Performance of the Veterans Choice Program for Improving Access to Colonoscopy at a Tertiary VA Facility

Abstract

Introduction: The Veterans Choice Program (VCP) was designed to provide a pathway for veterans to access health care in the community if wait times at the US Department of Veterans Affairs (VA) were > 30 days. However, the performance of this program, in terms of timeliness, quality assurance, and overall utilization by veterans for colonoscopy is not well studied.

Methods: We reviewed records of veterans at VA Pittsburgh Healthcare System (VAPHS) who underwent VCP colonoscopy from June 2015 through March 2017. We compared the number of days from the scheduling encounter to the first available colonoscopy at VAPHS to the actual colonoscopy through the VCP. Additionally, we examined the availability of procedure and pathology results, documentation of quality metrics, and if clear follow-up recommendations were present in community care records. We then separately examined VCP utilization in a representative sample (5% margin of error, 95% CI) of all colonoscopy referrals through the VCP.

Results: During the study period 3,855 veterans were eligible for colonoscopy via the VCP, and 190 colonoscopies were performed through VCP. Records were absent for 29 exams (15.3%). There was no statistically significant difference for the number of days from a veteran's initially scheduled first-available colonoscopy at VAPHS when compared with the actual VCP colonoscopy (median 2 days earlier, P = .62). Pathology results were absent in 14 of 118 (11.9%) patient records, and follow-up recommendations were absent in 29 of 161 (18%) cases. Documentation of colonoscopy quality metrics were deficient in 27% to 70% of procedure reports. In a utilization sample of 350 veterans, only 26 (7.4%) veterans referred for colonoscopy had documented VCP colonoscopies, and 231 (66%) had a VAPHS colonoscopy. The median actual wait time for colonoscopy was 61 days for VAPHS and 66 days through VCP (P = .15).

Conclusions: Colonoscopies referred through the VCP were not performed sooner in aggregate compared with the first available colonoscopy at VAPHS, although there was wide variability in wait times. We recommend additional mechanisms be put into place when outsourcing to community care: Ensure seamless and require prompt transfer of records back to the VA, require reporting of quality metrics standard at the VA for community care colonoscopies, and establish clinically meaningful wait-time thresholds for referral into the community, rather than static ones.

FIGURE 1

Colonoscopy Scheduling Flowchart^a Abbreviations: VCP, Veterans Choice Program; VAPHS, US Department of Veterans Affairs Pittsburg Healthcare System. ^aThe difference in days between scheduled VAPHS and actual VCP colonoscopies was determined by finding difference between Box (B) and Box (A).

FIGURE 2

Difference in Days Between Scheduled VAPHS Colonoscopy and Actual VCP Colonoscopy Abbreviations: VCP, Veterans Choice Program; VAPHS, US Department of Veterans Affairs Pittsburg Healthcare System.

FIGURE 3

Veterans Choice Program Colonoscopy Quality Metrics

FIGURE 4

Flowchart of VCP Utilization for Colonoscopy at VAPHS Abbreviations: VCP, Veterans Choice Program; VAPHS, US Department of Veterans Affairs Pittsburg Healthcare System.