Advertisement

Preventive Care Delivery After the Veterans Choice Program

      Introduction

      The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program.

      Methods

      The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011–October 2014 and November 2015–December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre–post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019.

      Results

      Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre–post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits.

      Conclusions

      Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Department of Veterans Affairs
        Expanded Access to non-VA Care through the Veterans Choice Program. Final rule.
        Fed Regist. 2015; 80 (To be codified at 38 CFR 17.): 66419-66429
        • Panangala SV
        The Veterans Choice Program (VCP): program implementation.
        Congressional Research Service, Washington, DCSeptember 19, 2018
        https://fas.org/sgp/crs/misc/R44562.pdf
        Date accessed: September 1, 2019
      1. Data trends 2017 - diabetes mellitus.
        Fed Pract. 2017; 34: S20-S21
        • Agha Z
        • Lofgren RP
        • VanRuiswyk JV
        • Layde PM
        Are patients at Veterans Affairs Medical Centers sicker? A comparative analysis of health status and medical resource use.
        Arch Intern Med. 2000; 160 (https://doi.org/10.1001/archinte.160.21.3252): 3252-3257
        • Zullig LL
        • Jackson GL
        • Dorn RA
        • et al.
        Cancer incidence among patients of the U.S. Veterans Affairs Health Care System.
        Mil Med. 2012; 177 (https://doi.org/10.7205/milmed-d-11-00434): 693-701
        • Maciosek MV
        • Coffield AB
        • Flottemesch TJ
        • Edwards NM
        • Solberg LI
        Greater use of preventive services in U.S. health care could save lives at little or no cost.
        Health Aff (Millwood). 2010; 29 (https://doi.org/10.1377/hlthaff.2008.0701): 1656-1660
        • Bechini A
        • Ninci A
        • Del Riccio M
        • et al.
        Impact of influenza vaccination on all-cause mortality and hospitalization for pneumonia in adults and the elderly with diabetes: a meta-analysis of observational studies.
        Vaccines (Basel). 2020; 8 (https://doi.org/10.3390/vaccines8020263): 263
        • Dos Santos G
        • Tahrat H
        • Bekkat-Berkani R
        Immunogenicity, safety, and effectiveness of seasonal influenza vaccination in patients with diabetes mellitus: a systematic review.
        Hum Vaccin Immunother. 2018; 14 (https://doi.org/10.1080/21645515.2018.1446719): 1853-1866
        • Marques Antunes M
        • Duarte GS
        • Brito D
        • et al.
        Pneumococcal vaccination in adults at very-high risk or established cardiovascular disease: systematic review and meta-analysis.
        Eur Heart J Qual Care Clin Outcomes. 2020; 7 (https://doi.org/10.1093/ehjqcco/qcaa030): 97-106
        • Jones AL
        • Fine MJ
        • Stone RA
        • et al.
        Veteran satisfaction with early experiences of health care through the Veterans Choice Program: a concurrent mixed methods study.
        J Gen Intern Med. 2019; 34 (https://doi.org/10.1007/s11606-019-05116-1): 1925-1933
        • Stroupe KT
        • Martinez R
        • Hogan TP
        • et al.
        Experiences with the veterans’ choice program.
        J Gen Intern Med. 2019; 34 (https://doi.org/10.1007/s11606-019-05224-y): 2141-2149
        • Schlosser J
        • Kollisch D
        • Johnson D
        • Perkins T
        • Olson A
        VA-community dual care: veteran and clinician perspectives.
        J Community Health. 2020; 45 (https://doi.org/10.1007/s10900-020-00795-y): 795-802
        • Tsai J
        • Yakovchenko V
        • Jones N
        • et al.
        “Where's my choice?” an examination of veteran and provider experiences with hepatitis C treatment through the Veteran Affairs Choice Program.
        Med Care. 2017; 55 (https://doi.org/10.1097/MLR.0000000000000706): S13-S19
        • Ross JS
        • Keyhani S
        • Keenan PS
        • et al.
        Use of recommended ambulatory care services: is the Veterans Affairs quality gap narrowing?.
        Arch Intern Med. 2008; 168 (https://doi.org/10.1001/archinte.168.9.950): 950-958
        • Yoon J
        • Leung LB
        • Rubenstein LV
        • et al.
        Use of the Veterans’ Choice Program and attrition from Veterans Health Administration primary care.
        Med Care. 2020; 58 (https://doi.org/10.1097/MLR.0000000000001401): 1091-1097
        • Higashi T
        • Wenger NS
        • Adams JL
        • et al.
        Relationship between number of medical conditions and quality of care.
        N Engl J Med. 2007; 356 (https://doi.org/10.1056/NEJMsa066253): 2496-2504
        • Jellinger PS
        • Dickey RA
        • Ganda OP
        • et al.
        AACE medical guidelines for clinical practice for the diagnosis and treatment of dyslipidemia and prevention of atherogenesis [published correction appears in Endocr Pract. 2008;14(6):802-3].
        Endocr Pract. 2000; 6: 162-213
        https://pubmed.ncbi.nlm.nih.gov/11428356/
        Date accessed: September 1, 2019
        • Siu AL
        • U.S. Preventive Services Task Force
        Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2015; 163 (https://doi.org/10.7326/M15-2223): 778-786
        • U.S. Preventive Services Task Force
        Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2009; 150 (https://doi.org/10.7326/0003-4819-150-6-200903170-00008): 396-404
        • Centers for Disease Control and Prevention (CDC)
        Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)–United States, 2012-13 influenza season.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 613-618
        • Moyer VA
        • U.S. Preventive Services Task Force
        Screening for HIV: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2013; 159 (https://doi.org/10.7326/0003-4819-159-1-201307020-00645): 51-60
        • American Diabetes Association
        Standards of medical care in diabetes–2012.
        Diabetes Care. 2012; 35 (https://doi.org/10.2337/dc12-s011): S11-S63
        • Massarweh NN
        • Itani KMF
        • Morris MS
        The VA MISSION Act and the future of veterans’ access to quality health care.
        JAMA. 2020; 324 (https://doi.org/10.1001/jama.2020.4505): 343-344
        • Griffith KN
        • Ndugga NJ
        • Pizer SD
        Appointment wait times for specialty care in Veterans Health Administration facilities vs community medical centers.
        JAMA Netw Open. 2020; 3 (https://doi.org/10.1001/jamanetworkopen.2020.14313)e2014313
        • Mattocks KM
        • Cunningham K
        • Elwy AR
        • et al.
        Recommendations for the evaluation of cross-system care coordination from the VA state-of-the-art working group on VA/non-VA care.
        J Gen Intern Med. 2019; 34 (https://doi.org/10.1007/s11606-019-04972-1): 18-23
        • Nevedal AL
        • Wagner TH
        • Ellerbe LS
        • Asch SM
        • Koenig CJ
        A qualitative study of primary care providers’ experiences with the Veterans Choice Program.
        J Gen Intern Med. 2019; 34 (https://doi.org/10.1007/s11606-018-4810-2): 598-603
        • Sayre GG
        • Neely EL
        • Simons CE
        • Sulc CA
        • Au DH
        • Michael Ho P
        Accessing care through the Veterans Choice Program: the Veteran experience.
        J Gen Intern Med. 2018; 33 (https://doi.org/10.1007/s11606-018-4574-8): 1714-1720
        • Thorpe JM
        • Thorpe CT
        • Schleiden L
        • et al.
        Association between dual use of Department of Veterans Affairs and Medicare Part D drug benefits and potentially unsafe prescribing.
        JAMA Intern Med. 2019; 179 (https://doi.org/10.1001/jamainternmed.2019.2788): 1584-1586
        • Lemle RB
        Choice program expansion jeopardizes high-quality VHA mental health services.
        Fed Pract. 2018; 35: 18-24
        • Aggarwal NK
        Ramifications of the VA MISSION Act of 2018 on mental health: potential implementation challenges and solutions.
        JAMA Psychiatry. 2020; 77 (https://doi.org/10.1001/jamapsychiatry.2019.3883): 337-338
        • Finley EP
        • Mader M
        • Haro EK
        • et al.
        Use of guideline-recommended treatments for PTSD among community-based providers in Texas and Vermont: implications for the Veterans Choice Program.
        J Behav Health Serv Res. 2019; 46 (https://doi.org/10.1007/s11414-018-9613-z): 217-233
        • Finley EP
        • Noël PH
        • Mader M
        • et al.
        Community clinicians and the Veterans Choice Program for PTSD care: understanding provider interest during early implementation.
        Med Care. 2017; 55 (https://doi.org/10.1097/MLR.0000000000000668): S61-S70
        • Mattocks KM
        • Baldor R
        • Bean-Mayberry B
        • et al.
        Factors impacting perceived access to early prenatal care among pregnant veterans enrolled in the Department of Veterans Affairs.
        Womens Health Issues. 2019; 29 (https://doi.org/10.1016/j.whi.2018.10.001): 56-63
        • Katon JG
        • Ma EW
        • Sayre G
        • et al.
        Women Veterans’ experiences with Department of Veterans Affairs maternity care: current successes and targets for improvement.
        Womens Health Issues. 2018; 28 (https://doi.org/10.1016/j.whi.2018.08.006): 546-552
        • Rauscher GH
        • Johnson TP
        • Cho YI
        • Walk JA
        Accuracy of self-reported cancer-screening histories: a meta-analysis.
        Cancer Epidemiol Biomarkers Prev. 2008; 17 (https://doi.org/10.1158/1055-9965.EPI-07-2629): 748-757
        • Cronin KA
        • Miglioretti DL
        • Krapcho M
        • et al.
        Bias associated with self-report of prior screening mammography.
        Cancer Epidemiol Biomarkers Prev. 2009; 18 (https://doi.org/10.1158/1055-9965.EPI-09-0020): 1699-1705
        • Zelaya CE
        • Nugent CN
        Trends in health insurance and type among military Veterans: United States, 2000-2016.
        Am J Public Health. 2018; 108 (https://doi.org/10.2105/AJPH.2017.304212): 361-367