Ethical issues arising from variation in health services utilization at the end of life.

Research on health services delivery, particularly at the end of life, has demonstrated that more care does not necessarily lead to better technical quality, patient satisfaction, or outcomes. These findings raise three ethical issues: (1) justice in the allocation of scarce resources across health service areas; (2) nonmaleficence in the provision of appropriate amounts of care to patients; and (3) transparency about local healthcare practice so patients can make enlightened decisions about healthcare choices. We conclude that in this era of healthcare accountability, managers and clinicians can use these ethical principles to drive change in the process of providing more efficient, more effective, and more patient-centered care, especially at the end of life.

Utilization of VA and Medicare services by Medicare-eligible veterans: the impact of additional access points in a rural setting.

The Veterans Health Administration (VA) has recently established community-based outpatient clinics (CBOCs) to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare-eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolied in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded by Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.

Listserv use enhances quality and safety in multisite quality improvement efforts.

A listserv is an e-mail group to which people subscribe based upon common interests. We used a retrospective study to examine the relationship between listserv use and team success for health care quality improvement efforts. We hypothesized high listserv use would be associated with team success. Eighty-seven Department of Veterans Affairs teams participated in facilitated quality improvement efforts to address three areas: improving safety in high-hazard areas, improving the disability evaluation process, and reducing falls and related injuries. We coded messages sent to the listserv according to sender (faculty or participant), team, and content. We correlated the volume of messages sent per team with team success and with team and facility characteristics. Teams with high listserv contributions were more likely to complete their first test of change, report facility use of nonpunitive methods of investigating medical incidents, and report their information systems were useful. We found a negative correlation between listserv contribution and the number of face-to-face meetings and a physician as an active team member, but we found no relationship between team success and listserv contribution. Team listserv contribution was not associated with team success in multisite quality improvement efforts. Successful teams may be accessing information on the listserv but not sending a message to indicate use.

A model for improving the quality and timeliness of compensation and pension examinations in VA facilities.

In response to external and internal customer dissatisfaction and in anticipation of markedly higher volumes of examination requests, the Department of Veterans Affairs (VA) produced an eight-month facilitated quality-improvement project designed to improve the quality and timeliness of compensation examination processing. To determine whether participation in the project was associated with better outcomes and to identify team characteristics that were associated with high performance, we obtained centrally collected facility-level performance measures on quality and timeliness of the examinations. To determine factors associated with team success, we compared measures of leadership support reported by teams with high and low performance outcomes. Thirty teams representing 34 VA medical centers and 22 Veterans Benefits Administration's regional offices participated in the project. Monthly volumes were significantly higher for participating teams, and volumes increased significantly over time for both groups. At the beginning of the project, examination timeliness was substantially worse for participating teams (34.1 versus 29.9 days, p = .03); by the end, participants had better performance (28.5 versus 30.3 days, p = .00). Quality measures were maintained. By the end of the project, high performers reported improved leadership, frontline support, resource availability, alignment with strategic goals, and leadership mandate when compared to performance at the beginning of the project; low performers reported the opposite. These results suggest that the principles of clinical improvement can be applied successfully to teach teams how to achieve process improvements within a large healthcare organization. Visible, ongoing support by leadership and alignment of project objectives with strategic goals are associated with improved project outcomes.