CME Author: Zeena Nackerdien
Study Authors: Madeline Penn, Saurabha Bhatnagar, et al.
Target Audience and Goal Statement: Primary care physicians, dermatologists, cardiologists, and orthopedic specialists
The goal was to learn more about wait times for new patients receiving care at U.S. Department of Veterans Affairs (VA) medical centers and wait times in the private sector.
Study investigators addressed the following questions:
- What were the wait times as determined from VA scheduling data for primary care, dermatology, cardiology, and orthopedics in metropolitan areas?
- How did VA wait times compare with private sector wait times as determined from published survey data?
Synopsis and Perspective:
The VA medical system has been beset with a number of much-publicized issues and debates including manipulation of scheduling data in Phoenix, a staffing lag, and talk of privatization. The department responded to the first damaging incident by working to improve access, including primary care, mental health, and other specialty care services. Despite reports that 22% of VA patients are now seen on the same day as their requested appointments, adequacy of access to VA care remains unclear.
Part of the reason may be due to the fact that no benchmark exists for a reasonable wait time for new patients requiring access to primary or specialty care. While the VA tracked and reported on wait times, comparisons with private sector data were not available until publication of this study.
New appointment wait times were compared between VA medical centers in 15 major metropolitan areas and data from a published private sector survey. This retrospective, repeated cross-sectional study focused on four specialties: primary care, dermatology, cardiology, and orthopedics.
The primary outcome of interest was patient wait time. Patient scheduling served as the metric for VA wait times. Wait times in the private sector came from the Merritt Hawkins (MH) survey using a pre-specified secret shopper method. Secondary evaluations included the change in overall and unique patients seen in the entire VA system and patient satisfaction survey measures of care access from 2014 to 2017.
Overall mean VA wait times were slightly greater than in the private sector in 2014 (22.5 vs 18.7 days, P=0.20), and were similar across specialties and regions, according to Madeline Penn, BS, BA, of the Department of Veterans Affairs in Washington, D.C., and colleagues in their report in JAMA Network Open.
By 2017, the overall mean wait times for new appointments in the VA had dropped to 17.7 days, while increasing to 29.8 days in the private sector (P<0.001). Mean VA wait times improved by 4.92 days from 2014 to 2017 (P=0.046). However, the change in wait times for private sector appointments was not statistically significant, Penn and colleagues noted.
Overall mean (SD) wait times for VA were shorter in three of the four evaluated specialties:
- Primary care: 20.0 (10.4) vs 40.7 (35.0) days; (P=0.005)
- Dermatology: 15.6 (12.2) vs 32.6 (16.5) days; (P<0.001)
- Cardiology: 15.3 (12.6) vs 22.8 (10.1) days; (P=0.04)
But orthopedics was an exception to the above-mentioned results. While wait times at the VA improved from 2014 to 2017 for this specialty, they remained significantly longer than in the private sector at 20.9 (SD 13.3) vs 12.4 (SD 5.5) days (P=0.01).
Overall, the volume of encounters rose from 476,461 (fiscal year starting in October; FY14) to 17,331,538 (FY17). Concurrently, the number of unique patients seen rose from 4,996,564 (FY14) to 5,118,446 (FY17). Of all unique veteran patients, 9.4% were women, 1.4% were younger than 24 years, 18.5% were 25-44, 33.0% were 45-64, 32.4% were 65-79, and 14.7% were 80 or older.
Notably, patient satisfaction measures of access during the study timeframe also improved (satisfaction scores increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, P < 0.05).
While this study was a comparative analysis of large U.S. metropolitan regions, it did not have information regarding nearly one-quarter of veterans living in rural areas. Follow-up studies are necessary to cover the entire VA healthcare system. Other study limitations included lack of mental health wait times (not mentioned in private sector surveys) and different methods for collecting wait times between the MH report and VA data.
Source Reference: JAMA Network Open, Jan. 18, 2019; DOI:10.1001/jamanetworkopen.2018.7096
Study Highlights: Explanation of Findings
No statistically significant differences between private sector and VA mean wait times were observed in 2014 for primary care, dermatology, cardiology, and orthopedics in 15 major metropolitan areas in this first-of-its-kind comparative analysis. Mean wait times in the private sector remained static in 2017. However, in that same year mean wait times were statistically significantly shorter for the VA versus the private sector, as wait times over the course of 3 years improved in the VA facilities for 3 of the 4 specialties. While wait times for orthopedics in VA have closed the gap, that parameter remained longer in 2017 compared with the private sector.
“Concurrently, there was an increase in the number of unique patients seen, volume of encounters, and an improvement in Consumer Assessment of Healthcare Providers and Systems (CAHPS) access score ratings within the VA, further supporting the finding that access to care has improved over time within the VA,” according to the authors.
Senior author David Shulkin, MD — the former VA Secretary, who was still at the VA when the paper was submitted — elaborated on study findings in comments to the New York Times: “There’s an impression that VA hospitals are not as efficient as the private sector. This study shows that we’ve made significant progress, and now wait times in many cases are actually shorter than in the private sector.”
An editorial accompanying the JAMA Network Open paper noted that the National Academy of Medicine identified timely access as one of the six fundamental attributes of high-quality primary care. Peter Kaboli, MD, MS, of Iowa City Veterans Affairs Healthcare System, and Stephan Fihn, MD, MPH, of the University of Washington in Seattle and JAMA Network Open‘s deputy editor wrote that translating this statement into practice has proven difficult: in some highly publicized instances, the VA’s measurements of wait times were much shorter than those actually experienced by patients, resulting in congressional hearings and national investigations. Inordinately complex scheduling protocols, inadequately trained schedulers, constantly changing metrics, and unrealistic performance expectations were some of the reasons cited for the inaccuracies. Since that time, the VA made concerted efforts to improve access.
The editorialists agreed with the authors that these findings “should help to disabuse the unfortunate yet widely held belief that access in the VA is substantially inferior to that in the private sector.” But they stopped short from fully embracing the conclusions for some of the following reasons:
- Most appointments in the VA and elsewhere are made by current patients for non-acute problems; this study did not address how easily established patients could obtain return appointments
- A scheduling system might indicate a delay of 6 months for a follow-up visit meant to take place 6 months later, even though that appointment was scheduled for when it was needed
- In an era of virtual care, focusing solely on face-to-face encounters may provide a distorted perspective about access
- The reported ~3%-4% improvement in patient satisfaction measures occurred when the researchers shifted from asking about care needs in the past 12 months to asking about care needs in the past 6 months, which may have accounted for the change
Despite these caveats and with other exceptions, the 7 million veterans who receive care from the VA are able to obtain routine and urgent care in a similar timeframe to other Americans. Bearing in mind the need to manage unrealistic expectations — e.g., universal access to same-day appointments — the editorialists suggested that more reliable and valid metrics were essential to monitoring the evolution of access to care in the VA and in the community.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco