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- Title
Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records.
- Authors
O'Hare, Ann M.; Butler, Catherine R.; Laundry, Ryan J.; Showalter, Whitney; Todd-Stenberg, Jeffrey; Green, Pam; Hebert, Paul L.; Wang, Virginia; Taylor, Janelle S.; Van Eijk, Marieke; Matthews, Kameron L.; Crowley, Susan T.; Carey, Evan
- Abstract
<bold>Importance: </bold>Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system.<bold>Objective: </bold>To describe the implications for the VA system of recent increases in VA-financed non-VA care.<bold>Design, Setting, and Participants: </bold>This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021.<bold>Exposures: </bold>Mentions of community care in participant EHRs.<bold>Main Outcomes and Measures: </bold>Dominant themes pertaining to VA-financed non-VA care.<bold>Results: </bold>Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes.<bold>Conclusions and Relevance: </bold>The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.
- Subjects
UNITED States; MEDICAL care; KIDNEY diseases; QUALITATIVE research; RESEARCH funding; VETERANS; UNITED States. Dept. of Veterans Affairs
- Publication
JAMA Internal Medicine, 2022, Vol 182, Issue 7, p710
- ISSN
2168-6106
- Publication type
journal article
- DOI
10.1001/jamainternmed.2022.1379