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The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

ABSTRACT: OBJECTIVE:To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data. DATA SOURCES/STUDY SETTING:One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool. STUDY DESIGN:We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days. PRINCIPAL FINDINGS:With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs. CONCLUSIONS:The relationship between cost and quality depends on facility size and current level of performance.

SUBMITTER: Burgess JF

PROVIDER: S-EPMC6153156 | biostudies-other | 2018 Oct

REPOSITORIES: biostudies-other

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The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

Burgess James F JF Shwartz Michael M Stolzmann Kelly K Sullivan Jennifer L JL

Health services research 20180518 5

<h4>Objective</h4>To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data.<h4>Data sources/study setting</h4>One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resid ...[more]

PMID: 29777535

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Project description:BackgroundTo monitor progress towards eliminating health disparities, community health centers have reported on hypertension control, diabetes control, and birthweight by race and ethnicity since 2008.ObjectiveTo evaluate racial/ethnic time trends in quality outcomes in health centers and to assess both within- and between-center disparities in outcomes.Design and sampleUsing 2009-2014 data from all US health centers (n = 1047 centers, serving 19.6 million patients/year), we evaluated racial/ethnic time trends in quality outcomes for health centers and assessed within- and between-center disparities.Main measuresPercentage of patients achieving control of blood pressure < 140/90 mmHg among hypertensive persons, control of glycosylated hemoglobin ? 9.0% among diabetic persons, and birthweight ? 2500 g. All outcomes were reported by race/ethnicity.Key resultsThere was no evidence of improved outcomes among racial/ethnic subgroups from 2009 to 2014, though electronic health record adoption, medical recognition, and insurance coverage rates increased substantially. Two exceptions were increased rates of normal birthweight for black patients (87.0% to 88.8%, or 0.3 percentage points/year, p = 0.02) and decreased rates of diabetes control for white patients (74.2% to 69.5%, or -1.0 percentage points/year, p < 0.01). Within centers, the largest racial/ethnic disparities in 2009 were white/black disparities in hypertension control (8.7 percentage points, 95% CI 7.4-10.1), white/black disparities in diabetes control (3.4 percentage points, 95% CI 2.0-4.7), and white/Hispanic disparities in diabetes control (4.4 percentage points, 95% CI 2.8-6.0). All disparities remained statistically unchanged from 2009 to 2014. White patients were more likely to be seen at a health center in the top performance quintile compared with black and Hispanic patients (p < 0.001).ConclusionsThough quality outcomes in health centers continued to compare favorably to other care settings, we found no evidence of improved quality or reduced disparities in diabetes control, hypertension control, or birthweight from 2009 to 2014. Within- and between-center racial/ethnic disparities in quality were evident, and both should be targeted in future interventions.

Project description:Background/objectivesCOVID-19 has caused significant morbidity and mortality in nursing homes. Vaccination against SARS-COV-2 holds promise for reduction in COVID-19. This operational analysis describes the proportion of SARS-COV-2 positive tests before, during, and after vaccination.DesignRetrospective longitudinal cohort analysis from October 1, 2020 until February 14, 2021.SettingA total of 130 Department of Veterans Affairs (VA) Community Living Centers (CLC), analogous to nursing homes.InterventionVaccination for SARS-CoV-2.MeasurementsThe primary measure is the proportion of SARS-CoV-2 positive tests among CLC residents. In a pooled analysis of weekly testing and vaccine data, the proportion of positive tests was compared for the unvaccinated, first dose, and second dose. For each CLC, we identified the week in which 50% of CLC residents were vaccinated (index week). The analysis aligned the index week for CLCs and examined the proportion of SARS-CoV-2 positive tests at the CLC level before and after. As a reference, we plotted the proportion of positive tests in nursing homes in the same county as the CLC using publicly reported data.ResultsWithin the pooled VA CLCs, the first SARS-CoV-2 vaccine dose was delivered to 50% of CLC residents within 1 week of availability and second dose within 5 weeks. Relative to the index week, the risk ratio of SARS-CoV-2 positive tests in the vaccinated relative to unvaccinated was significantly lower in Week 4 (relative risk 0.37, 95% confidence interval 0.20-0.68). Throughout the study period, the proportion of SARS-CoV-2 positive tests in community nursing homes was higher compared to VA CLC and also declined after vaccine availability.ConclusionThe proportion of SARS-CoV-2 positive tests significantly declined in VA CLCs 4 weeks after vaccine delivery and continued to decline in vaccinated and unvaccinated residents. The results describe the importance of SARS-CoV-2 surveillance and vaccination in VA nursing home residents.

Project description:ImportanceThe Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.ObjectiveTo examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, setting, and participantsThis cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.ExposuresA laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main outcomes and measuresOverall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).ResultsA total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and relevanceDespite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

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The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

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The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

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