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Use of Recommended Ambulatory Care ServicesIs the Veterans Affairs Quality Gap Narrowing?
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
Arch Intern Med. 2008;168(9):950-958.
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.
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.
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