolled in VA health 

re or receiving VA mpensation or 

nsions

Treatment use over past 12 months – VA and non-VA outpatient health care visits, VA and non-VA mental health treatmentGender, age, race, education level, marital status, combat exposure; health insurance status, employment status, urban/rural residence; disability status, SF-12 mental and physical health components

Outpatient health care:1) VA visit counts associated with younger age, unmarried status, lack of health insurance, unemployment, disability rating, poorer physical health (all p<0.01) 2) non-VA visits associated with female gender, older age, college education, unemployment, disability rating, poorer physical and mental health (all p<0.01) Mental healthcare use:1) VA use associated with younger age, unmarried status, unemployment, lack of health insurance2) non-VA use associated with female gender, younger age, college education, unmarried status, unemployed, urban residence, and poorer physical and mental health

N/A N/A

lusion: English 

eaking, receiving 

atient or outpatient 

ntal health service 

HS), mid 2004 to 

d 2006 

MHS utilization (outpatient, inpatient, residential), Global Assessment of Functioning (GAF), and Behavior and Symptoms Identification Scale-24 (BASIS-24) after 3 monthsDemographics, partial self-pay for care, employment, social support, emotional support, problems getting to treatment, housing, level of care at enrollment, baseline GAF and BASIS-24, diagnoses, comorbidities, disability, service connection, MHS use 6 months prior

1) Increased outpatient utilization among patients who reported fewer access problems and no social support (both p<0.05); greatest predictor of use was clinical need2) Increased inpatient hospitalization associated with homelessness; greatest predictor was clinical need

GAF and BASIS-24 at 3 months not significantly related to access or outpatient utilization; inpatient hospitalization predicted worse GAF and BASIS-24 at 3 months

N/A
33

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

lusion: Primary gnosis of alcohol 

pendence; 

mpleted VA 

atient program, 

charged 

h outpatient 

pointment, resided 

primary service 

ea of the inpatient 

ility 

Attendance at aftercare appointment within 30 days of dischargeTravel distance, socio-medical characteristics (age, race, severity of illness, marital status, level of urbanization)

Patients living farther from the treatment program were less likely to choose to attend their aftercare appointment as were urban residing (with distance held constant) patients and unmarried patients

N/A Older patients and rural residents 

more negatively affected by distance than younger patients or urban residents 

lusion: Walk-ins to 

ychiatric Evaluation 

nic in Emergency 

dicine Service

clusion: missing 

ta, out of state 

idence, restricted dical records

Disposition (admission or outpatient appointment) Age, marital status, employment status, ethnicity, travel distance, number of psychiatric and medical comorbidities, number of psychosocial and environmental problems, current GAF

Admissions: 17% of those living <60 mi from VAMC; 43% of those living 60+ mi from VAMC (p=0.003); controlling for case mix OR=4.8 [1.06-22.1]; age >65 and lower GAF also associated with increased likelihood of admission

N/A N/A

lusion: homeless, 

rious mental 

ess, not involved in 

going community 

atment

Lifetime use of VA health servicesAge, gender, marital status, race/ethnicity, education, military service era, addiction severity, health problems, service connection, income, residence in city with VA hospital

Veterans with service connected disabilities or non-service connected pensions or veterans living in cities with VA medical centers or hospitals were more likely to have used VA services (all p<0.05)

N/A N/A

lusion: presently 

recently 

meless military 

erans; identified 

community, VA 

spitals and clinics, 

eran’s centers, 

sons

Use of any VA services in past 6 months Metropolitan/non-metropolitan location, demographics, military history, living situation, employment, medical history

Greater use associated with metropolitan location and VA financial support (p<0.001) 

N/A Significant interactions - metro/nonmetro & use of services (p<0.05): 

Age, military service period, monthly income, time homeless, past alcohol or drug dependency
34

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

lusion: Vietnam 

rvice, living on or 

hin 50 miles of 

ervation, born 

tween 1930 and 58

OTE: VA services 

scribed by authors 

more readily 

ailable for Northern 

ains veterans

Use of VA, Indian Health, other biomedical health services, and traditional healer (inpatient in past year, outpatient in past 6 months)

Significantly greater (p≤ 0.05) use of VA services by veterans from Northern Plains reservation communities for physical and mental health problems; significantly greater (p≤ 0.001) use of traditional healer by Southwest reservation veterans

N/A N/A

usion: discharged 

m internal medicine, 

gery, intermediate e, or neurology vices or a tertiary e VA medical center 

81 to 12/31/82 

usion: patients 

mitted to psychiatry 

vice, uncertainty 

ut readmission 

Early readmission (within 30 days of discharge) for any reasonLocation of residence (relative to VA medical center), number of surgical procedures, compensation and pension status, readmission risk class (based on diagnosis-related group), bed section of discharge, age

Increased distance of county of residence from VAMC associated with non-significant increased probability of early readmission; significantly increased probability if two or more surgeries performed, readmission risk above “very low,” or patient on intermediate, neurology, or surgery service at discharge 

N/A N/A

usion: veterans 

ble to use VA and 

dicare health care 

999, had used VA 

th services between 

7 and 1999

usion: veteran 

us unknown, missing 

nvalid zip code, lived 

uerto Rico or other 

territory, ≤65 years 

on 1/1/99, end-stage 

al disease, enrolled 

edicare+Choice 

e

VA and Medicare use (outpatient and inpatient services)Age; gender; race; vital status; VISN; priority level in VA;, health status risk score; distance to nearest VA inpatient hospital, VA outpatient center, and Medicare inpatient hospital; ZIP code (for poverty level); number of physicians, general hospitals, and beds in county of residence

Outpatient: decreased likelihood of exclusive use of VA as distance to VA increased; older age, higher health risk status, urban residence, and more hospital beds in county also associated with decreased exclusive use of VA; black race, high VA priority level, and high poverty level associated with increased exclusive use of VAInpatient services: same pattern(all p<0.01)

N/A N/A
35

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

usion: traumatic 

ons or demyelinating 

ase of the spinal 

d; intraspinal, 

malignant plasms, vascular 

lts, cauda equina 

drome, inflammatory 

ase of the spine, 

table traumatic 

ons of the spinal 

mn

usion: multiple 

rosis; missing, 

lid, or non U.S./

rto Rico zip code; 

bile clinic use; 

esidential care 

ent; home care and health related clinic 

s, no VA utilization

Number of outpatient visits; number of inpatient dischargesHistory of illness, travel distance to actual facility used; travel distance to nearest facility, age, race, gender, marital status, level of injury

Patients utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000); increased age, non-white race, and history of respiratory, kidney/urinary tract, circulatory, or digestive system disease associated with increased outpatient utilization (all p<0.01)Patients had less inpatient utilization if they lived at greater distances (p<0.000); history of illnesses of respiratory, skin/subcutaneous tissue/breast, kidney/urinary tract, circulatory, or digestive systems associated with increased inpatient utilization (all p<0.02)

N/A N/A

usion: diagnosis 

polar disorder, 

zophrenia, or other 

chosis in year FY 

0 with some VA 

tact in FY 1999

usion: little or no 

ngness to seek VA 

e, homeless, stay of 

+ days, died in FY 0

Total outpatient non-psychiatric visit days, total outpatient psychiatric visit daysAge, gender, race/ethnicity, marital status, urban/rural residence, distance to nearest relevant VA provider; psychiatric diagnosis type; comorbidity level, initial treatment location of FY

Patients further from outpatient care had fewer outpatient non-psychiatric visit days; older age, married, female, rural residence, initial visit at outpatient non-psychiatric facility, and higher comorbidity rating associated with increased visit days (all p<0.01)Patients further from psychiatric services had fewer outpatient psychiatric visit days; initial visit at non-psychiatric facility, higher comorbidity rating, and rural residence also associated with fewer psychiatric visits (all p<0.001)

N/A Negative effects of distance on 

outpatient non-psychiatric visits - greater for patients with schizophrenia than bipolar disorders and for patients >65 yrs; on outpatient psychiatric visits - greater for patients with schizophrenia and for ages 45 to 65 yrs.
36

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

usion: diagnosis of 

zophrenia or bipolar 

rder in FY 1998

usion: missing data 

laska resident

Time to first 12-month gap in 1) VA health services utilization and 2) VA mental health services (through the end of FY 2002)Age, gender, marital status, race/ethnicity, VA service connection status, homelessness, primary psychiatric diagnosis, comorbidity index, distance to nearest VA service site or VA provider of substantial psychiatric services, inpatient care in FY 1998, VA and non-VA inpatient beds per 1000 county residents

Risk of gap in health service utilization increased with increased distance to nearest VA facility, homelessness, inpatient stay in FY98, and unknown or non-white race; decreased with more VA beds, increased age, female gender, married, VA service connection, higher comorbidity score, diagnosis of schizophrenia (all p<0.05)Risk of gap in mental health utilization increased with residence further from VA psychiatric service site, age, female gender, non-white race, homelessness, higher comorbidity score, inpatient stay in FY98; decreased with married, VA service connection, diagnosis of schizophrenia (all p<0.05)

N/A N/A

usion: enrolled in 

A and Medicare for at 

t 1 month in 2002

VHA pharmacy useHealth status, income, race/ethnicity, age, metropolitan/nonmetropolitan status, participation in Medicaid, VA priority status

Decreased likelihood of using VHA pharmacy if enrolled in Medicare HMO plan with pharmacy benefits, older than 65 yrs, income of $20,000 or greater, female, priority status other than 1 (no copayment), Medicare state buy-in, resident of metropolitan statistical area, and patient at a teaching hospitalIncreased likelihood if Hispanic race and poorer health status

N/A N/A

usion: inpatient or 

patient VA or Fee 

s use FY 2003 & 

4 who were also 

dicare enrollees 

uding < 65 yrs)

usion: missing 

rity classification, 

nostic data, or ZIP 

e; died in FY 2003 or 

4; ZIP code outside 

S

Reliance on VA health care (overall, inpatient, outpatient)Age, gender, race, differential distance (distance to VA Medical Center minus distance to non-VA hospital), priority classification, aggregated conditions categories (ACCs)

Overall increased reliance on VA care if differential distance is lower, if under age 65, or if disability or low income VA priority classification; mental health and substance abuse ACCs significantly associated with increased reliance on VA careSimilar results for outpatient carePatients with transplant and amputation ACCs more likely to have inpatient VA care; other ACCs associated with inpatient VA care included infectious and parasitic disorders, substance abuse, mental health disorders, and eye disorders

N/A Interaction of age and distance was 

significant but parameter effects were less than main effectsMental health and diseases of eyes, ears, nose, and throat associated with increased reliance on VA care for <65 yr groupMental health, substance abuse, diabetes, and infectious diseases associated with increased VA care for ≥65 yr group
37

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

usion: Admitted to 

acute care hospital, 

harge diagnosis of 

cardial infarction usion: Death or 

dmission within 90 

s of index discharge; 

x length of stay 

0 days, reside >100 

rom a source of VA 

e or >200 mi from 

mitting facility 

Outpatient medical care visits within 30 and 90 days of discharge following acute MI admission; death from all causes or recurrent cardiac admission 91 to 365 days after dischargeAge, VA service connection, comorbidity index, alcoholism, teaching hospital, catheterization or revascularization procedure

Patients with service connected disability, over age 55, with comorbid conditions, discharged from a teaching hospital, and having revascularization are more likely to have 1 or more visits within 30 days; patients with history of alcohol abuse and living more than 20 miles from admitting hospital were less likely (all p<0.05); similar pattern for 1 or more visits within 90 days except comorbidity, alcoholism, and hospital type not related

Age greater than 55, comorbidities, and distance greater than 20 miles associated with increased risk of death within 1 year; revascularization procedure and any VA ambulatory care in 90 days after index visit associated with decreased risk of death (all p<0.05); age greater than 65, comorbidities, and any VA ambulatory care in 90 days associated with increased risk of readmission (all p<0.05)

N/A

usion: veterans ≥65 

rs old who visited at 

t one of three types 

A geriatric outpatient 

cs between 

/00 and 6/30/01 

 survived through 

0/01

6-month mortality (odds of dying between 10/1/01 and 3/31/02)Age, gender, principal diagnoses, comorbidity index, preventable hospitalization in past year, service connected disability (50% or greater); facility 3-month mortality rate, facility wait time

N/A Facility-level wait times 

of ≥31 days associated with significantly higher mortality; increased age, ≥ 50% service connected disability, preventable hospitalization, higher comorbidity index, and diagnosis of cancer or endocrine, neurological, psychiatric, pulmonary, or other disease associated with increased mortality; female gender associated with decreased mortality (all p<0.05)

N/A
38

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

usion: same as 

ve except visits 

ween 10/1/00 and 

/01, surviving 

ugh 6/30/01

Dependent variable: probability of hospitalization for an ambulatory care sensitive condition between 7/1/01 and 12/31/01Age, gender, principal diagnoses, comorbidity index, ambulatory care sensitive condition (ACSC) hospitalization in past year; facility 3-month ACSC hospitalization rate

Facility-level wait times of ≥29 days associated with greater probability of hospitalization for ACSC compared to wait times of <22.5 daysFacility average ACSC hospitalization rate, age, previous ACSC hospitalization, cormobidity index, and diagnosis of cancer, or endocrine, heart, or pulmonary disease also associated with increased probability of ACSC hospitalization (all p<0.02)

N/A N/A

usion: Admitted to 

stance abuse units, 

ble for outpatient 

rcare

usion: Discharged 

nst medical 

ce, death or re

pitalization within 90 s of index discharge, 

valid zip code of 

dence

Use of any outpatient aftercare, number of mental health clinic visits within 90 days (for those with at least one visit)Comorbidity index

Increased likelihood of receiving aftercare if distance < 50 miles with greatest likelihood if distance <10 miles; age, married, service-connected eligibility, psychiatric comorbidity, substance use disorder, and teaching hospital associated with increased likelihood; medical comorbidity index 1, 2, or > 4 associated with decreased likelihood (all p<0.05)Volume of aftercare only greater if distance <10 miles (relative to >50 miles)

N/A N/A 

usion: Non-veteran 

o longer in military 

vice

usion: refused 

ay or didn’t know 

ther ever in military 

vice

Health in general, maximum poor health days (physical, mental, or limited usual activity in prior month), inability to afford needed care in past year

Non-metropolitan VA patients age 18 to 44 were significantly more likely to say they needed to see a doctor but could not because of cost than others of same age (p<0.005); among 45 to 64 year olds, VA patients (regardless of residence) more likely to report cost as a factor in accessing needed treatment 

Self-reported health poorest for nonmetropolitan veterans in VA care age 45 or olderDays in past 30 of poor health highest for veterans in VA care regardless of residence(NOTE: veterans in VA care identified based on self-reported use of VA in past 12 months)

N/A
39

ans’ Access to Care Evidence-based Synthesis Program

clusion/Exclusion 

Criteria

Outcomes Assessed

Covariates

Impact on System-Level Outcomes Impact of Access 

on Patient-Level 

Outcomes

Interactions

usion: ≥65 yrs on 

e of admission, 

enrollee for whom 

dicare claims were 

mitted; received any 

4 high-risk elective 

cedures

Utilization of VA or non-VA care, utilization of lower or higher quality care

Overall, 89% of heart surgeries, 84% of vascular surgeries, and 79% of cancer resections obtained in non-VA hospitals with little difference based on residenceUrban residents more likely to obtain heart surgery (significant only for bypass grafting) and cancer resection in high performance hospitals; rural residents more likely to get vascular surgery in high performance hospitalsTravel time to high performing hospital indicated that urban veterans had least travel burden; travel time to high performance hospital for heart surgery was shorter than to low performance, regardless of residence; no difference for vascular surgery

N/A N/A

rticipant selection, outcomes assessment, and analysis (see text); †Access scores: 0=worst possible access, 100=best possible access; *N/A=Not 

 1 to September 30 of the following year); NS=non-significant; VISN=Veterans Integrated Service Network
40

ans’ Access to Care Evidence-based Synthesis Program

 efficacy of interventions designed to increase access for veterans (KQ2)

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

Community Based Outpatient Clinics (CBOCs) – Opening of satellite primary care clinics 

CBOCS 

36 

es

ding 

nt 

MCs

Randomly selected subset of veterans who had care at one of the selected CBOCs or VAMCs in the preceding six months.

Utilization of CBOCS / VAMC users

Veterans using CBOCs reported better access / timeliness and were more likely to report waits less than 20 minutes.

Veterans using CBOCS had more ratings of good / excellent visits; fewer problems in a variety of areas (e.g., emotional support, preferences, care coordination, education, courtesy).

N/A

CBOCs 

32 

nt 

MCs

All primary care patients treated at participating CBOCs or VAMCs.

Utilization of CBOCS / VAMC users

CBOC patients more likely to be new VA users.

CBOC patients had more primary care encounters and fewer specialty care encounters.

N/A

en 

OCS 

offered 

ary 

 and 

ned 

ng a 

month 

od in 

7

All veterans living in the CBOC catchment area who had any VA service use in the six months before the CBOC opened. Included a matched group of veterans residing outside the catchment area of any new CBOCs

Implementation of CBOCs / pre-CBOC implementation

Decrease in travel distance to the closest VA facility for those in CBOC catchment area.

Decrease in travel distance predicted increase in primary care encounters; across diagnoses, those in CBOC catchment had more primary care visits, ancillary visits, and extended care physical health visits.

N/A

 CBOC 

the 

nt 

MC

Veterans with an appointment at the CBOC or VAMC during the recruitment period; veterans who lived in the CBOC catchment area and received non-VHA primary care

Utilization of CBOCS / utilization of VAMC or nonVA care

All three groups (VAMC, CBOC, non-VA care) reported few problems finding clinic (93-100%) and found the hours of operation convenient (97-100%). There were no statistical comparisons. 

All three groups (VAMC, CBOC, non-VA care) reported satisfaction with care (93-100%); 82-83% of the VAMC and 90-93% of the CBOC veterans reported they had enough information about their condition and medication; 93% of CBOC and 90% of VAMC veterans felt they could care for themselves until next visit. There were no statistical comparisons. 

N/A
41

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

ounties 

the 

rict of 

mbia 

mpared 

e with 

without 

OCS 

opened 

1995-

8).

All veterans, based on census data

Implementation of CBOCs/ pre-CBOC implementation

Significantly greater proportion of veterans in counties with CBOCs accessed general VA medical services. In counties with CBOCs that had specialty mental health, mental health access greater.

N/A N/A

Primary Care Mental Health Integration – Co-location of primary care and mental health services

ater Los 

eles 

Medical 

ter

All veterans newly entering the Homeless Program

Implementation of integrated mental health, primary care, and homeless social services clinic / pre-implementation

Shorter wait time for initial primary care visit.

Improved preventive care, more primary care visits, lower emergency care service use.

No significant differences.

e VA 

ical 

ter

Veterans within mental health clinic without a primary care provider.

Integrated primary care services into mental health clinic / usual care.

Better self-reported access. More primary care visits, fewer ER 

visits, improved preventive care, higher satisfaction 

Higher (better) scores on the SF-36 physical component summary.

Puget 

nd 

th Care 

em

Veterans presenting for substance use treatment who did not have a primary care provider and had at least one chronic health or asymptomatic condition (e.g., high blood pressure).

Implemented an onsite (within the substance use clinic) primary care clinic /usual care

Shorter wait for initial primary care visit; greater odds of attending rescheduled initial visit; more likely to attend at least 1 primary care visit.

More likely to attend return primary care visits and averaged more primary care visits; less non-VA primary care. More likely to remain engaged in substance use treatment at 60 days.

No significant differences
42

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

e 

MC 

three 

OCs

Veterans who screened positive for depression in primary care.

Varying models of Primary Care Mental Health (PCMH). The VAMC had co-location of, and advance or open access to mental health providers; and standardized assessments. CBOC-A had walk in access one day per week, evaluation by a psychotherapy and a psychopharmacologically oriented provider, and standardized assessment. CBOC-B had a psychotherapist as part of the primary care team and back-up telepsychiatry services (by appointment). CBOC-C did not have PCMH, but mental health care was available at the CBOC. CBOC-D did not have PCMH and there was no mental health care on site (comparator).

Following implementation, VAMC and CBOC-A had increases in veterans seen in mental health within both 4 days and 30 days. CBOC-B had an increase of veterans seen within 30 days and percentage receiving optimal care. No differences in CBOCs C & D.

More patients at VAMC, CBOC-A, and CBOC-B received “optimal depression treatment.”

N/A

e River 

ction 

MC & 

OCs

Veterans who screened positive for depression in primary care

PCMH Integration / no PCMH integration 

More patients received mental health services in primary care and were seen in mental health; shorter wait time for initial mental health appointment (all outcomes only significant for VAMC, not CBOCs)

More patients received “optimal depression treatment” (at VAMC, not CBOC)

N/A

ve Case Management – High intensity treatment coordination to facilitate identification of and access to needed services

 VAMCs Elderly veterans in rural 

counties who were frail and at risk of repeated hospitalization

Pilot implementation of the Coordination and Advocacy for Rural Elders (CARE) program, which performs scheduled, standardized assessments; identifies problems; develops care plans; and tracks resolution of problems / no comparison

Over 56% received a medical service of referral / linkage. 

N/A N/A
43

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

e 

MCs with 

rsity in tion and 

demic 

ation

Hospitalized veterans with one of three chronic diseases without continuous primary care.

Implemented intensive primary care program designed to increase access to primary care; intervention included both an inpatient (e.g., followup planning, scheduling) and outpatient (e.g., appointment reminders, check-in phone call) components / usual care

Median time from hospital discharge to primary care shorter. Better satisfaction with self-reported access.

More likely to have at least one general medical clinic visit; more general medical clinic visits during six-months post-discharge; higher monthly hospital readmission rate; more days of hospital readmission; greater satisfaction with care.

No significant differences.

Telemedicine – Conducting encounters via telephone or interactive video conferencing

r 

MCS 

orida, 

rto 

, and 

rgia

Older veterans with type two diabetes at high risk for multiple VA inpatient and outpatient visits.

Nurse coordinators monitored data from a home telehealth messaging device and made phone calls or scheduled appointments with the physician as necessary / treatment as usual

Care coordinator-initiated primary care clinic visits increased by 8.9%.

Decrease in all cause hospitalization, diabetes related hospitalizations (no longer significant after controlling for baseline A1C).

N/A

me care 

ice line 

large 

MC in 

anapolis

All patients receiving home care services at the VAMC

In addition to traditional home care services, participants contacted VAMC using telehealth units / home care as usual

Most reported that their level of contact with VA providers increased.

No significant differences. Improvement 

on the mental component summary of the Health Related Quality of Life scale 

 VAMCs 

a long 

 care ty

Residents living at the Iowa Veterans Home.

Implemented interactive video conferencing to provide specialty consultation to veterans living at the long term care facility / no comparator

92% of veterans reported that using telemedicine made it easier to see the specialist.

81% of veterans reported satisfaction with the telemedicine consultation process.

N/A

 VAMCs 

out 

idisci

ary 

nd care 

ms

Veterans with a wound who sought care at a VAMC without a wound care team.

Implemented telemedicine to seek consultations from a remote wound care team/ no comparator

Veterans reported that telemedicine was more convenient than travelling to wound care team.

Almost all (92.8%) participants were satisfied with telemedicine.

N/A 
44

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

Outreach – Providing information about how to access care

e urban 

MC

Vietnam veterans living in vicinity of VAMC who are service-connected for PTSD without use of VA mental health or substance use services in the prior 12 months.

Outreach intervention with (1) a mailing which included information regarding PTSD treatment services and a letter from the PTSD program outlining three ways to initiate care (return postcard, call, or walkin clinic) , and (2) direct phone call during which veterans could ask about services, schedule an appointment, or address barriers / no intervention control group.

Significantly more likely to schedule an intake, present for intake session.

Significantly more likely to attend at least one follow-up session.

N/A

Copayments – Change in medication copayments

 large 

MC

Veterans on lipid-lowering medications

Increase in medication copayments from $2 to $7 / copayment exempt.

Lipid refill rates decreased for all veterans after copayment increase, but the decrease small among those without copayment.

N/A N/A

r large 

MCs

Veterans with diabetic or hypertension who had a prescription for those conditions (a portion of whom had copayments).

Increase in medication copayments from $2 to $7 / copayment exempt.

At the end of the study, lower adherence to diabetic and hypertensive medications among veterans with a copayment.

N/A N/A

Wide A random sample of 5% 

of VA pharmacy users.

Increase in medication copayments from $2 to $7 / copayment exempt.

Those with a copayment received 8% fewer 30-day refills than those without payments.

N/A N/A
45

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

wide All veterans receiving 

a diagnosis of schizophrenia or schizoaffective disorder from 1998-1999 (a portion of whom had copayments).

Increase in medication copayments from $2 to $7 / copayment exempt.

For all medication and medical prescriptions: those exempt from copayments, prescriptions increased steadily throughout study, while for those with a copayment, growth slowed after price increase. For psychiatric drugs: for those exempt from copayments, prescriptions increased throughout study, while for those with a copay, use decreased after price increase.

Copayment group more likely to have psychiatric admission.

N/A

Other Access Interventions

 types 

AMCs, 

e with 

without 

cialized 

b units

Veterans with lowerextremity amputations during study time frame.

Presence of Specialized Rehabilitation Unit (SRU) within the hospital / hospital without an SRU

No difference in the probability of receiving an initial rehabilitation consult; those in SRU more likely to receive specialized rehabilitation.

Longer length of non-ICU stays in SRU VAMCs. 

Problems in peripheral circulation more common in non-SRU VAMCs, skin breakdown more common in SRU VAMCs. 

bstance 

clinic 

n a 

e VAMC

Veterans receiving services within the substance use clinic

Implementation of the Healthy Liver Program, designed to increase access to services for the prevention (vaccination), identification (testing), and treatment (referrals) of viral hepatitis within a substance use clinic / preimplementation.

Testing for hepatitis increased, 94% of appropriate veterans started the vaccine series (vaccine was not available prior to implementation).

78% of those who learned they had hepatitis attended their intake at the hepatitis clinic.

N/A
46

ans’ Access to Care Evidence-based Synthesis Program

etting Patient

Characteristics

Intervention / 

Comparator

Impact of Intervention on 

Access

Impact of Intervention on SystemLevel Outcomes Impact on Intervention 

on PatientLevel 

Outcomes

 low me 

n 

h

oods 

n 

VA 

burgh 

thcare 

em

Elderly, urban, predominately African American men receiving care at one of the mobile care units.

Implemented a mobile care program, which had healthcare staff and resources to conduct basic medical care within the van/no comparator.

Accessibility of care was mentioned 26 times in 18 interviews (2nd most common topic behind quality of care).

Quality of care was mentioned 28 times in 18 interviews.

N/A