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. 2021 Jun 1;59(Suppl 3):S279-S285.
doi: 10.1097/MLR.0000000000001469.

The Impact of Community Care Referral on Time to Surgery for Veterans With Carpal Tunnel Syndrome

Jessica I Billig  1   2 , Richard R Evans  3 , Eve A Kerr  3   4   5 , Rodney A Hayward  3   4   5 , Erika D Sears  2   4   5
Affiliations

The Impact of Community Care Referral on Time to Surgery for Veterans With Carpal Tunnel Syndrome

Jessica I Billig et al. Med Care. .

Abstract

Background: The US Department of Veterans Affairs (VA) enacted policies offering Veterans care in the community, aiming to improve access challenges. However, the impact of receipt of community care on wait times for Veterans receiving surgical care is poorly understood.

Objectives: To compare wait times for surgery for Veterans with carpal tunnel syndrome who receive VA care plus community care (mixed care) and those who receive care solely within the VA (VA-only).

Research design: Retrospective cohort study.

Subjects: Veterans undergoing carpal tunnel release (CTR) between January 1, 2010 and December 31, 2016.

Measures: Our primary outcome was time from primary care physician (PCP) referral to CTR.

Results: Of the 29,242 Veterans undergoing CTR, 23,330 (79.8%) received VA-only care and 5912 (20.1%) received mixed care. Veterans receiving mixed care had significantly longer time from PCP referral to CTR (median mixed care: 378 days; median VA-only care: 176 days, P<0.001). After controlling for patient and facility covariates, mixed care was associated with a 37% increased time from PCP referral to CTR (adjusted hazard ratio, 0.63; 95% confidence interval, 0.61-0.65). Each additional service provided in the community was associated with a 23% increase in time to surgery (adjusted hazard ratio, 0.77; 95% confidence interval, 0.76-0.78).

Conclusions: VA-only care was associated with a shorter time to surgery compared with mixed care. Moreover, there were additional delays for each service received in the community. With likely increases in Veterans seeking community care, strategies must be used to identify and mitigate sources of delay through the spectrum of care between referral and definitive treatment.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

FIGURE 1
FIGURE 1
Kaplan-Meier estimate of Veterans receiving VA-only care and mixed care. VA indicates US Department of Veterans Affairs.
FIGURE 2
FIGURE 2
Forest plot of hazards ratios for Veterans receiving mixed care relative to VA-only care. Error bars reflect 95% confidence intervals for the hazard ratios. Models controlled for age, sex, race, Charlson Comorbidity Index, diabetes, VA priority group, primary care physician and surgeon in same facility, proportion of mixed care at the facility level, and complexity of the primary care clinic. Sample sizes: Any community care: n=29,191, facilities: 129; Any diagnostic testing: n=27,654, facilities: 129; Corticosteroid injection: n=3822, facilities: 121; Any hand therapy: n=17,448, facilities: 125; carpal tunnel release: n=29,191, facilities: 125; each additional service: n=29,191, facilities: 125. VA indicates US Department of Veterans Affairs.
FIGURE 3
FIGURE 3
Box and Whisker plots of differences in wait time between primary care referral to carpal tunnel release for Veterans receiving various CTS-related services in VA versus community settings. Each plot represents patients receiving each service in the VA, community, or not at all. CTS indicates carpal tunnel syndrome; CTR, carpal tunnel release; EDS, electrodiagnostic testing; NSTES, nonspecific therapy evaluation services; PCP, primary care physician; STM, specific therapeutic modalities.
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References

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    1. US Department of Veterans Affairs. Community Care. Available at: www.va.gov/COMMUNITYCARE/programs/veterans/General_Care.asp#Eligibility. Accessed January 6, 2020.
    1. Jablecki C, Andary M, Floeter M, et al. . Practice parameter: electrodiagnostic studies in carpal tunnel syndrome: report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58:1589–1592. - PubMed

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