Background:Prior studies at the national level indicate that primary care wait times exceeded the 20-day veterans Health Administration (VA) wait time standards set for primary care. Longer wait times were also reported for Black and Hispanic versus White veterans.Objectives:Examine variation in wait time for primary care at the facility level by race and ethnicity over time and determine whether differences are due to within-facility differences (ie, at the same facility) or between-facility differences (ie, differences in facilities used).Research Design:Observational study using VA and Community Care (CC) data from Fiscal Year (FY) FY2021 to FY2023.Subjects:All veterans (n=642,180) who had an outpatient primary care consult in VA or CC.Measures:Wait time for an outpatient primary care consult.Methods:We used multivariate regression models calculated using all 3 FYs combined and separately by FY models to predict consult wait times. We then used the Kitagawa decomposition to partition differences in mean adjusted wait times between Hispanic/Black veterans and White veterans into within-facility differences and between-facility differences.Results:Overall, Hispanic veterans waited on average 6.7 days longer than White veterans, attributed to longer wait times within the same facility. Black veterans waited 1.2 days less than White veterans, partially accounted for by their higher use of facilities with shorter wait times for all veterans. Within-facility results were reasonably stable across FYs.Conclusions:Continued investigation at the local level is important for ensuring timely access to primary care for all racial and ethnic groups.

BACKGROUND:Prior studies at the national level indicate that primary care wait times exceeded the 20-day veterans Health Administration (VA) wait time standards set for primary care. Longer wait times were also reported for Black and Hispanic versus White veterans. OBJECTIVES:Examine variation in wait time for primary care at the facility level by race and ethnicity over time and determine whether differences are due to within-facility differences (ie, at the same facility) or between-facility differences (ie, differences in facilities used). RESEARCH DESIGN:Observational study using VA and Community Care (CC) data from Fiscal Year (FY) FY2021 to FY2023. SUBJECTS:All veterans (n=642,180) who had an outpatient primary care consult in VA or CC. MEASURES:Wait time for an outpatient primary care consult. METHODS:We used multivariate regression models calculated using all 3 FYs combined and separately by FY models to predict consult wait times. We then used the Kitagawa decomposition to partition differences in mean adjusted wait times between Hispanic/Black veterans and White veterans into within-facility differences and between-facility differences. RESULTS:Overall, Hispanic veterans waited on average 6.7 days longer than White veterans, attributed to longer wait times within the same facility. Black veterans waited 1.2 days less than White veterans, partially accounted for by their higher use of facilities with shorter wait times for all veterans. Within-facility results were reasonably stable across FYs. CONCLUSIONS:Continued investigation at the local level is important for ensuring timely access to primary care for all racial and ethnic groups.

Importance Surgical quality assessment has largely focused on addressing risk-adjusted postoperative outcomes, which neglects quality assessment across the entire perioperative surgical continuum. The Veterans Health Administration (VA) has the unique opportunity to employ a surgical episode framework to measure surgical quality more broadly and inform quality improvement across VA-delivered and VA-purchased Community Care (VA-CC). Objective To develop an innovative surgical episode quality measurement model encompassing preoperative, perioperative, and postoperative care phases for 3 common, elective surgical procedures of varying complexity for potential application to VA and private sector settings. Evidence Review In this study, modified Delphi panels were conducted virtually with participants from VA and private sector settings across the US. Multidisciplinary clinical and quality experts participated in the panels and included surgical and nonsurgical specialists relevant to the included conditions. The study team performed an environmental scan (April 2023 to August 2024) to identify current and draft new quality measures followed by 3 modified Delphi panels (October to December 2024) utilizing the RAND-UCLA Appropriateness Method to rate the measures for carpal tunnel release (CTR), inguinal hernia repair (IHR), and total knee arthroplasty (TKA). Participants completed a 2-step rating of all measures for face validity, feasibility, improvement opportunity, and/or appropriateness on 9-point Likert scales, with the main outcome being appropriateness. Measures with a median appropriateness score of 7 to 9 without disagreement were included in the models. Findings A total of 31 panelists participated. The environmental scan identified 594 measures and recommendations across all procedures, including 250 currently utilized measures and 344 new measure recommendations that emphasized appropriate preoperative evaluation, intraoperative best practices, and minimization of postoperative complications. A total of 61 measures (17 for CTR, 18 for IHR, and 26 for TKA) were presented to the panelists. After the second round of ratings, 40 measures (15 CTR, 8 IHR, and 17 TKA) were included in the models. Conclusions and Relevance This Delphi panel study of expanded episode-based surgical quality measurement provides a roadmap to assess and improve quality across the entire perioperative surgical continuum—including the preoperative, perioperative, and postoperative care phases. Future work will operationalize this model across the 3 procedures to assess variations in quality for surgical care provided in VA and VA-CC settings.

Background In 2014, Congress passed the Veterans Access, Choice, and Accountability Act (Choice Act) to improve access to care, temporarily expanding VA-purchased Community Care (VA-CC) through a network of contracted community providers, with eligibility criteria based on appointment wait times and distance to care. In 2018, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act established a permanent, consolidated VA-CC program, providing new eligibility criteria, and expanding services. This scoping review summarizes the VA-CC literature since passage of the Choice Act across five domains: Access, Program Implementation, Quality, Coordination of Care, and Costs. Methods Four bibliographic databases were searched from 2014 to April 2023: Ovid MEDLINE, Embase, Cochrane CENTRAL, and CINAHL. A separate search identified RAND Corporation publications and U.S. Government Accountability Office’s (GAO) reports from 2014 to 2023. Fifteen publication characteristics were extracted including standard scoping review elements (e.g., publication year, key findings) and VA-CC specific variables such as legislation, domain, health care specialty area, and study participant type (e.g., Veterans, providers, staff). Results Of 2,284 unique records, 89 publications and 11 GAO reports were retained. Most assessed Access (n=60) or Coordination of Care (n=32), while 11 examined Costs. Nearly half (n=46) focused on specialty care, and approximately 80% (n=78) examined VA-CC in relation to Veterans (versus providers or staff). Few publications examined multiple domains or considered domains jointly (e.g., Access and Quality). Overall, VA-CC reduced drive times; however, wait times were largely unchanged, and some Veterans continued to travel farther than their nearest VA facility for care. Findings related to Quality and Costs were mixed, varying by population and outcomes examined. Publications addressing Coordination of Care and Program Implementation described both persistent challenges and potential solutions. Conclusions The Choice and MISSION Acts were designed to improve Veterans’ access to care, but they have also affected coordination, quality, and costs. Together, these findings underscore the need to evaluate multiple domains concurrently to understand the trade-offs and inform improvements across the health care delivery system.

Deprescribing, intentional medication discontinuation or dose reduction, can reduce potentially inappropriate medication use and medication-related harms. Engaging patients in deprescribing discussions may increase likelihood of deprescribing and promote shared decision-making. To examine the impact of patient-directed educational brochures on patient engagement and deprescribing discussions with primary care providers (PCPs). We mailed medication-specific brochures 2 weeks prior to each patient’s PCP appointment (4/12/2021–10/7/2022), followed by a mailed survey 2 weeks after scheduled PCP visits. Patients from three Veterans Affairs facilities with scheduled PCP appointments eligible for one of three medication-based cohorts (proton pump inhibitor, gabapentin, diabetes-hypoglycemia risk). Our primary outcome was patient-reported deprescribing discussions with their PCP (yes/no). Descriptive statistics characterized engagement with and reactions to the brochure. Multivariable logistic regression models determined associations of patient characteristics, attitudes, and brochure-engagement with reported deprescribing discussions. Adjusting only for patient characteristics, discussions were less likely if respondents were Black (vs. White: OR 0.47, 95

Implementation fidelity—the degree to which an intervention is executed as intended—is critical for evaluating healthcare interventions' success. Contextual determinants such as organizational culture, communication, and leadership influence how interventions unfold at the site level. The Veterans Health Administration (VA) developed the Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook to improve standardization of patient safety reporting across VA-delivered and VA-purchased care. While the Guidebook aims to enhance reporting fidelity, little is known about which local contextual factors influence its implementation success across diverse VA sites. This study examined the contextual determinants associated with site-level variation in Guidebook implementation fidelity. We conducted a cross-sectional, mixed-methods evaluation of 18 geographically diverse VA Medical Centers. Data were collected from 32 interviews with 45 key personnel involved in Guidebook implementation. Using the 2009 Consolidated Framework for Implementation Research (CFIR), 12 constructs were rated at each site. Fidelity was assessed across three safety processes (reporting, investigation, and improvement) on a three-point scale. We used Coincidence Analysis, a configurational comparative method, to identify combinations of CFIR constructs (difference-makers) that consistently distinguished higher- from lower-fidelity sites. Guidebook fidelity varied across sites (range = 0.23 to 1.59). We identified three key CFIR constructs associated with higher fidelity: Networks Communications, Relative Priority, and Leadership Engagement. Of these, Networks Communications was both a necessary and sufficient condition for higher fidelity, serving as a precondition for high levels of Leadership Engagement. Sites that rated highly in Relative Priority were more likely to fully implement Guidebook processes. These constructs fostered strong collaboration, timely information exchange, and internal alignment on the importance of patient safety reporting. Effective communication networks and perceived priority of the intervention were central to high-fidelity implementation of the VA’s safety reporting Guidebook. These findings highlight critical levers for improving implementation fidelity in complex healthcare systems. Targeted strategies that strengthen communication and emphasize the value of safety interventions may enhance implementation success, offering valuable insights for patient safety efforts both within and beyond the VA.

BACKGROUND:More than one in three older adults use potentially inappropriate medications (PIMs), and those with chronic conditions are more likely to be on multiple PIMs. Deprescribing, defined as stopping or dose-reducing a medication, can avoid harms from PIMs. Despite its benefits, deprescribing is rarely adopted into clinical practice. OBJECTIVES:We examined the effectiveness, sustainability, and safety of a patient-engagement strategy in a pragmatic trial at three facilities. METHODS:Subjects were mailed brochures for one of three PIMs (proton pump inhibitors, high-dose gabapentin, and diabetes agents with hypoglycemia risk) if they had chronic active prescriptions before a primary care provider (PCP) visit. Control subjects received usual care. RESULTS:There were 2448 patients in the control group (n = 2448) and 2480 patients in the implementation strategy cohort (n = 2480). In a mixed effect multivariable logistic regression model with PCP and site treated as random factors and controlling for patient and PCP characteristics, implementation strategy patients were significantly more likely to have deprescribing at 12-months compared with controls (odds ratio [OR] = 1.19; 95% confidence interval [CI] = 1.04, 1.35; p = 0.012). In a multinomial logistic regression model controlling for patient characteristics, implementation strategy patients were significantly more likely to exhibit sustained deprescribing (deprescribing at 6 and 12 months, OR = 1.32 [95% CI = 1.13, 1.55]) but not short-term (6 months only, OR = 0.96 [95% CI = 0.79, 1.16]) or delayed (12 months only, OR = 0.99 [95% CI = 0.84, 1.17]) deprescribing. There were five potential severe adverse drug withdrawals (0.2% incidence rate) possibly related to deprescribing. CONCLUSIONS:Despite low intensity, patient-directed education materials are an effective and safe implementation strategy to promote and sustain deprescribing. TRIAL REGISTRATION:ClinicalTrials.gov, NCT0429490, NCT04294901.

OBJECTIVE:To characterize the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022. BACKGROUND:Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature have never been systematically reviewed. METHODS:We searched for 2021 to 2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of 3 methodological criteria: (1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH), (2) accounting for clustering of patients within hospitals or other subunits ("providers"), and (3) distinguishing within-provider and between-provider effects. RESULTS:We identified 224 papers describing racial and/or ethnic differences. Of the 38 single-institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for the clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of the overall disparities were driven by within versus between-provider effects. CONCLUSIONS:Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and, therefore, may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies.

Objective:To characterize the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022.Background:Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature have never been systematically reviewed.Methods:We searched for 2021 to 2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of 3 methodological criteria: (1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH), (2) accounting for clustering of patients within hospitals or other subunits ("providers"), and (3) distinguishing within-provider and between-provider effects.Results:We identified 224 papers describing racial and/or ethnic differences. Of the 38 single-institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for the clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of the overall disparities were driven by within versus between-provider effects.Conclusions:Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and, therefore, may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies.

The Veterans Health Administration (VA) increasingly purchases community-based care (CC) to improve healthcare access, including behavioral health. In 2018, VA introduced standardized episodes of care (SEOCs) to guide authorization and purchase of CC services for specific indications in a defined timeframe without bundling payment. In this retrospective cross-sectional study, we describe trends in VA and CC behavioral healthcare utilization using the VA Outpatient Psychiatry SEOC definition. Counts of Outpatient Psychiatry SEOC-allowable service and procedure codes during fiscal years 2016–2019 were organized according to four SEOC-defined service types (evaluation and management, laboratory services, psychiatry services, transitional care) and measured as percentages of all included codes. Trends comparing behavioral healthcare utilization between Veterans using any CC versus VA only were analyzed using a linear mixed effects model. We identified nearly 3 million Veterans who registered 60 million qualifying service and procedure codes, with overall utilization increasing 77.8

ObjectiveTo evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them.Data Sources and Study SettingQualitative data collected from key informants at 18 geographically diverse VA facilities across 17 Veterans Integrated Services Networks (VISNs).Study DesignWe conducted semi-structured interviews from 2019 to 2022 with VISN Patient Safety Officers (PSOs) and VA facility patient safety and quality managers (PSMs and QMs) and VA Facility Community Care (CC) staff to assess lessons learned by examining organizational contextual factors affecting Guidebook implementation based on the Consolidated Framework for Implementation Research (CFIR).Data Collection/Extraction MethodsInterviews were conducted virtually with 45 facility staff and 10 VISN PSOs. Using directed content analysis, we identified CFIR factors affecting implementation. These factors were mapped to the Expert Recommendations for Implementing Change (ERIC) strategy compilation to identify lessons learned that could be useful to our operational partners in improving implementation processes. We met frequently with our partners to discuss findings and plan next steps.Principal FindingsSix CFIR constructs were identified as both facilitators and barriers to Guidebook implementation: (1) planning for implementation; (2) engaging key knowledge holders; (3) available resources; (4) networks and communications; (5) culture; and (6) external policies. The two CFIR constructs that were only barriers included: (1) cosmopolitanism and (2) executing implementation.ConclusionsOur findings suggest several important lessons: (1) engage all collaborators involved in implementation; (2) ensure end-users have opportunities to provide feedback; (3) describe collaborators' purpose and roles/responsibilities clearly at the start; (4) communicate information widely and repeatedly; and (5) identify how multiple high priorities can be synergistic. This evaluation will help our partners and key VA leadership to determine next steps and future strategies for improving Guidebook implementation through collaboration with VA staff.

Importance The 2018 Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act was implemented to increase timely access to care by expanding veterans' opportunities to receive Veterans Affairs (VA)-purchased care in the community (community care [CC]). Because health equity is a major VA priority, it is important to know whether Black and Hispanic veterans compared with White veterans experienced equitable access to primary care within the VA MISSION Act. Objective To examine whether utilization of and wait times for primary care differed between Black and Hispanic veterans compared with White veterans in rural and urban areas after the implementation of the VA MISSION Act. Design, Setting, and Participants This cross-sectional study used VA and CC outpatient and consult data from the VA's Corporate Data Warehouse for fiscal years 2021 to 2022 (October 1, 2020, to September 30, 2022). Separate fixed-effects multivariable models were run to predict CC utilization and wait times. Each model was run twice, once comparing Black and White veterans and then comparing Hispanic and White veterans. Adjusted risk ratios (ARRs) were calculated for Black and Hispanic veterans compared with White veterans within rurality status for both outcomes. Main Outcomes and Measures VA and CC primary care utilization as measured by primary care visits (utilization cohort); VA and CC primary care access as measured by mean wait times (access cohort). Results A total of 5 046 087 veterans (994 517 [19.7%] Black, 390 870 [7.7%] Hispanic, and 3 660 700 [72.6%] White individuals) used primary care from fiscal years 2021 to 2022. Utilization increased for all 3 racial and ethnicity groups, more so in CC than VA primary care. ARRs were significantly less than 1 regardless of rurality status, indicating Black and Hispanic veterans compared with White veterans were less likely to utilize CC for primary care. There were 468 246 primary care consultations during the study period. The overall mean (SD) wait time was 33.3 (32.4) days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. Black veterans compared with White veterans had significantly longer wait times in CC (ARRs >1) but significantly shorter wait times in VA (ARRS <1) regardless of rurality status in VA and CC. CC wait times for Hispanic veterans compared with White veterans were longer in rural areas only and in VA rural and urban areas (ARRs >1). Conclusion and Relevance The results of this cross-sectional study suggest that additional research should explore the determinants and implications of utilization differences among Black and Hispanic veterans compared with White veterans. Efforts to promote equitable primary care access for all veterans are needed so that policy changes can be more effective in ensuring timely access to care for all veterans.

OBJECTIVE:Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors.METHODS:This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care.RESULTS:Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06).CONCLUSIONS:With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.

BACKGROUND:Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. METHODS:In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. RESULTS:A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). CONCLUSION:Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.

IMPORTANCE Prior studies indicate that Black and Hispanic vs White veterans wait longer for care. However, these studies do not capture the COVID-19 pandemic, which caused care access disruptions, nor implementation of the US Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION), which is intended to improve care access by increasing veterans' options to use community clinicians. OBJECTIVE To determine whether wait times increased differentially for Black and Hispanic compared with White veterans from the pre-COVID-19 to COVID-19 periods given concurrent MISSION implementation. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the VA's Corporate DataWarehouse for fiscal years 2019 to 2021 (October 1, 2018, to September 30, 2021). Participants included Black, Hispanic, and White veterans with a new consultation for outpatient cardiology and/or orthopedic services during the study period. Multivariable mixed-effects models were used to estimate individual-level adjusted wait times and a likelihood ratio test of the significance of wait time disparity change over time. MAIN OUTCOMES AND MEASURES Overall mean wait times and facility-level adjusted relative mean wait time ratios. RESULTS The study included 1 162 148 veterans (mean [SD] age, 63.4 [14.4] years; 80.8% men). Significant wait time disparities were evident for orthopedic services (eg, Black veterans had wait times 2.09 [95% CI, 1.57-2.61] days longer than those for White veterans) in the pre-COVID-19 period, but not for cardiology services. Mean wait times increased from the pre-COVID-19 to COVID-19 periods for both services for all 3 racial and ethnic groups (eg, Hispanic wait times for cardiology services increased 5.09 [95% CI, 3.62-6.55] days). Wait time disparities for Black veterans (4.10 [95% CI, 2.44-5.19] days) and Hispanic veterans (4.40 [95% CI, 2.76-6.05] days) vs White veterans (3.75 [95% CI, 2.30-5.19] days) increased significantly from the pre-COVID-19 to COVID-19 periods (P <.001). During the COVID-19 period, significant disparities were evident for orthopedic services (eg, mean wait times for Hispanic vs White veterans were 1.98 [95% CI, 1.32-2.64] days longer) but not for cardiology services. Although therewas variation inwait time ratios across the 140 facilities, only 6 facility wait time ratios were significant during the pre-COVID-19 period and 26 during the COVID-19 period. CONCLUSIONS AND RELEVANCE These findings suggest that wait time disparities increased from the pre-COVID-19 to COVID-19 periods, especially for orthopedic services for both Black and Hispanic veterans, despite MISSION's goal to improve access. Facility-level analyses identified potential sites that could be targeted to reduce disparities.

Background: Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences. Objectives: Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference. Subjects: Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019–2021. Measures: Wait time for a new-patient consult Methods: In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups. Results: Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (−0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. Conclusions: The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.

Background Hospital-specific template matching (HS-TM) is a newer method of hospital performance assessment. Objective To assess the interpretability, credibility, and usability of HS-TM-based vs. regression-based performance assessments. Research design We surveyed hospital leaders (January-May 2021) and completed follow-up semi-structured interviews. Surveys included four hypothetical performance assessment vignettes, with method (HS-TM, regression) and hospital mortality randomized. Subjects Nationwide Veterans Affairs Chiefs of Staff, Medicine, and Hospital Medicine. Measures Correct interpretation; self-rated confidence in interpretation; and self-rated trust in assessment (via survey). Concerns about credibility and main uses (via thematic analysis of interview transcripts). Results In total, 84 participants completed 295 survey vignettes. Respondents correctly interpreted 81.8% HS-TM vs. 56.5% regression assessments, p < 0.001. Respondents “trusted the results” for 70.9% HS-TM vs. 58.2% regression assessments, p = 0.03. Nine concerns about credibility were identified: inadequate capture of case-mix and/or illness severity; inability to account for specialized programs ( e.g. , transplant center); comparison to geographically disparate hospitals; equating mortality with quality; lack of criterion standards; low power; comparison to dissimilar hospitals; generation of rankings; and lack of transparency. Five concerns were equally relevant to both methods, one more pertinent to HS-TM, and three more pertinent to regression. Assessments were mainly used to trigger further quality evaluation (a “check oil light”) and motivate behavior change. Conclusions HS-TM-based performance assessments were more interpretable and more credible to VA hospital leaders than regression-based assessments. However, leaders had a similar set of concerns related to credibility for both methods and felt both were best used as a screen for further evaluation.

Background Polypharmacy (taking >= five medications) is common and associated with adverse drug events, medication nonadherence, and increased mortality and healthcare costs. Primary care providers are uniquely positioned to deprescribe unnecessary medications, yet little is known about factors that influence their deprescribing decisions. Objectives We sought to identify factors that influence primary care providers' recommendations to deprescribe potentially unnecessary medications. Methods This study represents a secondary data analysis from a national, cross-sectional survey assessing providers' beliefs, attitudes, and experiences regarding medication deprescribing. A random sample of 2475 providers in Veterans Affairs (VA) primary care clinics were invited; 411 responded (16.6% response rate). Respondents included physicians (n = 304), nurse practitioners/physician assistants (n = 68), and clinical pharmacists (n = 39). Respondents estimated the proportion of their patients taking a potentially unnecessary medication. Of these patients, providers then identified the proportion for whom they recommended medication deprescribing (response options: <20%, 20%-39%, 40%-59%, 60%-79%, >= 80%). We used multivariable logistic regression to determine factors associated with recommending deprescribing to >= 80% of candidate patients. Results Although most respondents indicated having patients taking unnecessary medications, less than one-third reported recommending deprescribing to most (>= 80%) of their candidate patients. In adjusted analyses, factors significantly associated with increased likelihood of recommending deprescribing included having more patients who asked for medication information, providers' self-rated comfort with deprescribing, and having support to monitor patients after deprescribing. When the indication for a medication was unclear, providers reported being less likely to recommend deprescribing. Conclusion Most providers indicated caring for patients taking potentially unnecessary medications, yet they did not consistently say they recommended deprescribing to these patients. Our findings suggest that requiring prescriptions to include their reason for use and models of primary care designed to strengthen interdisciplinary teamwork and communication, such as the patient-centered medical home, could address barriers providers face to deprescribing medications.

Importance Recent legislation expanded veterans’ access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance. Objective To determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates). Design, Setting, and Participants This 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA’s Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services’ methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period. Exposures Of the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased. Main Outcomes and Measures The primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility’s TKAs. Results Among the study sample’s 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs. Conclusions and Relevance In this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans’ decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.