Dueker Jeffrey M, Khalid Asif
is a Gastroenterologist and is the Section Chief of Gastroenterology at VA Pittsburgh Healthcare System in Pennsylvania. Jeffrey Dueker is an Assistant Professor of Medicine and Asif Khalid is an Associate Professor of Medicine at the University of Pittsburgh Medical Center.
Fed Pract. 2020 May;37(5):224-228.
The Veterans Choice Program (VCP) was designed to provide a pathway for veterans to access health care in the community if wait times at the US Department of Veterans Affairs (VA) were > 30 days. However, the performance of this program, in terms of timeliness, quality assurance, and overall utilization by veterans for colonoscopy is not well studied.
We reviewed records of veterans at VA Pittsburgh Healthcare System (VAPHS) who underwent VCP colonoscopy from June 2015 through March 2017. We compared the number of days from the scheduling encounter to the first available colonoscopy at VAPHS to the actual colonoscopy through the VCP. Additionally, we examined the availability of procedure and pathology results, documentation of quality metrics, and if clear follow-up recommendations were present in community care records. We then separately examined VCP utilization in a representative sample (5% margin of error, 95% CI) of all colonoscopy referrals through the VCP.
During the study period 3,855 veterans were eligible for colonoscopy via the VCP, and 190 colonoscopies were performed through VCP. Records were absent for 29 exams (15.3%). There was no statistically significant difference for the number of days from a veteran's initially scheduled first-available colonoscopy at VAPHS when compared with the actual VCP colonoscopy (median 2 days earlier, = .62). Pathology results were absent in 14 of 118 (11.9%) patient records, and follow-up recommendations were absent in 29 of 161 (18%) cases. Documentation of colonoscopy quality metrics were deficient in 27% to 70% of procedure reports. In a utilization sample of 350 veterans, only 26 (7.4%) veterans referred for colonoscopy had documented VCP colonoscopies, and 231 (66%) had a VAPHS colonoscopy. The median actual wait time for colonoscopy was 61 days for VAPHS and 66 days through VCP ( = .15).
Colonoscopies referred through the VCP were not performed sooner in aggregate compared with the first available colonoscopy at VAPHS, although there was wide variability in wait times. We recommend additional mechanisms be put into place when outsourcing to community care: Ensure seamless and require prompt transfer of records back to the VA, require reporting of quality metrics standard at the VA for community care colonoscopies, and establish clinically meaningful wait-time thresholds for referral into the community, rather than static ones.
退伍军人选择计划（VCP）旨在为退伍军人提供一条途径，以便在美国退伍军人事务部（VA）等待时间超过30天时，能在社区获得医疗保健服务。然而，该计划在及时性、质量保证以及退伍军人对结肠镜检查的总体利用率方面的表现尚未得到充分研究。
我们回顾了匹兹堡退伍军人医疗系统（VAPHS）中2015年6月至2017年3月期间接受VCP结肠镜检查的退伍军人记录。我们比较了从预约到VAPHS首次可进行结肠镜检查的天数与通过VCP实际进行结肠镜检查的天数。此外，我们检查了检查和病理结果的可得性、质量指标的记录，以及社区护理记录中是否有明确的后续建议。然后，我们分别在通过VCP进行的所有结肠镜检查转诊的代表性样本（误差幅度5%，95%置信区间）中检查VCP的利用率。
在研究期间，3855名退伍军人有资格通过VCP进行结肠镜检查，其中190例通过VCP进行了结肠镜检查。29例检查（15.3%）记录缺失。与实际的VCP结肠镜检查相比，退伍军人最初在VAPHS预约的首次可进行结肠镜检查的天数没有统计学上的显著差异（中位数早2天，P = 0.62）之一。118份患者记录中有14份（11.9%）没有病理结果，161例中有29例（18%）没有后续建议。结肠镜检查质量指标的记录在27%至70%的检查报告中存在缺陷。在350名退伍军人的利用率样本中，只有26名（7.4%）被转诊进行结肠镜检查的退伍军人有记录显示进行了VCP结肠镜检查，231名（66%）进行了VAPHS结肠镜检查。VAPHS结肠镜检查的实际中位等待时间为61天，通过VCP为66天（P = 0.15）。
总体而言，通过VCP转诊的结肠镜检查与VAPHS首次可进行的结肠镜检查相比，并没有更快进行，尽管等待时间存在很大差异。我们建议在将服务外包给社区护理时应建立额外机制：确保无缝衔接并要求及时将记录转回VA，要求社区护理结肠镜检查报告符合VA的质量指标标准，并为转诊到社区建立具有临床意义的等待时间阈值，而不是固定的阈值。
