0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Use of Recommended Ambulatory Care Services:  Is the Veterans Affairs Quality Gap Narrowing? FREE

Joseph S. Ross, MD, MHS; Salomeh Keyhani, MD; Patricia S. Keenan, PhD; Susannah M. Bernheim, MD, MHS; Joan D. Penrod, PhD; Kenneth S. Boockvar, MD; Alex D. Federman, MD, MPH; Harlan M. Krumholz, MD, SM; Albert L. Siu, MD, MSPH
[+] Author Affiliations

Author Affiliations: HSR&D Targeted Research Enhancement Program and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Administration Medical Center, Bronx, New York (Drs Ross, Keyhani, Penrod, Boockvar, and Siu); Departments of Geriatrics and Adult Development (Drs Ross, Penrod, Boockvar, and Siu), Health Policy (Dr Keyhani), and Internal Medicine (Dr Federman), Mount Sinai School of Medicine, New York, New York; and Division of Health Policy and Administration, Department of Epidemiology and Public Health (Drs Keenan and Krumholz), Section of Geriatrics, Department of Internal Medicine (Dr Bernheim), and Section of Cardiovascular Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (Dr Krumholz), Yale University School of Medicine, and Yale–New Haven Hospital Center for Outcomes Research and Evaluation (Dr Krumholz), New Haven, Connecticut. Dr Bernheim is now with Department of Internal Medicine, Yale University School of Medicine and Performance Management, Yale–New Haven Hospital.


Arch Intern Med. 2008;168(9):950-958. doi:10.1001/archinte.168.9.950.
Text Size: A A A
Published online

Background  Veterans Affairs medical centers (VAMCs) provide better preventive and chronic disease care when compared with other health care organizations, although recent health care quality improvement initiatives outside the VAMC sector may have narrowed quality differences.

Methods  Using the nationally representative 2000 and 2004 surveys of the Behavior Risk Factor Surveillance System, which included 152 310 community-dwelling insured adults in 2000 and 251 570 in 2004, we compared self-reported use of 17 recommended ambulatory care services for cancer prevention, cardiovascular risk reduction, diabetes mellitus management, and infectious disease prevention among insured adults receiving and not receiving care at VAMCs.

Results  A total of 2852 insured adults (1.9%) received care at VAMCs in 2000 and 7155 (2.4%) received care at VAMCs in 2004. Use of 9 of the 17 services was greater in 2004 when compared with 2000 (P ≤ .05). In 2000, receiving VAMC care was associated with greater use of 6 of the 17 services; in 2004, receiving VAMC care was associated with greater use of 12 of the 17 services (P ≤ .05). In 2004, greater use among these 12 services ranged from 10% greater use of cholesterol screening to 40% greater use of colorectal cancer screening. For 13 of the 17 services, the likelihood of service use among adults receiving VAMC care when compared with adults not receiving VAMC care was not significantly different in 2004 than in 2000. However, this likelihood was significantly greater (for VAMC vs non-VAMC use) in 2004 than in 2000 for breast cancer screening (relative risk [RR], 1.21 [95% confidence interval {CI}, 1.15-1.25] vs 0.80 [95% CI, 0.58-0.98]; P < .001), dilated eye examination among adults with diabetes (RR, 1.12 [95% CI, 1.07-1.15] vs 1.01 [95% CI, 0.88-1.09]; P = .04), and influenza (RR, 1.30 [95% CI, 1.24-1.36] vs 1.06 [95% CI, 0.89-1.21]; P = .006) and pneumococcal (RR, 1.27 [95% CI, 1.23-1.31] vs 1.04 [95% CI, 0.86-1.21]; P = .005) vaccinations.

Conclusion  Despite increasing emphasis on quality of care and improved performance throughout the US health care system, adults receiving VAMC care remain more likely to receive recommended ambulatory care.

Adults receiving health care at Veterans Affairs medical centers (VAMCs) receive recommended services for preventive care, diabetes mellitus care, and inpatient management of acute myocardial infarction and heart failure at greater rates than adults covered by other insurance plans, including Medicare and managed care organizations.14 Better health care quality at VAMCs has been attributed to a nationally integrated health care system reform in 1995, which created organizational and structural differences between VAMC and non-VAMC sectors, including information technology implementation, performance measurement and reporting, service integration, and realigned payment policies.511

Since the mid-1990s, private insurers, Medicare, and Medicaid have substantially expanded efforts to incorporate performance measurement and information technology and changed payment policies in an effort to improve quality. These efforts include reporting of managed care plan performance using Health Plan Employer Data and Information Set measures,12 which have been expanded to include Medicaid and Medicare plans,13 federal emphasis on electronic medical record capability and use,14 and greater focus on pay for performance to improve quality.1518 Moreover, 2 Institute of Medicine reports19,20 brought national attention to quality of care, evidence-based care, and alignment of payment incentives, raising the question of whether quality in the non-VAMC sector would catch up with quality in the VAMCs.

Quality improvement that involves the separate implementation of initiatives within a fragmented, nonintegrated, health care system without complete adoption of an interoperable medical record may or may not be capable of equaling the high quality of care achieved by the VAMC health care system reform. Our objectives were to (1) examine use of recommended ambulatory care services among insured adults receiving and not receiving care at VAMCs in 2000 and 2004 and (2) determine whether the likelihood of receiving recommended services has changed from 2000 to 2004 between insured adults receiving and not receiving care at VAMCs.

STUDY DESIGN AND SAMPLE

We used data from the 2000 and 2004 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a federally funded cross-sectional telephone survey of the civilian, noninstitutionalized adult population older than 17 years. The survey is designed and conducted annually by the Centers for Disease Control and Prevention (CDC) in collaboration with state health departments. All 50 states, in addition to the District of Columbia, participated in the 2000 and 2004 BRFSS. In 2000, the median response rate was 48.9%,21 whereas in 2004 it was 52.7%.22

The BRFSS survey instrument has 2 relevant parts. First, the core includes questions asked by all states concerning health-related perceptions, conditions, and behaviors, as well as sociodemographic characteristics. Second, the optional CDC modules include questions on specific topics that states may elect to use. States that asked questions relevant to each health care service varied in number.23,24 Questions examining cancer prevention services were asked within core and optional modules in 2000 and within core modules in 2004. In 2000, 5 to 51 states asked about cancer prevention services (depending on the service) and accounted for 13% to 100% of the weighted sample. Questions examining cardiovascular risk reduction services were asked within core and optional modules in 2000 and within optional modules in 2004, although questions about medical history of hypercholesterolemia, hypertension, and cardiovascular disease were asked within optional modules in both years. In 2000, 6 to 51 states asked about cardiovascular risk reduction services and accounted for 14% to 100% of the weighted sample, whereas 6 to 20 states accounted for 13% to 40% of the weighted sample in 2004. Questions that examined diabetes management services were asked within optional modules in 2000 and within core and optional modules in 2004, although medical history of diabetes was asked within a core module in both years. In 2000, 6 to 46 states asked about diabetes management services and accounted for 15% to 86% of the weighted sample, whereas 6 to 51 states accounted for 13% to 100% of the weighted sample in 2004. Questions that examined infectious disease prevention services were asked within optional modules by 17 states, accounting for 39% of the weighted 2000 sample, and within core modules in 2004. Because the BRFSS is a publicly available anonymous data source, our study was exempted from review by the James J. Peters VA Medical Center institutional review board. Additional information about BRFSS survey instruments and procedures is available from the CDC.25

Our samples included 152 310 insured adults (aged ≥ 18 years) in 2000 and 251 570 insured adults in 2004 from all 50 states and the District of Columbia. We excluded adults who reported having no health care coverage when they were surveyed. In addition, we excluded people who did not report their age (< 0.6%) or health insurance coverage status (< 0.4%).

STUDY VARIABLES

We examined self-reported use of 17 recommended health care services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention. Before performing analyses, we categorized dichotomously use or nonuse of each service to evaluate adequate, rather than optimal, care based on the recommended age range and interval published in national guidelines (Table 1).

Table Graphic Jump LocationTable 1. Ambulatory Health Care Services Examined, From the Behavioral Risk Factor Surveillance System, 2000 and 2004

Cancer prevention services included self-reported rates of fecal occult blood testing within the past 2 years or sigmoidoscopy or colonoscopy within the past 5 years for adults 50 years or older for colorectal cancer screening,26 mammography within the past 2 years for women 40 years or older for breast cancer screening,27 and Papanicolaou tests within the past 3 years for women between the ages of 18 and 64 years with an intact uterus for cervical cancer screening.28

Cardiovascular risk reduction services included serum cholesterol measurement within the past 5 years for men and women (aged ≥ 35 and ≥ 45 years, respectively)29; annual serum cholesterol measurement for adults with hypercholesterolemia, hypertension, or cardiovascular disease30; regular aspirin use for adults with cardiovascular disease and without therapeutic contraindications31,32; and annual advice from a health care professional regarding smoking cessation for adults who smoke.33

Diabetes management services included annual measurement of serum cholesterol and serum glycosylated hemoglobin, annual foot examination by a health care professional, dilated eye examination within the past 2 years, annual influenza vaccination, and lifetime pneumococcal vaccination for adults with diabetes.34 Infectious disease prevention services included annual influenza vaccination for adults 50 years or older35 and lifetime pneumococcal vaccination for adults 65 years or older.36

Our main independent variable was use of VAMCs to obtain health care services. All respondents were asked, “Have you ever served on active duty in the US Armed Forces?” If they answered affirmatively and were not in active military service, they were considered to be veterans and were then asked, “In the last 12 months have you received some or all of your health care from VA facilities?” and could respond all, some, or none. We categorized the sample as receiving or not receiving VAMC care, combining adults who received all or some health care from VAMCs into a single category.

We categorized the sample by the following sociodemographic characteristics, all of which were included in our analyses after testing for multicollinearity to adjust for their independent effects on each outcome: age, sex, race/ethnicity, annual household income, employment, education level, marital status, household size, and state of residence, as well as self-reported health status (Table 2). To examine (and adjust for) frequency of physician contact, we also categorized the sample by having visited a physician in the past year (asked in 2000 only) and identification of a personal physician or health care professional (asked for 10% of the weighted sample in 2000 and for the full sample in 2004). The BRFSS defined response categories for all sociodemographic variables, including race/ethnicity, in addition to self-reported health status.

Table Graphic Jump LocationTable 2. Weighted Sociodemographic Characteristics, Health Care Access Characteristics, and Clinical Characteristics and Medical History for Insured Adults, Stratified by Year and Receipt of Care at Veterans Affairs Medical Centers, From the Behavioral Risk Factor Surveillance System, 2000 and 2004a
STATISTICAL ANALYSIS

We described respondent characteristics using standard means and frequency analyses. We used χ2 tests to examine the bivariate relationships between use of recommended services and use of VAMC care in 2000 and 2004. We used multivariate logistic regression to assess the independent effect of VAMC care on use of each recommended service, creating independent models for each outcome in each year and controlling for the sociodemographic characteristics noted previously, self-reported health status, and either having visited a physician in the past year (2000) or identification of a personal physician or health care professional (2004). In addition, to examine whether the independent effect of VAMC care on use of each recommended service changed from 2000 to 2004, we conducted a pooled multivariate analysis that combined 2000 and 2004 data and included survey year and an interaction term between survey year and VAMC care in our logistic regression analyses. Moreover, because adults receiving health care at VAMCs are more likely to be older and male, to examine the robustness of our results, we repeated each analysis among men 65 years or older. Last, to examine the robustness of the association between receiving recommended care and receiving VAMC care, we repeated each analysis among the subpopulation least likely to use VAMCs, women younger than 65 years. Because both sets of results were largely the same, only the results from the full sample analyses are presented. Individuals missing sociodemographic or outcome data were excluded from the relevant adjusted analyses.

To facilitate interpretation of our results given our analysis of nonrare events, odds ratios from adjusted analyses were converted to risk ratios using standard techniques.37 All analyses took into account the complex survey design and weighted sampling probabilities of the data source and were performed using SAS-callable SUDAAN statistical software version 9.01 (Research Triangle Institute, Research Triangle Park, North Carolina).38,39 All statistical tests were 2-tailed.

SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS

Among 152 310 insured adults included in our 2000 sample, 2852 (1.9%) received care at VAMCs, whereas 7155 (2.4%) received care at VAMCs among 251 570 insured adults in 2004. In each year, compared with adults not receiving VAMC care, adults receiving VAMC care were significantly more likely to be older, male, black, and not in the labor force; to be divorced, separated, or widowed; to live alone or with only 1 other person; to have lower incomes; and to report fair or poor health status (P ≤ .05, Table 2). In addition, adults receiving VAMC care were significantly more likely to be obese and to have a medical history of diabetes, hypertension, or cardiovascular disease when compared with adults not receiving VAMC care in each year (P ≤ .05).

Compared with adults receiving VAMC care in 2000, adults receiving VAMC care in 2004 were significantly more likely to be older, not in the labor force, and married and to have higher incomes and levels of education (P ≤ .05, Table 2). Moreover, adults receiving VAMC care in 2004 were significantly less likely to smoke and more likely to have a medical history of diabetes or hypertension when compared with adults receiving VAMC care in 2000 (P ≤ .05).

USE OF RECOMMENDED SERVICES

Use varied widely among recommended services in both years (Table 3). Among the total sample of adults, use of 9 of the 17 recommended services was significantly greater in 2004 when compared with 2000, with the largest increases in use of colorectal cancer screening, tobacco cessation counseling, and pneumococcal vaccination for adults with diabetes (P ≤ .05). Among adults receiving VAMC care, only breast cancer screening and influenza vaccination rates were significantly greater in 2004 when compared with 2000, whereas, among adults not receiving VAMC care, use of 9 of the 17 recommended services was significantly greater in 2004 when compared with 2000 (P ≤ .05).

Table Graphic Jump LocationTable 3. Weighted Use of Recommended Ambulatory Health Care Services Among Insured Adults, Stratified by Year and Receipt of Care at Veterans Affairs Medical Centers, From the Behavioral Risk Factor Surveillance System, 2000 and 2004
VAMC CARE AND USE OF RECOMMENDED SERVICES

Use of VAMCs was strongly associated with greater use of recommended ambulatory care services (Table 4). In 2000, VAMC care was associated with greater use of 6 of the 17 services examined; in 2004, VAMC care was associated with greater use of 12 of the 17 services examined. For cancer prevention, breast cancer screening was 20% lower among women receiving VAMC care in 2000 but 21% greater in 2004 when compared with adults not receiving VAMC care, cervical cancer screening was 9% greater in 2000 and 10% greater in 2004, and colorectal cancer screening was not significantly different in 2000 and 40% greater in 2004.

Table Graphic Jump LocationTable 4. Adjusted Data Between Insured Adults Receiving and Not Receiving Care at Veterans Affairs Medical Centers and Use of Recommended Ambulatory Health Care Services, From the Behavioral Risk Factor Surveillance System, 2000 and 2004a

For cardiovascular risk reduction, cholesterol screening was 12% greater among adults receiving VAMC care in 2000 and 10% greater in 2004 when compared with adults not receiving VAMC care, whereas tobacco cessation counseling was 72% greater in 2000 and 31% greater in 2004. Cholesterol monitoring among adults with hypertension was not significantly different in 2000 but was 10% greater in 2004. Both cholesterol monitoring and regular aspirin use among adults with cardiovascular disease were greater in 2000 (19% and 13%, respectively), but neither was significantly different in 2004. Cholesterol monitoring among adults with hypercholesterolemia was not significantly different in 2000 and 2004.

For diabetes management, pneumococcal vaccination was 52% greater among adults receiving VAMC care in 2000 and 34% greater in 2004 when compared with adults not receiving VAMC care. Physician foot examination, dilated eye examination, and influenza vaccination were not significantly different in 2000 but were 20%, 12%, and 26% greater, respectively, in 2004 among adults receiving VAMC care. Neither cholesterol nor glycosylated hemoglobin monitoring was significantly different in either 2000 or 2004.

Finally, for infectious disease prevention, neither influenza vaccination nor pneumococcal vaccination was significantly different in 2000 when comparing adults receiving and not receiving VAMC care, but these rates were 30% and 27% greater, respectively, in 2004 among adults receiving VAMC care.

VAMC CARE AND USE OF RECOMMENDED SERVICES FROM 2000 TO 2004

Although VAMC care was associated with greater use of most recommended services in each year, this greater likelihood of service use was not significantly different between 2000 and 2004 for most services. However, for breast cancer screening, dilated eye examination for adults with diabetes, and influenza and pneumococcal vaccination, adults receiving VAMC care had an increased greater likelihood of service use in 2004 when compared with 2000 (P ≤ .05, Table 4). In addition, a nonsignificant association was found for adults receiving VAMC care to have an increased greater likelihood of receiving colorectal cancer screening in 2004 when compared with 2000 (P = .06). For no service did the greater likelihood of service use decline from 2000 to 2004, although nonsignificant associations were found for adults receiving VAMC care to have a decreased greater likelihood of receiving both cholesterol monitoring among adults with cardiovascular disease and smoking cessation counseling in 2004 when compared with 2000 (P = .06).

Among all adults, use of nearly all recommended ambulatory care services either increased or remained stable from 2000 to 2004. However, in both 2000 and 2004, adults receiving VAMC care reported significantly greater use of most recommended services when compared with adults not receiving VAMC care. These findings are especially striking given that adults receiving VAMC care typically have difficulty accessing the private health care system because they are poorer and sicker,40 the number of adults seeking VAMC care has been increasing by 4% per year,41 and successive supplementary budget requests have been made as the Department of Veterans Affairs experienced budget shortfalls.42

The greater likelihood of service use among adults receiving VAMC care did not decrease from 2000 to 2004 for any service examined. Quality in the non-VAMC sector has not yet caught up to quality in the VAMC sector because differences in use of recommended services did not narrow over time. However, use of most recommended services increased from 2000 to 2004 among adults not receiving VAMC care, whereas use only modestly increased among adults receiving VAMC care, suggesting that a quality performance ceiling may not yet have been reached in the non-VAMC sector but may have been reached in the VAMC sector. During the next 5 years, it is unclear if the continued promotion of quality in the non-VAMC sector—through expanded efforts to incorporate performance measurement, pay for performance, and information technology—will lead to the continued increased delivery of recommended ambulatory care services in the non-VAMC sector, narrowing quality differences.

The current differences in health care quality between these sectors may still be growing wider for certain services. The greater likelihood of service use among adults receiving VAMC care increased from 2000 to 2004 for breast cancer screening, dilated eye examination among adults with diabetes, and influenza and pneumococcal vaccinations. That VAMCs have managed to maintain or improve the quality of care relative to adults not receiving VAMC care highlights the importance of several unique reforms undertaken nationally in the VAMC system in 1995 that have not yet been adopted outside the VAMC sector. These include institution of an integrated and intraoperable comprehensive electronic medical record system in all VAMCs that contains a physician-reminder system designed to increase recommended care for high-priority conditions such as diabetes and emphasizes prevention (ie, cancer screening and vaccinations) and care management. Moreover, process and outcome quality indicators were monitored and performance managers were held accountable for meeting improvement goals. In addition, data gathering and monitoring were performed by an independent agency—the External Peer Review Program. Critically, these reforms were likely to be easier to implement and maintain for the VAMC system than for a fragmented private and public health care system.

As of 2004, receiving VAMC care was associated with 10% to 40% greater use of services for cancer prevention, 10% to 31% greater use of services for cardiovascular risk reduction, 12% to 34% greater use of services for diabetes management, and 27% to 30% greater use of services for infectious disease prevention. For 5 examined services, no significant difference was found between adults receiving and not receiving VAMC care in 2004: cholesterol monitoring among adults with diabetes, hypercholesterolemia, and cardiovascular disease; glycosylated hemoglobin monitoring among adults with diabetes; and regular aspirin use among adults with cardiovascular disease. However, our study was limited by the few states opting to ask questions on cholesterol measurement in the 2000 and 2004 BRFSS surveys, resulting in small samples in which to examine cholesterol-related outcomes. In fact, for 2 of these cholesterol outcomes, a nonsignificant association was found for greater likelihood of use among adults receiving VAMC care.

Our study is one of the first to examine use of a variety of recommended ambulatory care services among a nationally representative sample of insured adults receiving VAMC care. We took advantage of a large survey that included adults insured by multiple potential sources to determine recent estimates of the use of recommended ambulatory care services for adults receiving and not receiving health care at VAMCs. However, several factors must be considered in interpreting its results.

First, we compared insured adults receiving VAMC care with all other insured adults, some of whom may not have received care during the prior year. We took several steps to minimize this potential bias but were limited by the 2004 BRFSS of not asking whether respondents visited any physician in the prior year among its core questions: we limited our sample to insured adults; we adjusted our 2004 analyses for the identification of 1 or more personal physicians or health care professionals; and we examined many recommended services that were specific to adults with chronic diseases, such as diabetes or cardiovascular disease, who are more likely to have visited a physician in the past year. In addition, we repeated the multivariate analysis using the 2000 sample without inclusion of the variable that examined receipt of care during the prior year; our results were nearly identical, providing some reassurance that lacking this variable has not biased our 2004 results.

Second, our study was limited to process measures of ambulatory care quality and cannot be generalized to short-term or inpatient care or other important dimensions of quality, such as outcomes and patient care experiences.

Third, adults receiving VAMC care in our study may differ in unobservable ways from adults not receiving VAMC care in their propensity to use health care services. Whereas our comparison over time likely accounted for any differences between adults receiving and not receiving VAMC care that are fixed over time, it is possible that the composition of adults receiving VAMC care changed in ways for which we cannot account between 2000 and 2004.

Finally, data are self-reported. Although the tendency of respondents to overreport health promotion and disease prevention activities is widely recognized,4345 there is little reason to think that overreporting would be different among adults receiving and not receiving VAMC care. More important, a limitation of many prior studies comparing adults receiving and not receiving VAMC care is bias introduced by the more thorough documentation provided by VAMC electronic medical records. Because our study relied on self-reported data, our results are not biased by documentation differences. Moreover, surveys provide an accessible data source for ongoing comparison of health care quality among populations46 and may more accurately capture use of services available from multiple locations, such as influenza vaccination.

In conclusion, we found that despite increasing emphasis on quality of care and improved performance in the non-VAMC sector, adults receiving VAMC care remain more likely to receive most of the recommended ambulatory care services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention. Because this better quality of care likely reflects the increased use of information technology, performance measure and reporting, service integration, and realigned payment policies implemented at all VAMCs, our results suggest that there is substantial potential for improvement within the US health care provision system as a whole.

Correspondence: Joseph S. Ross, MD, MHS, Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10025 (joseph.ross@mssm.edu).

Accepted for Publication: November 9, 2007.

Author Contributions: Dr Ross had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the analysis. Study concept and design: Ross, Keyhani, Keenan, and Bernheim. Acquisition of data: Ross. Analysis and interpretation of data: Ross, Keenan, Penrod, Boockvar, Federman, Krumholz, and Siu. Drafting of the manuscript: Ross. Critical revision of the manuscript for important intellectual content: Ross, Keyhani, Keenan, Bernheim, Penrod, Boockvar, Federman, Krumholz, and Siu. Statistical analysis: Ross. Administrative, technical, and material support: Ross and Siu. Study supervision: Ross and Krumholz.

Financial Disclosure: None reported.

Funding/Support: This study was not directly supported by any external grants or funds. Drs Ross, Keyhani, Penrod, Boockvar, and Siu are currently supported by Department of Veterans Affairs Health Services Research and Development Service project No. TRP-02-149; Dr Ross is currently supported by the Hartford Foundation; Dr Bernheim was supported by training grant T32AG1934 from the National Institutes on Aging; Dr Boockvar is currently supported by the Department of Veterans Affairs Health Services Research and Development career development program; and Dr Federman is a scholar in the Robert Wood Johnson Generalist Physician Faculty Scholars Program sponsored by the Robert Wood Johnson Foundation.

Role of the Sponsor: Neither the Department of Veterans Affairs nor the Hartford Foundation or the Robert Wood Johnson Foundation had any role in the design or conduct of the study; collection, management, analysis or interpretation of the data; or preparation, review, or approval of the manuscript.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Previous Presentation: This study was presented at the Veterans Affairs HSR&D 2007 Annual Research Meeting; February 23, 2007; Arlington, Virginia.

Jha  AKPerlin  JBKizer  KWDudley  RA Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003;348 (22) 2218- 2227
PubMed
Petersen  LANormand  SLLeape  LLMcNeil  BJ Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare. Circulation 2001;104 (24) 2898- 2904
PubMed
Kerr  EAGerzoff  RBKrein  SL  et al.  Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med 2004;141 (4) 272- 281
PubMed
Asch  SMMcGlynn  EAHogan  MM  et al.  Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004;141 (12) 938- 945
PubMed
Ashton  CMSouchek  JPetersen  NJ  et al.  Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med 2003;349 (17) 1637- 1646
PubMed
Doebbeling  BNVaughn  TEWoolson  RF  et al.  Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods. Med Care 2002;40 (6) 540- 554
PubMed
Demakis  JGMcQueen  LKizer  KWFeussner  JR Quality Enhancement Research Initiative (QUERI): a collaboration between research and clinical practice. Med Care 2000;38 (6) ((suppl 1)) I17- I25
PubMed
Feussner  JRKizer  KWDemakis  JG The Quality Enhancement Research Initiative (QUERI): from evidence to action. Med Care 2000;38 (6) ((suppl 1)) 11- 16
PubMed
Kizer  KW The “new VA”: a national laboratory for health care quality management. Am J Med Qual 1999;14 (1) 3- 20
PubMed
Kizer  KW Promoting innovative nursing practice during radical health system change. Nurs Clin North Am 2000;35 (2) 429- 441
PubMed
Kizer  KWDemakis  JGFeussner  JR Reinventing VA health care: systematizing quality improvement and quality innovation. Med Care 2000;38 (6) ((suppl 1)) I7- I16
PubMed
National Committee on Quality Assurance, The State of Managed Care Quality: 1997.  Washington, DC National Committee on Quality Assurance1997;
National Committee on Quality Assurance, The State of Health Care Quality: 2002.  Washington, DC National Committee on Quality Assurance2002;
Brailer  D Action through collaboration: a conversation with David Brailer [interview by Robert Cunningham]. Health Aff (Millwood) 2005;24 (5) 1150- 1157
PubMed
Berwick  DMDeParle  NAEddy  DM  et al.  Paying for performance: Medicare should lead. Health Aff (Millwood) 2003;22 (6) 8- 10
PubMed
Epstein  AMLee  THHamel  MB Paying physicians for high-quality care. N Engl J Med 2004;350 (4) 406- 410
PubMed
Lindenauer  PKRemus  DRoman  S  et al.  Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007;356 (5) 486- 496
PubMed
Rosenthal  MBFrank  RGLi  ZEpstein  AM Early experience with pay-for-performance: from concept to practice. JAMA 2005;294 (14) 1788- 1793
PubMed
Institute of Medicine, To Err Is Human: Building a Safer Health System.  Washington, DC National Academy Press2000;
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century.  Washington, DC National Academy Press2001;
Centers for Disease Control and Prevention, 2000 Behavioral Risk Factor Surveillance System summary data quality report. http://ftp.cdc.gov/pub/Data/Brfss/2000SummaryDataQualityReport.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2004 Behavioral Risk Factor Surveillance System summary data quality report. http://ftp.cdc.gov/pub/Data/Brfss/2004SummaryDataQualityReport.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2000 Behavioral Risk Factor Surveillance System questionnaire. http://www.cdc.gov/brfss/questionnaires/pdf-ques/2000brfss.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2004 Behavioral Risk Factor Surveillance System state questionnaire [revised February 2004]. http://www.cdc.gov/brfss/questionnaires/pdf-ques/2004brfss.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, Technical documents and survey data. http://www.cdc.gov/brfss/technical_infodata/surveydata.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for colorectal cancer. http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for breast cancer. http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for cervical cancer. http://www.ahrq.gov/clinic/uspstf/uspscerv.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for lipid disorders in adults. http://www.ahrq.gov/clinic/uspstf/uspschol.htm. Accessed September 17, 2007
AACE Lipid Guidelines Committee American Association of Clinical Endocrinologists, AACE medical guidelines for clinical practice for the diagnosis and treatment of dyslipidemia and prevention of atherogenesis. Endocr Pract 2000;6 (2) 162- 213
PubMed
Albers  GWAmarenco  PEaston  JDSacco  RLTeal  P Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126 (3) ((suppl)) 483S- 512S
PubMed
Antman  EMAnbe  DTArmstrong  PW  et al.  ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44 (3) E1- E211
PubMed10.1016/j.jacc.2004.07.014
US Preventive Services Task Force, Counseling to prevent tobacco use. http://www.ahrq.gov/clinic/uspstf/uspstbac.htm. Accessed September 17, 2007
American Diabetes Association, Standards of medical care in diabetes. Diabetes Care 2004;27 ((suppl 1)) S15- S35
PubMed
Bridges  CBHarper  SAFukuda  KUyeki  TMCox  NJSingleton  JAAdvisory Committee on Immunization Practices, Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2003;52 (RR-8) 1- 34
 Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46 (RR-8) 1- 24
Zhang  JYu  KF What's the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280 (19) 1690- 1691
PubMed
Frane  J SUDAAN: Professional Software for Survival Data Analysis.  Research Triangle Park, NC Research Triangle Institute1989;
LaVange  LMStearns  SCLafata  JEKoch  GGShah  BV Innovative strategies using SUDAAN for analysis of health surveys with complex samples. Stat Methods Med Res 1996;5 (3) 311- 329
PubMed
Long  JAPolsky  DMetlay  JP Changes in veterans' use of outpatient care from 1992 to 2000. Am J Public Health 2005;95 (12) 2246- 2251
PubMed
Congressional Research Service, Veterans' Medical Care: FY2007 Appropriations.  Washington, DC Congressional Research Service2007;
US Government Accountability Office, VA Health Care: budget formulation and reporting on budget execution need improvement. http://www.gao.gov/new.items/d06958.pdf. Accessed September 17, 2007
Brown  JBAdams  ME Patients as reliable reporters of medical care process: recall of ambulatory encounter events. Med Care 1992;30 (5) 400- 411
PubMed
Johnson  TPO’Rourke  DPBurris  JEWarnecke  RB An investigation of the effects of social desirability on the validity of self-reports of cancer screening behaviors. Med Care 2005;43 (6) 565- 573
PubMed
Newell  SAGirgis  ASanson-Fisher  RWSavolainen  NJ The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review. Am J Prev Med 1999;17 (3) 211- 229
PubMed
Ross  JSBradley  EHBusch  SH Use of health care services by lower-income and higher-income uninsured adults. JAMA 2006;295 (17) 2027- 2036
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Ambulatory Health Care Services Examined, From the Behavioral Risk Factor Surveillance System, 2000 and 2004
Table Graphic Jump LocationTable 2. Weighted Sociodemographic Characteristics, Health Care Access Characteristics, and Clinical Characteristics and Medical History for Insured Adults, Stratified by Year and Receipt of Care at Veterans Affairs Medical Centers, From the Behavioral Risk Factor Surveillance System, 2000 and 2004a
Table Graphic Jump LocationTable 3. Weighted Use of Recommended Ambulatory Health Care Services Among Insured Adults, Stratified by Year and Receipt of Care at Veterans Affairs Medical Centers, From the Behavioral Risk Factor Surveillance System, 2000 and 2004
Table Graphic Jump LocationTable 4. Adjusted Data Between Insured Adults Receiving and Not Receiving Care at Veterans Affairs Medical Centers and Use of Recommended Ambulatory Health Care Services, From the Behavioral Risk Factor Surveillance System, 2000 and 2004a

References

Jha  AKPerlin  JBKizer  KWDudley  RA Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003;348 (22) 2218- 2227
PubMed
Petersen  LANormand  SLLeape  LLMcNeil  BJ Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare. Circulation 2001;104 (24) 2898- 2904
PubMed
Kerr  EAGerzoff  RBKrein  SL  et al.  Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med 2004;141 (4) 272- 281
PubMed
Asch  SMMcGlynn  EAHogan  MM  et al.  Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004;141 (12) 938- 945
PubMed
Ashton  CMSouchek  JPetersen  NJ  et al.  Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med 2003;349 (17) 1637- 1646
PubMed
Doebbeling  BNVaughn  TEWoolson  RF  et al.  Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods. Med Care 2002;40 (6) 540- 554
PubMed
Demakis  JGMcQueen  LKizer  KWFeussner  JR Quality Enhancement Research Initiative (QUERI): a collaboration between research and clinical practice. Med Care 2000;38 (6) ((suppl 1)) I17- I25
PubMed
Feussner  JRKizer  KWDemakis  JG The Quality Enhancement Research Initiative (QUERI): from evidence to action. Med Care 2000;38 (6) ((suppl 1)) 11- 16
PubMed
Kizer  KW The “new VA”: a national laboratory for health care quality management. Am J Med Qual 1999;14 (1) 3- 20
PubMed
Kizer  KW Promoting innovative nursing practice during radical health system change. Nurs Clin North Am 2000;35 (2) 429- 441
PubMed
Kizer  KWDemakis  JGFeussner  JR Reinventing VA health care: systematizing quality improvement and quality innovation. Med Care 2000;38 (6) ((suppl 1)) I7- I16
PubMed
National Committee on Quality Assurance, The State of Managed Care Quality: 1997.  Washington, DC National Committee on Quality Assurance1997;
National Committee on Quality Assurance, The State of Health Care Quality: 2002.  Washington, DC National Committee on Quality Assurance2002;
Brailer  D Action through collaboration: a conversation with David Brailer [interview by Robert Cunningham]. Health Aff (Millwood) 2005;24 (5) 1150- 1157
PubMed
Berwick  DMDeParle  NAEddy  DM  et al.  Paying for performance: Medicare should lead. Health Aff (Millwood) 2003;22 (6) 8- 10
PubMed
Epstein  AMLee  THHamel  MB Paying physicians for high-quality care. N Engl J Med 2004;350 (4) 406- 410
PubMed
Lindenauer  PKRemus  DRoman  S  et al.  Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007;356 (5) 486- 496
PubMed
Rosenthal  MBFrank  RGLi  ZEpstein  AM Early experience with pay-for-performance: from concept to practice. JAMA 2005;294 (14) 1788- 1793
PubMed
Institute of Medicine, To Err Is Human: Building a Safer Health System.  Washington, DC National Academy Press2000;
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century.  Washington, DC National Academy Press2001;
Centers for Disease Control and Prevention, 2000 Behavioral Risk Factor Surveillance System summary data quality report. http://ftp.cdc.gov/pub/Data/Brfss/2000SummaryDataQualityReport.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2004 Behavioral Risk Factor Surveillance System summary data quality report. http://ftp.cdc.gov/pub/Data/Brfss/2004SummaryDataQualityReport.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2000 Behavioral Risk Factor Surveillance System questionnaire. http://www.cdc.gov/brfss/questionnaires/pdf-ques/2000brfss.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, 2004 Behavioral Risk Factor Surveillance System state questionnaire [revised February 2004]. http://www.cdc.gov/brfss/questionnaires/pdf-ques/2004brfss.pdf. Accessed September 17, 2007
Centers for Disease Control and Prevention, Technical documents and survey data. http://www.cdc.gov/brfss/technical_infodata/surveydata.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for colorectal cancer. http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for breast cancer. http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for cervical cancer. http://www.ahrq.gov/clinic/uspstf/uspscerv.htm. Accessed September 17, 2007
US Preventive Services Task Force, Screening for lipid disorders in adults. http://www.ahrq.gov/clinic/uspstf/uspschol.htm. Accessed September 17, 2007
AACE Lipid Guidelines Committee American Association of Clinical Endocrinologists, AACE medical guidelines for clinical practice for the diagnosis and treatment of dyslipidemia and prevention of atherogenesis. Endocr Pract 2000;6 (2) 162- 213
PubMed
Albers  GWAmarenco  PEaston  JDSacco  RLTeal  P Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126 (3) ((suppl)) 483S- 512S
PubMed
Antman  EMAnbe  DTArmstrong  PW  et al.  ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44 (3) E1- E211
PubMed10.1016/j.jacc.2004.07.014
US Preventive Services Task Force, Counseling to prevent tobacco use. http://www.ahrq.gov/clinic/uspstf/uspstbac.htm. Accessed September 17, 2007
American Diabetes Association, Standards of medical care in diabetes. Diabetes Care 2004;27 ((suppl 1)) S15- S35
PubMed
Bridges  CBHarper  SAFukuda  KUyeki  TMCox  NJSingleton  JAAdvisory Committee on Immunization Practices, Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2003;52 (RR-8) 1- 34
 Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46 (RR-8) 1- 24
Zhang  JYu  KF What's the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280 (19) 1690- 1691
PubMed
Frane  J SUDAAN: Professional Software for Survival Data Analysis.  Research Triangle Park, NC Research Triangle Institute1989;
LaVange  LMStearns  SCLafata  JEKoch  GGShah  BV Innovative strategies using SUDAAN for analysis of health surveys with complex samples. Stat Methods Med Res 1996;5 (3) 311- 329
PubMed
Long  JAPolsky  DMetlay  JP Changes in veterans' use of outpatient care from 1992 to 2000. Am J Public Health 2005;95 (12) 2246- 2251
PubMed
Congressional Research Service, Veterans' Medical Care: FY2007 Appropriations.  Washington, DC Congressional Research Service2007;
US Government Accountability Office, VA Health Care: budget formulation and reporting on budget execution need improvement. http://www.gao.gov/new.items/d06958.pdf. Accessed September 17, 2007
Brown  JBAdams  ME Patients as reliable reporters of medical care process: recall of ambulatory encounter events. Med Care 1992;30 (5) 400- 411
PubMed
Johnson  TPO’Rourke  DPBurris  JEWarnecke  RB An investigation of the effects of social desirability on the validity of self-reports of cancer screening behaviors. Med Care 2005;43 (6) 565- 573
PubMed
Newell  SAGirgis  ASanson-Fisher  RWSavolainen  NJ The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review. Am J Prev Med 1999;17 (3) 211- 229
PubMed
Ross  JSBradley  EHBusch  SH Use of health care services by lower-income and higher-income uninsured adults. JAMA 2006;295 (17) 2027- 2036
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 28

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com