VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA.
OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA.
J Gen Intern Med. 2023 Mar;38(4):889-897. doi: 10.1007/s11606-022-07800-1. Epub 2022 Oct 28.
Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care.
To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status.
Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering.
13,720 CCN and 40,638 comparison appointments.
Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment.
Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively.
After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.
通过《退伍军人事务部使命法案》实施的社区护理网络 (CCN)，VA 扩大了供应商合同，并为退伍军人的社区护理制定了网络充足标准。
确定 CCN 的早期实施是否总体上影响了社区初级保健 (PC) 预约的等待时间，以及农村/城市和 PC 短缺地区 (HPSA) 的情况。
使用 2019 年 2 月至 2020 年 2 月期间的 VA 管理数据，并采用差异法，我们比较了在 VA 设施实施 CCN（CCN 预约）和未实施 CCN（对照预约）前后预约的等待时间。我们对所有预约进行了回归模型分析，并按农村/城市和 PC HPSA 状况进行了分层。所有模型均调整了退伍军人特征和 VA 设施水平聚类。
13720 个 CCN 和 40638 个对照预约。
等待时间，以从授权使用社区 PC 到退伍军人第一次相应预约的天数来衡量。
总体而言，在 CCN 实施后，未经调整的等待时间增加了 35.7 天（[34.4，37.1]95%CI）。在调整分析中，平均而言，对照预约的等待时间增加了 33.7 天（[26.3，41.2]95%CI，p < 0.001）；CCN 预约的等待时间没有显著差异（组间平均差异：5.4 天，[-3.8，14.6]95%CI，p = 0.25）。在分层分析中，CCN 预约的等待时间增加范围为 29.6 天（[20.8，38.4]95%CI，p < 0.001）至 42.1 天（[32.9，51.3]95%CI，p > 0.001），而 CCN 预约的额外差异范围为 13.4 天（[3.5，23.4]95%CI，p = 0.008）至-15.1 天（[-30.1，-0.1]95%CI，p = 0.05），适用于城市和 PC HPSA 预约。
在 CCN 的早期实施后，VA 设施的社区 PC 等待时间急剧增加，无论农村/城市或 PC HPSA 状况如何，这表明社区护理需求可能超过了 VA 资源，因此 CCN 的影响有限。
