Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California.
Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California.
JAMA Surg. 2022 Dec 1;157(12):1115-1123. doi: 10.1001/jamasurg.2022.4978.
The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding.
To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders.
DESIGN, SETTING, AND PARTICIPANTS: This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019.
The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital.
Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days.
A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits.
Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.
美国退伍军人事务部 (VA) 的退伍军人选择计划 (VCP) 扩大了符合条件的患者在 VA 以外的社区环境中获得医疗保健的机会。对于 VCP 对手术机会和术后结果的影响知之甚少。自成立以来，已经报道了经常与不良术后结果相关的护理协调问题。关于 VCP 和术后结果关联的研究结果仅限于少数精选程序，并且结果不一致，这可能是由于未测量的混杂因素造成的偏差。
使用非随机化控制回归不连续性设计 (RDD) 来研究 VCP 与手术机会和术后结果的关联，以减少未测量混杂因素的影响。
设计、设置和参与者：这是一项针对退伍军人健康管理局 (VHA) 的非随机 RDD 研究。参与者包括 2014 年 10 月 1 日至 2019 年 6 月 1 日期间需要手术的在 VHA 注册的退伍军人。
VCP 扩大了符合条件的退伍军人在距离最近 VA 医院 40 英里或以上的 VA 付费社区护理的机会。
术后 30 天和 90 天的急诊就诊、住院再入院和死亡率。
共确定了 498427 名患者（平均[标准差]年龄 63.0[12.9]岁；450366 名男性[90.4%]）的 615473 例独特手术。总体而言，94783 例（15.4%）手术由 VHA 支付，手术类型的比例有所不同。接受 VA 付费手术的患者更可能是女性（9209[12.7%] vs 男性 38771[9.1%]）、白人（VA 付费 54544[74.4%] vs VA 提供 310077[73.0%]）和年龄小于 65 岁（VA 付费 36054[49.1%] vs VA 提供 229411[46.0%]），且合并症负担明显较轻（平均[标准差] 1.8[2.2] vs 2.6[2.7]）。非随机 RDD 显示，VCP 与符合条件的退伍军人中 VA 付费手术比例略有增加 0.03（95%CI，0.01-0.05；P=0.01）。然而，术后死亡率、再入院率或急诊就诊率没有差异。
VA 中医疗保健机会的扩大与私营部门手术执行情况的转变有关，但与手术结果没有可衡量的关联。这些发现可能减轻了因护理协调问题导致的护理扩大到单一医疗保健系统之外时患者结果恶化的担忧，尽管尚不清楚这些额外的手术是否合适或改善了患者的结果。
