Increasing Veterans’ Access to Health Care After Legislated Expansion of VA Community CarePrograms: A Scoping Review

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Mengeling, Diana J. Govier, Avery Laliberte, Heather Healy, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9657762/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. policy making case management delivery of health care quality of health care health services research Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 BACKGROUND Since the United States (U.S.) Civil War, Congress has sought to fulfill President Lincoln’s promise to care for those who have served their country and for their families. What this has meant for Veterans has continued to evolve, culminating in today’s Veterans Health Administration, the largest integrated health care system in the nation. In 1945, VA began its first ‘Community Care Programs’ called the Hometown Program and the Hometown Pharmacy Program, which set the precedent for collaboration with community health providers. 1 Prior to 2014, the Veterans Affairs (VA) purchased care through fee-basis arrangements with non-VA health care providers when VA could not provide needed services 2 . The most common types of purchased care included long-term, home-based, emergency, outpatient, and inpatient services, particularly when the nearest VA facility was distant 3 . This changed considerably in 2014 with passage of the Veterans Access, Choice, and Accountability Act (Choice Act) 4 , which expanded eligibility for VA-purchased Community Care (VA-CC) through a network of contracted community providers and established standardized eligibility criteria based on appointment wait times and distance to care 5 . Congress allotted VA three months to prepare for implementation of this expanded program 5 . This required readiness across VA and community providers, administrators, schedulers, contractors, and supporting information technology systems. The goal was to improve Veterans’ access to care, but there were many unknowns, including whether access would improve, what Veterans’ experiences, preferences, and satisfaction with the program would be, and how a focus on access might affect other aspects of care such as quality, coordination of care, and costs. In 2018, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act 6 (MISSION Act) was passed, which created a permanent, consolidated VA-CC program, incorporating elements from the Choice Act while introducing new eligibility criteria and expanded services 7 . The VA has seen significant growth in Veterans enrollment and healthcare utilization since the passage of the Choice Act of 2014, the MISSION Act of 2018, and the Honoring Our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). Given VA budget shortfalls, 8 it is imperative that Congress has access to timely evidence on existing gaps in research to inform decision-making, consistent with the Foundations for Evidence-Based Policymaking Act of 2018. This study supports those efforts by conducting a scoping review of research on VA-CC since the passage of the Choice Act in 2014. The purpose of this review is to summarize the research on VA-CC over this period. Given the breadth of the research, the scoping review results are organized into five domains: Access, Program Implementation, Quality, Coordination of Care, and Costs. METHODS We chose a scoping review 9 to address our broad objective of summarizing the literature related to the VA-CC program and because a review had not yet been undertaken specific to VA-CC. The methodology and terminology in systematic reviews has advanced over time and extensions have been developed to facilitate reporting different types of systematic reviews 9 – 11 (Supplementary File 1). Scoping reviews provide a summary of the evidence and identify knowledge gaps and are considered a precursor to a systematic review 9 . In comparison, evidence maps, which are similar to scoping reviews, do not allow for in-depth examination of the content and unlike systematic reviews, scoping reviews do not critically appraise the evidence for decision-making purposes 9 . Data Sources and Searches The following databases were searched for eligible citations from 2014 to April 10, 2023: Ovid MEDLINE, Embase (Embase.com), Cochrane CENTRAL (Wiley), and CINAHL (EBSCO). A librarian (HH) designed and executed the search strategies. A date limit was used to focus on literature published after the enactment of the Choice Act in 2014. In addition, the librarian conducted a gray literature search of the RAND Corporation’s research publications ( https://www.rand.org/research.html ) and the U.S. Government Accountability Office’s (GAO) reports and testimonies ( https://www.gao.gov/reports-testimonies ) from 2014 to 2023. The full search strategies for the databases and websites are available in Supplementary File 2. Selection Strategy We included papers that presented findings specific to VA-CC. We excluded papers that were not relevant to or that presented results prior to VA-CC (i.e., prior to the Choice Act). Works focused on non-VA care that were not part of VA-CC were also excluded (e.g., care provided to Veterans by community providers who were not part of VA’s network of community providers, e.g., VA and Medicare comparisons). We excluded perspective pieces, editorials, meeting abstracts, and dissertations. Abstracts were reviewed independently by at least two team members (MAM, DJG, AL, DMH). If the two reviewers disagreed on inclusion, a group arbitration system was used. We used Rayyan to conduct our initial screening of papers prior to extraction. Rayyan was developed to expedite the initial screening of abstracts for systematic reviews by health care professionals. 12 The citations for all included abstracts were moved to Zotero where PDFs were attached for subsequent extraction. 13 Data Extraction and Summaries Fifteen characteristics were extracted from each article. We predetermined these characteristics based on routine information collected for scoping reviews (e.g., publication year, keywords, sample size, funding source, study aims, key findings) and content areas informed by our experience as VA-CC funded researchers (MAM, DJG, DMH), such as legislated program (i.e., Choice Act, MISSION Act), health care domain (access, program implementation, quality, coordination of care, and costs), topic area (i.e., primary care, mental health, women’s health, specialty care, urgent/emergency care, and health care system functions), and participant type (i.e., Veterans, Providers, Administrators/Staff, and Hospitals/Facilities). Several additional characteristics included data source (i.e., primary, extant, or both), specific mention of the VA-CC network contractor (i.e., Health Net, TriWest, Optum), focus on specific populations (e.g., rural, women), whether an intervention was evaluated (yes or no), and health care focus (i.e., outcomes, utilization, experiences, evaluation). After data extraction, each of the domains identified from individual articles was reviewed to create a written summary. During this process, themes emerged that were used in the write-up to better communicate these findings. One post-extraction addition to the findings was for the ‘coordination of care’ domain. During the process of summarizing the articles, it became apparent that a large proportion of articles used qualitative methods rather than quantitative methods. Although this was not part of the extraction, we chose to include this additional information. Each paper was extracted independently by two reviewers—an author (MAM, DJG, AL, DMH) and a research associate (RS, HM, AM, LM)—and entered into Microsoft Excel. Extracted information was compared, and where differences were found, MAM and AL jointly reviewed and reconciled the information. Authors of included publications were not contacted to confirm the scoping review’s presentation of their findings. We began by computing the frequencies for all characteristics. We then reviewed the literature in relation to the Choice and MISSION Acts; works that included data across Choice and MISSION Act VA-CC programs were labeled as ‘Both’. Lastly, we used domain categories to summarize and present findings on key extracted characteristics; studies reporting on more than one domain were included in each domain summary reported on. Investigators took responsibility for synthesizing individual domains and summarizing study findings (MAM, DJG, DMH). RESULTS OF THE LITERATURE SEARCH After removing duplicates, we screened 2,284 records identified from the database searches, of which 663 were sought for retrieval. Of these, most were excluded because they were not specific to VA-CC (See Fig. 1 ), leaving 134 records for full-text review. Among the 134, 23 were excluded due to incorrect publication type (e.g., perspective piece, opinion piece) and 22 were excluded because they were not studies about VA-CC, resulting in 89 papers included in this review. Among the GAO Reports and RAND publications, after removing duplicates, 61 reports were located and assessed for eligibility. Overall, 10 were excluded due to incorrect publication type, 38 for not being about VA-CC, and 2 for occurring prior to VA-CC legislation, resulting in 11 GAO reports retained for this scoping review. A combined total of 100 research articles and GAO reports were included in this scoping review. In the Results section, tables provide domain-specific lists of articles organized by publication year and alphabetized by first author. Overall Results Summary Of the 100 articles extracted, one-sixth (n = 16) included both primary and extant data 14 – 29 , with a third (n = 31) collecting primary data only 30 – 60 , and the remaining relying on existing data sources. Sample sizes were highly variable from inclusion of 9 staff members 32 to millions of Veterans 18 , 61 – 77 . Only four papers included findings related to an intervention 41 , 50 , 60 , 78 . Few papers provided findings specific to individual third-party administrators 15 , 21 , 24 , 25 , 28 , 54 , 57 . More than a third (n = 37) presented information by rurality 26 – 28 , 38 – 41 , 53 , 56 – 59 , 61 , 62 , 64 – 67 , 70 , 71 , 73 , 75 , 79 – 93 , with an additional four focusing on rural data only 48 – 50 , 68 and one using only urban data 51 . Four papers focused on women only 26 , 52 , 53 , 57 . Lastly, the health care focus on utilization (n = 51) 27 , 29 , 41 , 65 – 70 , 74 , 77 , 78 , 81 , 79 , 83 , 88 , 91 , 92 , 94 – 101 , 87 , 76 , 82 , 64 , 102 , 62 , 61 , 73 , 103 , 71 , 104 , 93 , 63 , 105 – 107 , 18 , 28 , 75 , 72 , 90 , 89 , 54 , 59 , 14 was the most common, followed by experiences (n = 39) 14 , 27 – 54 , 56 – 60 , 73 , 83 , 103 , 106 , 108 , outcomes (n = 16) 26 , 27 , 55 , 69 , 71 , 80 , 83 – 86 , 98 , 105 , 109 – 112 and evaluations (n = 10) 15 – 17 , 19 – 25 . Access was the most examined domain overall (n = 60), followed by Coordination of Care (n = 32), Program Implementation (n = 26), Quality (n = 22), and Costs (n = 11) (Fig. 2 ). VA-CC includes the Choice Act of 2014, which ended and was replaced by the MISSION Act of 2018. The MISSION Act was passed in 2018 and implemented in 2019, with some of the first studies published in 2019. The Program Implementation domain has been consistently studied under both Acts (Fig. 2 ). The first Choice Act articles were published in 2016 and continue to be published (Fig. 3 ). Many studies since 2019 have included data for both Choice and MISSION Act eras (Fig. 3 ). Studies on Access and Quality tended to focus on specialty care, whereas studies on Program Implementation and Coordination of Care focused most on health care system functions. Cost studies focused on both health care system functions and specialty care (Fig. 4 ). Approximately two of every five articles included findings on multiple domains. Access, Quality, and Costs findings were most often based on Veteran data (Fig. 5 ). Program Implementation and Coordination of Care analyses included data from multiple health system participants (e.g., Veterans, providers, administrators/staff) (Fig. 5 ). Results Summary by Domains Access In addition to appointment wait times and distance to care -- the most common eligibility criteria for VA-CC -- several additional access-related themes appeared in the literature. Among the 60 articles within the Access domain (Supplementary Table 1), we noted five themes: 1) wait times (n = 16), 2) distance to care (n = 3), 3) system capacity/provider availability (n = 10), 4) program uptake (n = 23), and 5) Veteran and provider perceptions of access to the VA and VA-CC (n = 11). Wait Times Overall, shorter wait times at VA facilities than within VA-CC were documented for most facilities and specialties during Choice 63 , 82 , 87 , 95 , 104 , 109 and MISSION 23 , 78 , 81 periods, and across periods 77 . Under the Choice Act, one study found shorter VA-CC wait times for colonoscopies and another for appointments made after VA appointment cancellations due to COVID-19 98,103 . Factors associated with longer VA-CC wait times included Medicaid expansion and VA program implementation issues with scheduling 17 , 19 , 20 , 23 , 76 , 95 , 96 , under both Choice and MISSION Acts. Distance to Care Studies show VA’s Community Care Network improved access to primary care most for rural Veterans, yet a significant proportion of rural Veterans still do not have access to primary care that meets VA access-to-care standards 79 . Under the Choice Act, both Veterans who sought care in a VA facility and through VA-CC frequently drove further than their nearest VA facility; moreover, the extra travel distance was further for those who sought care in VA-CC compared to Veterans who received care at VA facilities 102 . Efforts to anticipate the impacts of legislative changes between the Choice and MISSION Acts found that many more Veterans at high risk for hospitalization would be eligible for VA-CC under MISSION based on the new drive time criteria, which would likely see greater use of VA-CC for outpatient specialty care among this population 91 . Under Choice, Veterans were eligible for VA-CC if they lived more than 40 miles from a VA facility; under the MISSION Act, Veterans are eligible for VA-CC if the drive time to a primary care or mental health care appointment is longer than 30 minutes or longer than 60 minutes for a specialty care appointment. System Capacity/Provider Availability GAO has noted data deficiencies that prevent VA from accurately monitoring VA-CC network adequacy 15 . Moreover, many researchers have found provider and resource shortages within VA-CC and more generally for nursing homes, women’s health care services, rural areas, and for health care specialties 29 , 37 , 53 , 56 , 59 , 75 . Among VA-users eligible for purchased care based on distance, approximately 1 in 6 live in designated primary care shortage areas and 7 in 10 in mental health care shortage areas 75 . Further, VA's regional telehealth Clinical Resource Hubs-Mental Health (CRH-MH) program was significantly more likely to serve rural Veterans than VA-CC 27 . Increases in mental health care access for rural Veterans were achieved primarily by changes in VA care delivery; VA-CC had less effect 68 , 92 . Program Uptake In the first year of Choice Act implementation, there was low uptake of VA-CC services 90 . However, utilization for many types of care have increased over time, both within VA 27,93,97 and through VA-CC 61,62,67,69,89,93,97,105,110 . Studies that have sought to identify the characteristics of Veterans more likely to use VA-CC have found that rural residence, eligibility for VA-CC based on distance, female gender, older age, being non-married, having higher education, experiencing financial hardship, having certain mental health conditions, having ≥ 3 chronic conditions, and a higher VA disability rating were associated with a greater likelihood of VA-CC use 28 , 36 , 62 , 64 , 68 , 72 , 74 , 93 . Importantly, although Veterans with severe behavioral health conditions were more likely to be treated in VA inpatient care, there is increasing use of outpatient behavioral health care in VA-CC and Veterans receiving VA-CC outpatient behavioral health care are more likely to see less highly trained providers 67 . Veterans’ reasons for using both VA and VA-CC included convenience, access to needed services, and seeking a second opinion 58 . Early use of VA-CC under the Choice Act was associated with less attrition from VA 71 . Despite this, researchers found that Veterans’ reliance on VA care declined for primary care, mental health, and specialty care 70 . Veterans who received care at a VA-CC ED were more likely to use VA-CC specialty care compared to after a VA ED visit 88 , and increases in VA-CC hospitalizations were offset by similar decreases in VA hospitalizations 69 . Researchers suggest increasing VA emergency department (ED) capacity will likely reduce VA-CC use 94 . An analysis of low-value service utilization found that most low-value services were delivered by VA rather than VA-CC providers 65 . Veteran and Provider Perceptions of Access Eleven articles focused on perceptions and experiences of access to care, most pertaining to temporal or geographic access and availability or choice of services and providers 36 , 39 , 40 , 53 , 54 , 57 , 73 , 106 . Two articles made direct comparisons between VA and VA-CC, with mixed results on whether VA or VA-CC provided better access 73 , 106 . In the FY16 and FY17 Survey of Healthcare Experiences of Patients (SHEP), Veterans reported better experiences of specialty care access in VA-CC compared with VA, while access experiences were similar between VA-CC and VA for primary care and mental health care 106 . In the FY16 and FY19 SHEP, rural and urban Veterans reported similar VA-CC access experiences for specialty care, while rural Veterans reported better VA-CC access experiences than urban Veterans for primary care 73 . However, among rural Veterans, access experiences were worse in VA-CC than in VA except for specialty care, although access experiences in both VA-CC and VA improved over time, with greater improvements in VA-CC access experiences 73 . Studies often identified Veterans’ access concerns as administrative in nature rather than related to VA-CC appointment experiences 35 , 39 , 40 , 48 , 52 , 53 , 57 . For example, VA-CC authorization delays and further issues after authorizations impacted Veteran satisfaction with VA-CC access. These included scheduling delays, and lack of information or assistance identifying VA-CC providers 35 , 39 , 40 , 48 , 53 . Some administrative burdens were reported more frequently among Veterans who had sought but did not ultimately use VA-CC 35,53 . Veterans who used VA-CC were generally satisfied with appointment access, including distance to, timeliness of, and choice of providers 35 , 36 . However, some studies found that travel barriers and perceived delays in establishing and receiving care in VA-CC impacted Veterans’ perceptions of and satisfaction with access to VA-CC 36,40,53 . VA maternity care coordinators helped women Veterans navigate challenges related to finding VA-CC maternity care, 53 while perceived access to VA-CC maternity care depended on the regional network Choice Act contractor 57 . In addition, Veterans expressed concern that by sending Veterans to VA-CC, the VA would downsize their own facilities and make less effort to hire their own providers 48 . Some VA providers expressed concern that VA-CC may not be able to accommodate Veterans’ specific appointment needs (e.g., significant others’ attendance at appointments, specific appointment times) 54 . Coordination of Care Across VA and VA-CC The thirty-two articles addressing coordination of care covered a broad range of coordination aspects (Supplementary Table 2), which we have summarized into the following two themes: 1) navigation and care management between VA and VA-CC providers (n = 32), and 2) Veteran and provider experiences (n = 10). Navigation and Care Management between VA and VA-CC Providers Coordination of care comprised a wide definitional scope. Studies addressed scheduling assistance 28 , 35 , 37 , 43 , 52 , assistance with resolving billing issues 28 , 39 , 40 , 52 – 54 and communication issues 32 , 39 , 40 , 44 – 46 , 48 , 49 , 51 , 52 , 58 , 59 , 83 , 108 , as well as perceptions of hassles following referrals from VA to VA-CC and perceived long wait times for follow-up 35 , and interventions implementing new staff to assist with medication management across VA and non-VA care 41 . Most studies used qualitative data 14 , 28 , 31 , 32 , 34 – 37 , 39 , 40 , 43 – 46 , 48 – 54 , 56 , 58 , 59 , 83 , 106 , 108 , 113 collected from Veterans, providers, and support staff and brought to light issues and possible leverage points to alleviate coordination challenges for better system functioning 48 . One implementation of a referral coordination initiative 114 in Michigan found improved process efficiency through a nurse-led process that combined the roles of care coordinator and care navigator 78 . This process, which included early Veteran engagement that informed Veterans of their VA and VA-CC options, increased retention in VA care by streamlining inter-VA facility services 78 . Some of the suggested changes included creating new roles specifically for coordination of care, such as a record tracker, patient liaison, and provider point-of-contact 45 , as well as creating more role clarity 44 and improving communication technologies used by Veterans, VA providers, and VA-CC providers 44 , 52 . Among the nine articles addressing primary care 33 , 34 , 46 , 48 , 51 , 56 , 58 , 73 , 106 , the burden of coordinating care between VA and VA-CC providers under the Choice Act was highlighted 33 , 34 and communication challenges under both Acts were a frequent theme 46 , 51 , 58 . Notably, a qualitative observational study focused on coordination of care between VA-CC home health aides and VA primary care teams and showed limited communication between the VA care team and home health providers 51 . In another study including surveys of Veterans and providers, Veterans reported that VA and VA-CC providers were informed about the others’ care more than half the time 58 . Rural Veterans reported better overall health and ease of managing care 58 . Both VA and VA-CC providers reported problems with managing medications, sharing test results, communicating with specialists, and sharing discharge summaries 58 . Veteran and Provider Experiences Two studies addressing primary and specialty care highlighted the “Survey of Healthcare Experiences of Patients” (SHEP) results showing Veterans rated VA care better in the areas of communication, coordination of care, and provider ratings 73 , 106 . Other studies discussed the burden on providers of coordinating care, hesitancies that providers have with the VA-CC system, 33,34 and communication issues 46 , 58 . Data collected from Veterans who used VA and VA-CC showed that communication between VA and VA-CC providers was variable 58 . Similarly, VA-CC providers reported sending communications to VA providers less often than their VA counterparts sent to VA-CC providers 58 . In many cases, Veterans transferred documents between providers, acting as necessary go-betweens due to gaps in coordination of care. This finding was echoed in semi-structured interviews with Veterans who revealed successes and challenges with interorganizational coordination of care relaying workarounds they had found to help overcome such challenges 37 , as well as by Veterans and their families who discussed how they had to fill in gaps in coordinating the care for their Veterans 108 . Among articles addressing coordination of care, two addressed health-related social needs: one focused on homeless Veterans 36 and another addressed those with poor health status 28 . Veterans experiencing homelessness who used VA and VA-CC services, compared to those using the VA without community care, were more likely to endorse unfavorable coordination experiences in primary care. Veterans experiencing homelessness who were more likely to use VA-CC were female, older, had higher education levels, experienced more financial hardship, had three or more chronic conditions, and had higher rates of psychological distress, depression, or posttraumatic stress disorder (PTSD) 36 . Additionally, Veterans experiencing homelessness who had travel barriers, psychological distress, or lower social support were more likely to have lower satisfaction with VA-CC 36 . Both studies recommended improving communication between VA and VA-CC providers 28 , 36 . VA-CC Program Implementation The Program Implementation domain included 26 articles (Supplementary Table 3). The primary difference between articles included in the Access vs. Program Implementation domains was whether they addressed outcomes or processes. For example, articles in the Access domain evaluated access as an outcome of Choice and MISSION implementation, while articles related to access in the Implementation domain described activities and processes that facilitated or impeded access to care under Choice and MISSION. Early findings for the Choice Act suggested that the program was implemented without adequate preparation 42 . Multiple studies identified issues with scheduling 28 , 59 , care coordination 59 , and billing confusion 28 , 54 . Studies identified critical information missing from patient records for VA-CC services (e.g., pathology results) 104 , challenges with health information exchange interoperability 37 , and differences in utilization by rurality 89 . Implementation was hampered by a steep learning curve for leadership and staff and a lack of VA-CC adaptability to local processes 47 , 59 . Some VA providers expressed reservations about sending Veterans to VA-CC providers 54 . A common difficulty during Choice Act implementation was engaging VA-CC providers, resulting in VA-CC provider networks not being sufficiently developed, that is having enough providers and the right type of providers in the right locations to ensure adequate access to VA-CC 30,37,42,59 . Community providers most interested in participating tended to be Veterans themselves, those already providing care to Veterans or who had pre-established working relationships with the VA 30,32,34 , and those interested in the mission of providing care to Veterans 30 . GAO conducted numerous evaluations of VA-CC program implementation noting the limitations of projecting future costs 18 , 22 , providing oversight of VA and third-party administrator processes 15 , 21 , 23 , 25 without having sufficient metrics and processes in place 16 , 17 , 19 , 20 , 24 . Research has shown that as more Veterans use non-VA hospitals, the technical efficiency of VA hospitals decreases considerably 100 . Additionally, Veterans who go to a VA-CC Emergency Department (ED) have a greater proportion of subsequent specialty care visits from VA-CC providers than Veterans with a VA ED visit 88 . However, researchers have shown that supplementing VA-CC with additional VA programs (e.g., management of specialty care referrals, telemedication management) improves VA care retention and reduces costs 41 , 78 . Quality of Care Quality of Care included 22 articles (Supplementary Table 4) summarized into three themes: 1) VA and VA-CC comparisons (n = 13), 2) VA-CC quality of practice (n = 5), and 3) other evaluations of quality of care (n = 4). VA and VA-CC Quality of Care Comparisons Comparisons of the quality of care provided by VA and VA-CC were mixed depending on the type of care examined 27 , 69 , 80 , 84 – 86 , 98 , 105 , 106 , 109 – 112 . No differences between VA-delivered and VA-CC quality were found in hernia surgeries 112 , cataract surgeries 85 , inpatient mortality 69 , post-operative mortality, readmissions, or emergency department visits for a set of 40 different surgical procedures 111 , or hepatitis C infection treatment failure rates and reasons for treatment failure 109 . While studies on total knee arthroplasties have found better overall quality in VA with respect to lower readmissions (83) and lower complication rates (85), quality of total knee arthroplasty was also found not to be associated with care setting (79). Patients who received VA Telemental health or were referred to VA-CC had similar ratings of satisfaction with patient-centeredness of care 27 . One study found VA-CC was associated with increased receipt of certain preventive care services 110 . Three studies identified VA providing better quality for colonoscopy care and patient experiences, as well as lower mortality following elective percutaneous revascularization 98 , 105 , 106 . VA-CC Quality of Care Other studies focused on VA-CC quality of care without direct comparisons to VA. Women Veterans receive their maternity care through VA-CC where rates of Cesarean-section were 35%, which is slightly higher than the national average of 32% 26 . Women Veterans of color were significantly more likely to deliver by Cesarean-section than White women Veterans 26 . Relatively few VA-CC primary care and mental health providers in Texas and Vermont reported using guideline-recommended psychotherapy or prescribing practices for PTSD 55 . In cases of VA-CC suicide-related safety events, poor communication between VA and VA-CC providers led to inadequate treatment or follow-up care, and VA providers were concerned that VA-CC providers and their environments were not adequately prepared to address patient safety (e.g., access to methods of strangulation in VA-CC emergency rooms and rehabilitation units) 83 . Further, there may have been ineffective controls used by VA and its contracts to identify health care providers eligible to participate in VA-CC, resulting in the inclusion of potentially ineligible providers 21 . Some VA providers believed that some VA-CC providers did not have the specific experience required to treat more advanced cases of hepatitis C virus or to manage common Veteran comorbidities such as mental illnesses and traumatic brain injury 54 . Other Evaluations of Quality of Care Two studies found Veterans were generally satisfied with their VA-CC care 35 , 53 . Veterans identified (a) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (b) a positive environment or “eco-system of care” as integral to their decisions about where to receive care; both VA-delivered care and VA-CC sometimes performed well on these factors and sometimes did not, influencing Veterans’ engagement with VA and VA-CC 38 . Finally, one study examined variation in VA facilities’ rates of low-value service use, with higher rates among VA facilities with a greater use of VA-CC, however, this association did not hold when adjusting for other facility characteristics 66 . Costs Eleven articles in total addressed costs (Supplementary Table 5), with all but one examining health care costs incurred by the VA health care system 14 , 18 , 22 , 39 , 41 , 65 , 99 , 101 , 107 , 109 , 115 . We have summarized the Costs domain into two themes: 1) VA and VA-CC comparisons (n = 3) and 2) other evaluations of costs (n = 8). VA and VA-CC Comparisons Among comparative studies, whether VA or VA-CC services were more costly depended on the service in question 101 , 107 , 109 . For example, in one California region, VA-CC was more costly than VA-direct care for hepatitis C treatment 109 , while nationally, VA-direct care was more costly than VA-CC for total knee arthroplasties and cataract surgeries 101 . Many of these studies may not account for all costs for VA-CC, including administrative costs for program administration and costs incurred by individual facilities to authorize and coordinate community care. In addition, a national study found that sleep studies were more costly in VA-CC than in VA due to lower rates of home testing and higher rates of in-laboratory sleep testing in VA-CC 107 . Other Evaluations of Costs Three studies examined costs of VA-CC care without comparing them to VA 14,65,115 . For example, prescription medication costs during the first year of the Veterans Choice Program totaled $ 27 million 14 , and in 2018, $ 205.8 million was spent on low-value or potentially inappropriate services across VA and VA-CC 65 . However, the latter study 65 did not separate out VA-CC from VA costs of care. Another study compared VA-CC and Medicare reimbursement for 10 common ophthalmic procedures in FY2020, finding that negotiated VA-CC fees regularly exceeded Medicare reimbursements for the same procedures 115 . One study examined perceptions of VA-CC costs and found that VA-CC medical billing problems for VA-CC emergency care contributed to Veterans’ perceptions of financial hardship 39 . In addition, two reports published by the GAO found that VA data and processes used to develop VA-CC budget estimates underestimated VA-CC costs 18 , 22 . Two studies found that interventions to address aspects of VA-CC medication prescribing could produce cost savings to the VA health care system 41 , 99 . For example, a pharmacist-led tele-medication management intervention at three VA medical centers produced cost savings from a reduction in VA-CC medication-related costs for oral antineoplastic therapies (i.e., oral chemotherapy) 41 . Similarly, a medication authorization review program was associated with significant savings to VA resulting from reductions in Veterans’ use of VA-CC prescribed non-approved prescription drugs 99 . DISCUSSION The Choice Act’s aim was to improve Veterans’ temporal and geographic access to care by employing a contracted network of community providers, thus expanding Veterans’ care options beyond VA facilities and providers 4 . This scoping review included numerous studies on access to care, finding that, in most cases, appointments with VA-CC were no timelier, and often less timely, than appointments within the VA. However, VA-CC did improve Veterans’ geographic access to care via reduced drive times. Yet, a subgroup of Veterans still drove further to VA-CC than their nearest VA facility for care, suggesting geographic access is only one of several considerations impacting Veterans’ decisions about where to seek care. This scoping review also identified additional aspects of access, including network capacity/provider shortages, program utilization, and program satisfaction, highlighting VA-CC impacts such as changes in Veterans’ reliance on VA care. Many rural Veterans became eligible for VA-CC under the Choice Act due to living farther than 40 miles from their nearest VA facility; however, VA-CC has not been able to improve geographic access for many rural Veterans 79 . This was not unexpected given well-documented and long-standing national rural health care workforce shortages 116 . Fortunately, distance to care is not the primary or sole factor rural Veterans use in deciding whether and where to seek health care. Research has found that rural Veterans consider distance alongside other factors such as care urgency, patient resources, and patient-provider relationships 117 , 118 . Evaluating improvements in Veterans’ access to health care may need more nuanced approaches that consider Veterans’ priorities and preferences, similar to VA’s Whole Health approach. ( https://www.va.gov/wholehealth/ ) The Whole Health approach focuses on what matters to the Veteran , considering Veterans’ values, needs, and goals. VA-CC demonstrates the limits of expanding VA’s network of providers to improve geographic access for rural Veterans. Improving access for Veterans requires the VA –the largest integrated health care system in the U.S. -- to further incorporate an expanded network of contracted community providers. The VA had 90 days to implement this legislated program under the Choice Act 4 within its health care system serving more than 9.5 million enrolled Veterans and eligible family members, made up of 172 medical centers and 1,100 outpatient clinics, supported by 371,000 health care professionals and support staff 119 . Issues with VA-CC program implementation included difficulties finding providers to participate in the VA-CC network, scheduling with VA-CC providers, and communicating with VA-CC providers about Veterans’ care. The authors caution that these prior studies should be considered within their historical context and in light of the current context. VA-CC continues to evolve and these studies have directly and indirectly informed its evolution 120 , 121 . For example, when VA-CC was initially implemented, third-party administrators who managed VA-CC provider networks were responsible for scheduling VA-CC appointments. However, when this approach proved ineffective, the VA established local Community Care Departments, which are currently responsible for managing consults, referrals, authorizations, scheduling appointments, coordinating health information exchange and care, and answering Veteran and provider questions, and have developed initiatives to help Veterans navigate the CNN 122 . Overall, quality findings were mixed and provide a less conclusive picture than that provided in prior reviews. Prior systematic reviews have shown that VA care is as good or better than non-VA care 123 – 125 . However, these prior works preceded the Choice Act 125 or were not limited to assessments of VA-CC quality 123 , 124 . In this scoping review, which focused solely on the quality of VA-delivered care and VA-CC, quality of care was measured in terms of health outcomes, such as clinical quality measures and adverse health care events (e.g., post-surgical complications); receipt of preventive services; and satisfaction with care. A unique area of ‘quality’ among the literature was VA-CC provider expertise, or lack thereof, related to the specific health care needs of the Veteran population served by the VA 126 . Veterans who use VA healthcare tend to report poorer health, to have less education and lower household incomes, to have served longer in the military and in combat, and to have a disability, more medical conditions as well as mental health disorders 127 , 128 . VA is different from non-VA healthcare in that it has systemwide clinical expertise to address service-connected conditions and disorders, including multiple co-morbid physical and mental health conditions 129 – 131 . In non-VA healthcare settings, for example, providers may not be knowledgeable about the specific healthcare needs of the Veteran population and/or lack the training necessary to provide quality care to Veterans. As part of the MISSION Act, the VA provides optional no-cost continuing medication education (CME) training to VA-CC providers 132 . However, it is unknown whether providers are willing to participate in these trainings, particularly if they see few Veterans or are unaware of the Veteran status of their patients or the VA engagement of their patients 133 . We found no research examining the use of these training materials or their impact on quality of Veterans’ care. The top three priorities in evaluating the coordination of VA care and VA-CC include: 1) identifying which Veterans would benefit most from additional care coordination support; 2) determining who is responsible for coordinating care for Veterans receiving VA-CC; and 3) developing measurement systems to assess the effectiveness of VA-CC coordination efforts for Veterans 134 . This scoping review identified some research on Veterans’ experience and satisfaction with coordination of care, including with referral coordination 78 . In 2019, the VA began the Referral Coordination Initiative (RCI) 114 to improve coordination of care for patients requiring VA-CC, however, due to pandemic-related disruptions, national implementation of the RCI was stalled, so it was not surprising that there were no studies that examined care coordination that identified Veterans who could benefit most from additional care coordination support. This VA-CC scoping review found a recurring theme of the process challenges that aligned with the SOTA’s second priority - role clarity. Lastly, there were no articles that proposed measurement systems to assess the effectiveness of VA-CC coordination efforts. This may be a direct consequence of the issues noted in the Program Implementation section, which outlined challenges with the interoperability of Health Information Exchanges, which is arguably essential to coordination of care across VA and VA-CC settings. The U.S. population of Veterans is declining, but the number of Veterans using VA health care is increasing 135 , as are the costs to provide care. From 2012 to 2022, there was an approximately 400% increase in costs in VA-purchased community care, largely due to the passage of the Choice and MISSION Acts; in 2012, VA spent approximately $ 4.5 billion dollars on VA-CC compared to the estimated VA-CC obligations of $ 21.3 billion in 2022 22 . This trend in VA’s medical care budget is expected to continue with increases of 23% in 2023 and 25% in 2024 135 . Comparisons including VA versus non-VA costs can inform VA decisions on what types of care VA should provide and what types of care to refer to the community (i.e., “make vs. buy”) 136 . However, only two studies thus far have compared costs of care in VA and VA-CC settings 101 , 109 . In addition, two studies evaluated medication management interventions aimed at managing VA-CC prescription medication costs 41 , 99 , but no studies have investigated cost savings related to other types of care delivery or value-based care, which are important for policy-related initiatives. We anticipate more research on these and related topics will be published in the future because of the MISSION Act, which established the VA Center for Care and Payment Innovation (CCPI) to improve Veteran care while reducing costs ( https://www.innovation.va.gov/careandpayment/ ). Although many studies addressed more than one domain, few studies investigated the potential synergistic benefits or trade-offs in improving one aspect of care delivery at the cost of another (e.g., expanding access without addressing quality of care). However, one research study conducted under the Choice Act found improved wait times for colonoscopies but lower surveillance guideline compliant care from VA-CC providers 98 . Another study found longer wait times and higher costs for VA-CC versus VA care 109 . A recent publication, not included in this scoping review, identified a potential unanticipated consequence of the MISSION Act—a shift in financing of care between VA and Medicare 137 . Overall non-VA ED utilization among Veterans may not have changed, but the payor of those visits is increasingly the VA and less likely Medicare, suggesting shifts in reliance to VA-CC 137 . These novel approaches at examining VA-CC in addition to studies that concurrently examine multiple aspects of the VA-CC program are needed to guide future evolutions of the program and inform policy. Limitations We chose a scoping review to summarize the topics and findings related to VA-CC programs to inform research and policy. An inherent limitation of any scoping review is that it does not grade the evidence, and therefore we cannot provide definitive recommendations 9 . However, given the breadth of the scoping review, we anticipate it will serve as a precursor to several domain-specific systematic reviews, particularly as the program under the MISSION Act becomes more established and the research more extensive. Second, there is the possibility that we may have excluded research that should have been included due to ‘community care’ being a phrase that is used in many contexts and not specific to VA’s expanded purchased care programs under the Choice and MISSION Acts. We attempted to prevent inaccurate exclusions through multiple review processes, however, a few may still have been missed. Lastly, this scoping review represents the literature available at a point in time. Research continues to be published, and we anticipate extending this work through future systematic reviews of individual domains and knowledge syntheses across domains. CONCLUSION The challenge with evaluating VA-CC, understanding its strengths and weaknesses, and providing evidence-based guidance for future improvements lies in synthesizing disparate findings into a coherent composite. As VA advances its vision of an integrated learning health system, this scoping review brings together the evidence needed to inform clinical and Congressional priorities and drive continued improvement in Veteran care and outcomes. Abbreviations VA Veterans Health Administration Choice Act Veterans Access, Choice, and Accountability Act VA-CC VA-purchased Community Care MISSION Act Maintaining Internal Systems and Strengthening Integrated Outside Networks Act GAO U.S. Government Accountability Office ED Emergency Department SHEP Survey of Healthcare Experiences of Patients PTSD Post-Traumatic Stress Disorder SOTA State-Of-The-Art CCPI Center for Care and Payment Innovation Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Funding: This work was supported by Award # VA HSR&D COR 23–190, VA SDR 20–390 from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service. Dr. Vanneman was also supported in part by VA HSR&D CDA 15–259 from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service. Dr. Govier was supported in part by career development awards from the VHA Office of Rural Health (NOMAD PROJ-04269) and VA Health Systems Research Service (IK2RD000662). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Authors' contributions: MAM, DJG, AL, and DMH worked to conceptualize the scoping review, had full access to all the data. MAM, DJG, SPY, MEV, KMM, AKR, DMH critically revised the manuscript for important intellectual content and approved the final version to be submitted for publication. HH designed the specific protocol of the scoping review literature pull. MAM, DJG, and DMH were involved in drafting the article and took responsibility for the accuracy of the data analysis. All authors read and approved the final manuscript. Acknowledgements: The authors would like to thank Shylo Ward (SW) for her management of the articles throughout the scoping review process; Senta Wiederholt (SW), Holly McCready (HM), Abby Moss (AM), Rachel Sears (RS), and Liz Mace (LM) for helping with article extraction; and Rachel Sears for creating the manuscript’s figures. Availability of data and materials: All data analyzed during this study can be recreated using the search strategy provided in Supplementary File 2. Competing interests: All authors are employed by the Department of Veterans Affairs (VA) and received VA funding to conduct this scoping review. References Fact Sheet 20 – 01: Overview of Non-VA Medical Care. U.S. Department of Veterans Affairs. 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Acad Emerg Med 30(4):379–387. 10.1111/acem.14667 Rosen AK, O’Brien W, Chen Q, Shwartz M, Itani KFM, Gunnar W (2017) Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration. Med Care 55(7 Suppl 1):S45–S52. 10.1097/MLR.0000000000000707 Vanneman ME, Harris AHS, Asch SM, Scott WJ, Murrell SS, Wagner TH (2017) Iraq and Afghanistan Veterans’ Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation. Med Care 55(7 Suppl 1):S37–S44. 10.1097/MLR.0000000000000678 Vanneman ME, Yoon J, Singer SJ et al (2022) Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Med (Baltim) 101(7):e28864. 10.1097/MD.0000000000028864 Wyse JJ, Shull S, Lindner S et al Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities. J Gen Intern Med Published online 2023. 10.1007/s11606-023-08027-4 Weaver FM, Hickok A, Prasad B et al (2020) Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act. J Gen Intern Med 35(9):2593–2599. 10.1007/s11606-020-05802-5 Tenso K, Pizer S, Palani S (2023) Delivery system emergency department capacity and its effect on nonsystem service utilization. Acad Emerg Med Off J Soc Acad Emerg Med Published online. 10.1111/acem.14694 Pham TT, Pacheco E, Abdul-Kafi O, Ascoli C, Imayama I, Joo MJ (2023) Evaluation of the Veteran’s Choice Program for Pulmonary Function Tests. J Gen Intern Med Published online. 10.1007/s11606-023-08068-9 Griffith KN, Asfaw DA, Childers RG, Wilper AP (2022) Changes in US Veterans’ Access to Specialty Care During the COVID-19 Pandemic. JAMA Netw Open 5(9):e2232515–e2232515. 10.1001/jamanetworkopen.2022.32515 Burdick R, Corcoran KL, Zhao X, Lisi A (2022) The rate of use of Veterans Affairs chiropractic care: a 5-year analysis. Chiropr Man Ther 30(1):4. 10.1186/s12998-022-00413-9 Petros V, Tsambikos E, Madhoun M, Tierney WM (2022) Impact of Community Referral on Colonoscopy Quality Metrics in a Veterans Affairs Medical Center. Clin Transl Gastroenterol 13(3):e00460. 10.14309/ctg.0000000000000460 Jennings AJ, Brown JN, Britt RB, McNaughton LA, Durkee M, Hashem MG (2022) Value of a Pharmacy-Adjudicated Community Care Prior Authorization Drug Request Service. Fed Pract Health Care Prof VA DoD PHS 39(8):356–360a. 10.12788/fp.0296 Oh D, Lee KH, Park J (2022) The Veterans Choice Act and Technical Efficiency of Veterans Affairs (VA) Hospitals. Healthc Basel Switz 10(6). 10.3390/healthcare10061101 Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK (2021) Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM Policy Pract 6(2):23814683211057902. 10.1177/23814683211057902 Pettey WBP, Wagner TH, Rosen AK, Beilstein-Wedel E, Shwartz M, Vanneman ME (2021) Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Med Care 59(Suppl 3):S307–S313. 10.1097/MLR.0000000000001491 Tran LD, Rose L, Urech T, Vashi A Encounters after appointments cancelled due to COVID-19 in the veterans affairs health care system. Published online 2021. 10.1101/2021.11.17.21266381 Dueker JM, Khalid A (2020) Performance of the Veterans Choice Program for Improving Access to Colonoscopy at a Tertiary VA Facility. Fed Pract Health Care Prof VA DoD PHS. 37(5):224–228 &PAGE=reference&D=pmnm5&NEWS=N&AN=32454576. http://ovidsp.ovid.com/ovidweb.cgi?T=JS Waldo SW, Glorioso TJ, Baron AE et al (2020) Outcomes Among Patients Undergoing Elective Percutaneous Coronary Intervention at Veterans Affairs and Community Care Hospitals. J Am Coll Cardiol 76(9):1112–1116. 10.1016/j.jacc.2020.05.086 Vanneman ME, Wagner TH, Shwartz M et al (2020) Veterans’ Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care. Health Aff Proj Hope 39(8):1368–1376. 10.1377/hlthaff.2019.01375 Donovan LM, Coggeshall SS, Spece LJ et al (2019) Use of In-Laboratory Sleep Studies in the Veterans Health Administration and Community Care. Am J Respir Crit Care Med 200(6):779–782. 10.1164/rccm.201902-0313LE O’Hare AM, Butler CR, Laundry RJ et al (2022) Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Intern Med 182(7):710–719. 10.1001/jamainternmed.2022.1379 Chao D, Buddha H, Damodaran C, Tran L, Strong R, Jackson CS (2020) Outcomes Comparison of the Veterans’ Choice Program With the Veterans Affairs Health Care System for Hepatitis C Treatment. Fed Pract Health Care Prof VA DoD PHS 37(Suppl 3):S18–S24. http://ovidsp.ovid.com/ovidweb.cgi?T=JS &PAGE=reference&D=pmnm5&NEWS=N&AN=32704227 Tummalapalli SL, Vittinghoff E, Hoggatt KJ, Keyhani S (2021) Preventive Care Delivery After the Veterans Choice Program. Am J Prev Med 61(1):55–63. 10.1016/j.amepre.2021.01.029 Graham LA, Schoemaker L, Rose L, Morris AM, Aouad M, Wagner TH (2022) Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surg 157(12):1115–1123. 10.1001/jamasurg.2022.4978 Mull HJ, Kabdiyeva A, Ndugga N, Gordon SH, Garrido MM, Pizer SD (2022) What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery. Health Serv Res Published online. 10.1111/1475-6773.14113 Lewinski AA, Bosworth HB, Goldstein KM et al (2021) Improving cardiovascular outcomes by using team-supported, EHR-leveraged, active management: Disseminating a successful quality improvement project. Contemp Clin Trials Commun 21:100705. 10.1016/j.conctc.2021.100705 U.S Department of Veterans Affiars, Veterans Health Administration. Referral Coordination Initiative Implementation Guidebook. Published online March 10, 2021. Accessed July 10 (2024) https://americansforprosperity.org/wp-content/uploads/2021/09/Referral-Coordination-Initiative-Guidebook-2.pdf Younessi DN, Margo CE, Greenberg PB, French DD (2021) VA Community Care and Medicare Reimbursement Comparison for Top Ten Ophthalmic Procedures. J Med Pract Manage 36(5):269–271. https://login.proxy.lib.uiowa.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true &db=jlh&AN=149814039&site=ehost-live Streeter RA, Zangaro GA, Chattopadhyay A, Perspectives (2017) Using Results from HRSA’s Health Workforce Simulation Model to Examine the Geography of Primary Care. Health Services Research. ;52(S1):481–507. Accessed July 2, 2024. https://onlinelibrary.wiley.com/doi/full/ 10.1111/1475-6773.12663 Buzza C, Ono SS, Turvey C et al (2011) Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare. J Gen Intern Med 26(2):648. 10.1007/s11606-011-1762-1 Ball DD, Sadler AG, Steffen MJ, Paez MB, Mengeling MA (2024) The impact of patient–provider relationships on choosing between VA and VA-purchased care: A qualitative study of health care decision-making among rural veterans. J Rural Health 40(3):430–437. 10.1111/jrh.12804 U.S. DEPARTMENT OF VETERANS AFFAIRS STRUCTURE. U.S. Department of Veterans Affairs. Accessed July 9 (2024) https://www.ruralhealth.va.gov/aboutus/structure.asp#top Kilbourne AM, Elwy AR, Sales AE, Atkins D (2017) Accelerating Research Impact in a Learning Health Care System: VA’s Quality Enhancement Research Initiative in the Choice Act Era. Med Care 55(7 Suppl 1):S4–S12. 10.1097/MLR.0000000000000683 Mengeling MA, Mattocks KM, Hynes DM, Vanneman ME, Matthews KL, Rosen AK (2021) Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care. Med Care 59(Suppl 3):S232–S241. 10.1097/MLR.0000000000001488 Greenstone CL, Peppiatt J, Cunningham K et al (2019) Standardizing Care Coordination Within the Department of Veterans Affairs. J Gen Intern Med 34(1):4–6. 10.1007/s11606-019-04997-6 Apaydin EA, Paige NM, Begashaw MM, Larkin J, Miake-Lye IM, Shekelle PG (2023) Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review. J Gen Intern Med 38(9):2179–2188. 10.1007/s11606-023-08207-2 Shekelle P, Maggard-Gibbons M, Blegen M et al (2023) VA versus Non-VA Quality of Care: A Systematic Review. Department of Veterans Affairs (US); Accessed August 26, 2024. http://www.ncbi.nlm.nih.gov/books/NBK591851/ O’Hanlon C, Huang C, Sloss E et al (2017) Comparing VA and Non-VA Quality of Care: A Systematic Review. J Gen Intern Med 32(1):105–121. 10.1007/s11606-016-3775-2 Eibner C, Krull H, Brown KM et al (2016) Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs. Rand Health Q 5(4):13. http://ovidsp.ovid.com/ovidweb.cgi?T=JS &PAGE=reference&D=pmnm3&NEWS=N&AN=28083423 Rose L, Schmidt A, Gehlert E, Graham LA, Aouad M, Wagner TH (2023) Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees. JAMA Netw Open 6(7):e2323884. 10.1001/jamanetworkopen.2023.23884 US Veterans Who Do and Do Not Utilize Veterans Affairs Health Care Services: Demographic, Military, Medical, and Psychosocial Characteristics. Psychiatrist.com. Accessed March 28 (2025) https://www.psychiatrist.com/pcc/veterans-who-do-and-do-not-utilize-va-services/ Shulkin DJ, Why, VA Health Care Is Different (2016). Fed Pract. ;33(5):9–11. Accessed March 28, 2025. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369034/ Pugh MJV, Finley EP, Copeland LA et al (2014) Complex Comorbidity Clusters in OEF/OIF Veterans: The Polytrauma Clinical Triad and Beyond. Med Care 52(2):172. 10.1097/MLR.0000000000000059 Creech SK, Pulverman,Carey S, Crawford, Jennifer N et al (2021) Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities. Behav Med 47(1):69–87. 10.1080/08964289.2019.1644283 U.S. Department of Veterans Affiars. Provider Education and Training. April 29 (2024) Accessed August 12, 2024. https://www.va.gov/COMMUNITYCARE/providers/EDU-Training.asp Vest BM, Kulak J, Hall VM, Homish GG (2018) Addressing Patients’ Veteran Status: Primary Care Providers’ Knowledge, Comfort, and Educational Needs. Fam Med. ;50(6):455–459. Accessed May 30, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147251/ Mattocks KM, Cunningham K, Elwy AR et al (2019) Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care. J Gen Intern Med 34(Suppl 1):18–23. 10.1007/s11606-019-04972-1 Rasmussen P, Farmer CM (2022) The Promise and Challenges of VA Community Care: Veterans’ Issues in Focus. RAND Corporation. 10.7249/PEA1363-5 Forum (2019) : Specialty Care and the MISSION Act. Accessed May 30, 2024. https://www.hsrd.research.va.gov/publications/forum/spring19/default.cfm?ForumMenu=Spring19-1 Rose L, Tran D, Wu S, Dalton A, Kirsh S, Vashi A (2023) Payer shifting after expansions in access to private care among veterans. Health Serv Res 58(6):1189–1197. 10.1111/1475-6773.14162 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryFile1PRISMAScR.docx Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist SupplementaryFile2SearchStrategy.docx Scoping Review Search Strategies SupplementaryTable1AccessDomain.docx Access Domain Scoping Review Papers and Reports SupplementaryTable2CareCoordinationDomain.docx Care Coordination Domain Scoping Review Papers and Reports SupplementaryTable3ProgramImplementationDomain.docx Program Implementation Domain Scoping Review Papers and Reports SupplementaryTable4QualityofCareDomain.docx Quality of Care Domain Scoping Review Papers and Reports SupplementaryTable5CostsDomain.docx Costs Domain Scoping Review Papers and Reports Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Reports\u003c/p\u003e","description":"","filename":"SupplementaryTable1AccessDomain.docx","url":"https://assets-eu.researchsquare.com/files/rs-9657762/v1/fdf92b522fc14afdf9237120.docx"},{"id":109121030,"identity":"fe9c87eb-95d8-40ec-b2fe-1596c82db6b8","added_by":"auto","created_at":"2026-05-12 17:19:09","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":26445,"visible":true,"origin":"","legend":"\u003cp\u003eCare Coordination Domain Scoping Review Papers and Reports\u003c/p\u003e","description":"","filename":"SupplementaryTable2CareCoordinationDomain.docx","url":"https://assets-eu.researchsquare.com/files/rs-9657762/v1/826ab3f78dec724750f381cc.docx"},{"id":109205120,"identity":"437dc262-622a-4622-93dd-d0245417b717","added_by":"auto","created_at":"2026-05-13 15:03:25","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":25121,"visible":true,"origin":"","legend":"\u003cp\u003eProgram Implementation Domain Scoping Review Papers and Reports\u003c/p\u003e","description":"","filename":"SupplementaryTable3ProgramImplementationDomain.docx","url":"https://assets-eu.researchsquare.com/files/rs-9657762/v1/bc1963b403d79d3d67e83f4c.docx"},{"id":109204918,"identity":"eec37560-709e-451e-89be-15c671d73cc1","added_by":"auto","created_at":"2026-05-13 15:02:50","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":22589,"visible":true,"origin":"","legend":"\u003cp\u003eQuality of Care Domain Scoping Review Papers and Reports\u003c/p\u003e","description":"","filename":"SupplementaryTable4QualityofCareDomain.docx","url":"https://assets-eu.researchsquare.com/files/rs-9657762/v1/024408a23de2ef955aec3fe7.docx"},{"id":109121031,"identity":"0f0456f6-d706-4628-ba97-f200d5fa02ee","added_by":"auto","created_at":"2026-05-12 17:19:09","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":19333,"visible":true,"origin":"","legend":"\u003cp\u003eCosts Domain Scoping Review Papers and Reports\u003c/p\u003e","description":"","filename":"SupplementaryTable5CostsDomain.docx","url":"https://assets-eu.researchsquare.com/files/rs-9657762/v1/566946a1fb75b94fef352b79.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eIncreasing Veterans’ Access to Health Care After Legislated Expansion of VA Community CarePrograms: A Scoping Review\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSince the United States (U.S.) Civil War, Congress has sought to fulfill President Lincoln\u0026rsquo;s promise to care for those who have served their country and for their families. What this has meant for Veterans has continued to evolve, culminating in today\u0026rsquo;s Veterans Health Administration, the largest integrated health care system in the nation. In 1945, VA began its first \u0026lsquo;Community Care Programs\u0026rsquo; called the Hometown Program and the Hometown Pharmacy Program, which set the precedent for collaboration with community health providers.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrior to 2014, the Veterans Affairs (VA) purchased care through fee-basis arrangements with non-VA health care providers when VA could not provide needed services \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The most common types of purchased care included long-term, home-based, emergency, outpatient, and inpatient services, particularly when the nearest VA facility was distant \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. This changed considerably in 2014 with passage of the Veterans Access, Choice, and Accountability Act (Choice Act) \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, which expanded eligibility for VA-purchased Community Care (VA-CC) through a network of contracted community providers and established standardized eligibility criteria based on appointment wait times and distance to care \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCongress allotted VA three months to prepare for implementation of this expanded program \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. This required readiness across VA and community providers, administrators, schedulers, contractors, and supporting information technology systems. The goal was to improve Veterans\u0026rsquo; access to care, but there were many unknowns, including whether access would improve, what Veterans\u0026rsquo; experiences, preferences, and satisfaction with the program would be, and how a focus on access might affect other aspects of care such as quality, coordination of care, and costs.\u003c/p\u003e \u003cp\u003eIn 2018, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e (MISSION Act) was passed, which created a permanent, consolidated VA-CC program, incorporating elements from the Choice Act while introducing new eligibility criteria and expanded services \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The VA has seen significant growth in Veterans enrollment and healthcare utilization since the passage of the Choice Act of 2014, the MISSION Act of 2018, and the Honoring Our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). Given VA budget shortfalls,\u003csup\u003e8\u003c/sup\u003e it is imperative that Congress has access to timely evidence on existing gaps in research to inform decision-making, consistent with the Foundations for Evidence-Based Policymaking Act of 2018.\u003c/p\u003e \u003cp\u003eThis study supports those efforts by conducting a scoping review of research on VA-CC since the passage of the Choice Act in 2014. The purpose of this review is to summarize the research on VA-CC over this period. Given the breadth of the research, the scoping review results are organized into five domains: Access, Program Implementation, Quality, Coordination of Care, and Costs.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe chose a scoping review \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e to address our broad objective of summarizing the literature related to the VA-CC program and because a review had not yet been undertaken specific to VA-CC. The methodology and terminology in systematic reviews has advanced over time and extensions have been developed to facilitate reporting different types of systematic reviews \u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e (Supplementary File 1). Scoping reviews provide a summary of the evidence and identify knowledge gaps and are considered a precursor to a systematic review \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. In comparison, evidence maps, which are similar to scoping reviews, do not allow for in-depth examination of the content and unlike systematic reviews, scoping reviews do not critically appraise the evidence for decision-making purposes \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources and Searches\u003c/h2\u003e \u003cp\u003eThe following databases were searched for eligible citations from 2014 to April 10, 2023: Ovid MEDLINE, Embase (Embase.com), Cochrane CENTRAL (Wiley), and CINAHL (EBSCO). A librarian (HH) designed and executed the search strategies. A date limit was used to focus on literature published after the enactment of the Choice Act in 2014. In addition, the librarian conducted a gray literature search of the RAND Corporation\u0026rsquo;s research publications (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rand.org/research.html\u003c/span\u003e\u003cspan address=\"https://www.rand.org/research.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and the U.S. Government Accountability Office\u0026rsquo;s (GAO) reports and testimonies (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gao.gov/reports-testimonies\u003c/span\u003e\u003cspan address=\"https://www.gao.gov/reports-testimonies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) from 2014 to 2023. The full search strategies for the databases and websites are available in Supplementary File 2.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSelection Strategy\u003c/h3\u003e\n\u003cp\u003eWe included papers that presented findings specific to VA-CC. We excluded papers that were not relevant to or that presented results prior to VA-CC (i.e., prior to the Choice Act). Works focused on non-VA care that were not part of VA-CC were also excluded (e.g., care provided to Veterans by community providers who were not part of VA\u0026rsquo;s network of community providers, e.g., VA and Medicare comparisons). We excluded perspective pieces, editorials, meeting abstracts, and dissertations. Abstracts were reviewed independently by at least two team members (MAM, DJG, AL, DMH). If the two reviewers disagreed on inclusion, a group arbitration system was used. We used Rayyan to conduct our initial screening of papers prior to extraction. Rayyan was developed to expedite the initial screening of abstracts for systematic reviews by health care professionals.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The citations for all included abstracts were moved to Zotero where PDFs were attached for subsequent extraction. \u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eData Extraction and Summaries\u003c/h3\u003e\n\u003cp\u003eFifteen characteristics were extracted from each article. We predetermined these characteristics based on routine information collected for scoping reviews (e.g., publication year, keywords, sample size, funding source, study aims, key findings) and content areas informed by our experience as VA-CC funded researchers (MAM, DJG, DMH), such as legislated program (i.e., Choice Act, MISSION Act), health care domain (access, program implementation, quality, coordination of care, and costs), topic area (i.e., primary care, mental health, women\u0026rsquo;s health, specialty care, urgent/emergency care, and health care system functions), and participant type (i.e., Veterans, Providers, Administrators/Staff, and Hospitals/Facilities). Several additional characteristics included data source (i.e., primary, extant, or both), specific mention of the VA-CC network contractor (i.e., Health Net, TriWest, Optum), focus on specific populations (e.g., rural, women), whether an intervention was evaluated (yes or no), and health care focus (i.e., outcomes, utilization, experiences, evaluation).\u003c/p\u003e \u003cp\u003eAfter data extraction, each of the domains identified from individual articles was reviewed to create a written summary. During this process, themes emerged that were used in the write-up to better communicate these findings. One post-extraction addition to the findings was for the \u0026lsquo;coordination of care\u0026rsquo; domain. During the process of summarizing the articles, it became apparent that a large proportion of articles used qualitative methods rather than quantitative methods. Although this was not part of the extraction, we chose to include this additional information.\u003c/p\u003e \u003cp\u003eEach paper was extracted independently by two reviewers\u0026mdash;an author (MAM, DJG, AL, DMH) and a research associate (RS, HM, AM, LM)\u0026mdash;and entered into Microsoft Excel. Extracted information was compared, and where differences were found, MAM and AL jointly reviewed and reconciled the information. Authors of included publications were not contacted to confirm the scoping review\u0026rsquo;s presentation of their findings. We began by computing the frequencies for all characteristics. We then reviewed the literature in relation to the Choice and MISSION Acts; works that included data across Choice and MISSION Act VA-CC programs were labeled as \u0026lsquo;Both\u0026rsquo;. Lastly, we used domain categories to summarize and present findings on key extracted characteristics; studies reporting on more than one domain were included in each domain summary reported on. Investigators took responsibility for synthesizing individual domains and summarizing study findings (MAM, DJG, DMH).\u003c/p\u003e"},{"header":"RESULTS OF THE LITERATURE SEARCH","content":"\u003cp\u003eAfter removing duplicates, we screened 2,284 records identified from the database searches, of which 663 were sought for retrieval. Of these, most were excluded because they were not specific to VA-CC (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), leaving 134 records for full-text review. Among the 134, 23 were excluded due to incorrect publication type (e.g., perspective piece, opinion piece) and 22 were excluded because they were not studies about VA-CC, resulting in 89 papers included in this review. Among the GAO Reports and RAND publications, after removing duplicates, 61 reports were located and assessed for eligibility. Overall, 10 were excluded due to incorrect publication type, 38 for not being about VA-CC, and 2 for occurring prior to VA-CC legislation, resulting in 11 GAO reports retained for this scoping review. A combined total of 100 research articles and GAO reports were included in this scoping review. In the Results section, tables provide domain-specific lists of articles organized by publication year and alphabetized by first author.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eOverall Results Summary\u003c/h3\u003e\n\u003cp\u003eOf the 100 articles extracted, one-sixth (n\u0026thinsp;=\u0026thinsp;16) included both primary and extant data \u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, with a third (n\u0026thinsp;=\u0026thinsp;31) collecting primary data only \u003csup\u003e\u003cspan additionalcitationids=\"CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46 CR47 CR48 CR49 CR50 CR51 CR52 CR53 CR54 CR55 CR56 CR57 CR58 CR59\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e, and the remaining relying on existing data sources. Sample sizes were highly variable from inclusion of 9 staff members \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e to millions of Veterans \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan additionalcitationids=\"CR62 CR63 CR64 CR65 CR66 CR67 CR68 CR69 CR70 CR71 CR72 CR73 CR74 CR75 CR76\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e. Only four papers included findings related to an intervention \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e. Few papers provided findings specific to individual third-party administrators \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. More than a third (n\u0026thinsp;=\u0026thinsp;37) presented information by rurality \u003csup\u003e\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan additionalcitationids=\"CR57 CR58\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e,\u003cspan additionalcitationids=\"CR65 CR66\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan additionalcitationids=\"CR80 CR81 CR82 CR83 CR84 CR85 CR86 CR87 CR88 CR89 CR90 CR91 CR92\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u003c/sup\u003e, with an additional four focusing on rural data only \u003csup\u003e\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e and one using only urban data \u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Four papers focused on women only \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. Lastly, the health care focus on utilization (n\u0026thinsp;=\u0026thinsp;51) \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan additionalcitationids=\"CR66 CR67 CR68 CR69\" citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e,\u003cspan additionalcitationids=\"CR95 CR96 CR97 CR98 CR99 CR100\" citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e,\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan additionalcitationids=\"CR106\" citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e was the most common, followed by experiences (n\u0026thinsp;=\u0026thinsp;39) \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46 CR47 CR48 CR49 CR50 CR51 CR52 CR53\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan additionalcitationids=\"CR57 CR58 CR59\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e\u003c/sup\u003e, outcomes (n\u0026thinsp;=\u0026thinsp;16) \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan additionalcitationids=\"CR84 CR85\" citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e,\u003cspan additionalcitationids=\"CR110 CR111\" citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e\u003c/sup\u003e and evaluations (n\u0026thinsp;=\u0026thinsp;10) \u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccess was the most examined domain overall (n\u0026thinsp;=\u0026thinsp;60), followed by Coordination of Care (n\u0026thinsp;=\u0026thinsp;32), Program Implementation (n\u0026thinsp;=\u0026thinsp;26), Quality (n\u0026thinsp;=\u0026thinsp;22), and Costs (n\u0026thinsp;=\u0026thinsp;11) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). VA-CC includes the Choice Act of 2014, which ended and was replaced by the MISSION Act of 2018. The MISSION Act was passed in 2018 and implemented in 2019, with some of the first studies published in 2019. The Program Implementation domain has been consistently studied under both Acts (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The first Choice Act articles were published in 2016 and continue to be published (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Many studies since 2019 have included data for both Choice and MISSION Act eras (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Studies on Access and Quality tended to focus on specialty care, whereas studies on Program Implementation and Coordination of Care focused most on health care system functions. Cost studies focused on both health care system functions and specialty care (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Approximately two of every five articles included findings on multiple domains. Access, Quality, and Costs findings were most often based on Veteran data (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Program Implementation and Coordination of Care analyses included data from multiple health system participants (e.g., Veterans, providers, administrators/staff) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResults Summary by Domains\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eAccess\u003c/h2\u003e \u003cp\u003eIn addition to appointment wait times and distance to care -- the most common eligibility criteria for VA-CC -- several additional access-related themes appeared in the literature. Among the 60 articles within the Access domain (Supplementary Table\u0026nbsp;1), we noted five themes: 1) wait times (n\u0026thinsp;=\u0026thinsp;16), 2) distance to care (n\u0026thinsp;=\u0026thinsp;3), 3) system capacity/provider availability (n\u0026thinsp;=\u0026thinsp;10), 4) program uptake (n\u0026thinsp;=\u0026thinsp;23), and 5) Veteran and provider perceptions of access to the VA and VA-CC (n\u0026thinsp;=\u0026thinsp;11).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eWait Times\u003c/h3\u003e\n\u003cp\u003eOverall, shorter wait times at VA facilities than within VA-CC were documented for most facilities and specialties during Choice \u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e,\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e and MISSION \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e periods, and across periods \u003csup\u003e\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e. Under the Choice Act, one study found shorter VA-CC wait times for colonoscopies and another for appointments made after VA appointment cancellations due to COVID-19 \u003csup\u003e98,103\u003c/sup\u003e. Factors associated with longer VA-CC wait times included Medicaid expansion and VA program implementation issues with scheduling \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e, under both Choice and MISSION Acts.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDistance to Care\u003c/h2\u003e \u003cp\u003eStudies show VA\u0026rsquo;s Community Care Network improved access to primary care most for rural Veterans, yet a significant proportion of rural Veterans still do not have access to primary care that meets VA access-to-care standards \u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e. Under the Choice Act, both Veterans who sought care in a VA facility and through VA-CC frequently drove further than their nearest VA facility; moreover, the extra travel distance was further for those who sought care in VA-CC compared to Veterans who received care at VA facilities \u003csup\u003e\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e\u003c/sup\u003e. Efforts to anticipate the impacts of legislative changes between the Choice and MISSION Acts found that many more Veterans at high risk for hospitalization would be eligible for VA-CC under MISSION based on the new drive time criteria, which would likely see greater use of VA-CC for outpatient specialty care among this population \u003csup\u003e\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e. Under Choice, Veterans were eligible for VA-CC if they lived more than 40 miles from a VA facility; under the MISSION Act, Veterans are eligible for VA-CC if the drive time to a primary care or mental health care appointment is longer than 30 minutes or longer than 60 minutes for a specialty care appointment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSystem Capacity/Provider Availability\u003c/h2\u003e \u003cp\u003eGAO has noted data deficiencies that prevent VA from accurately monitoring VA-CC network adequacy \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Moreover, many researchers have found provider and resource shortages within VA-CC and more generally for nursing homes, women\u0026rsquo;s health care services, rural areas, and for health care specialties \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e. Among VA-users eligible for purchased care based on distance, approximately 1 in 6 live in designated primary care shortage areas and 7 in 10 in mental health care shortage areas \u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e. Further, VA's regional telehealth Clinical Resource Hubs-Mental Health (CRH-MH) program was significantly more likely to serve rural Veterans than VA-CC \u003csup\u003e27\u003c/sup\u003e. Increases in mental health care access for rural Veterans were achieved primarily by changes in VA care delivery; VA-CC had less effect \u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProgram Uptake\u003c/h2\u003e \u003cp\u003eIn the first year of Choice Act implementation, there was low uptake of VA-CC services \u003csup\u003e\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e\u003c/sup\u003e. However, utilization for many types of care have increased over time, both within VA \u003csup\u003e27,93,97\u003c/sup\u003e and through VA-CC \u003csup\u003e61,62,67,69,89,93,97,105,110\u003c/sup\u003e. Studies that have sought to identify the characteristics of Veterans more likely to use VA-CC have found that rural residence, eligibility for VA-CC based on distance, female gender, older age, being non-married, having higher education, experiencing financial hardship, having certain mental health conditions, having\u0026thinsp;\u0026ge;\u0026thinsp;3 chronic conditions, and a higher VA disability rating were associated with a greater likelihood of VA-CC use \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u003c/sup\u003e. Importantly, although Veterans with severe behavioral health conditions were more likely to be treated in VA inpatient care, there is increasing use of outpatient behavioral health care in VA-CC and Veterans receiving VA-CC outpatient behavioral health care are more likely to see less highly trained providers \u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVeterans\u0026rsquo; reasons for using both VA and VA-CC included convenience, access to needed services, and seeking a second opinion \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Early use of VA-CC under the Choice Act was associated with less attrition from VA \u003csup\u003e71\u003c/sup\u003e. Despite this, researchers found that Veterans\u0026rsquo; reliance on VA care declined for primary care, mental health, and specialty care \u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. Veterans who received care at a VA-CC ED were more likely to use VA-CC specialty care compared to after a VA ED visit \u003csup\u003e\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e, and increases in VA-CC hospitalizations were offset by similar decreases in VA hospitalizations \u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. Researchers suggest increasing VA emergency department (ED) capacity will likely reduce VA-CC use \u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e. An analysis of low-value service utilization found that most low-value services were delivered by VA rather than VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eVeteran and Provider Perceptions of Access\u003c/h2\u003e \u003cp\u003eEleven articles focused on perceptions and experiences of access to care, most pertaining to temporal or geographic access and availability or choice of services and providers \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e. Two articles made direct comparisons between VA and VA-CC, with mixed results on whether VA or VA-CC provided better access \u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e. In the FY16 and FY17 Survey of Healthcare Experiences of Patients (SHEP), Veterans reported better experiences of specialty care access in VA-CC compared with VA, while access experiences were similar between VA-CC and VA for primary care and mental health care \u003csup\u003e\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e. In the FY16 and FY19 SHEP, rural and urban Veterans reported similar VA-CC access experiences for specialty care, while rural Veterans reported better VA-CC access experiences than urban Veterans for primary care \u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e. However, among rural Veterans, access experiences were worse in VA-CC than in VA except for specialty care, although access experiences in both VA-CC and VA improved over time, with greater improvements in VA-CC access experiences \u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eStudies often identified Veterans\u0026rsquo; access concerns as administrative in nature rather than related to VA-CC appointment experiences \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. For example, VA-CC authorization delays and further issues after authorizations impacted Veteran satisfaction with VA-CC access. These included scheduling delays, and lack of information or assistance identifying VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Some administrative burdens were reported more frequently among Veterans who had sought but did not ultimately use VA-CC \u003csup\u003e35,53\u003c/sup\u003e. Veterans who used VA-CC were generally satisfied with appointment access, including distance to, timeliness of, and choice of providers \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. However, some studies found that travel barriers and perceived delays in establishing and receiving care in VA-CC impacted Veterans\u0026rsquo; perceptions of and satisfaction with access to VA-CC \u003csup\u003e36,40,53\u003c/sup\u003e. VA maternity care coordinators helped women Veterans navigate challenges related to finding VA-CC maternity care, \u003csup\u003e53\u003c/sup\u003e while perceived access to VA-CC maternity care depended on the regional network Choice Act contractor \u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. In addition, Veterans expressed concern that by sending Veterans to VA-CC, the VA would downsize their own facilities and make less effort to hire their own providers \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. Some VA providers expressed concern that VA-CC may not be able to accommodate Veterans\u0026rsquo; specific appointment needs (e.g., significant others\u0026rsquo; attendance at appointments, specific appointment times) \u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCoordination of Care Across VA and VA-CC\u003c/h2\u003e \u003cp\u003eThe thirty-two articles addressing coordination of care covered a broad range of coordination aspects (Supplementary Table\u0026nbsp;2), which we have summarized into the following two themes: 1) navigation and care management between VA and VA-CC providers (n\u0026thinsp;=\u0026thinsp;32), and 2) Veteran and provider experiences (n\u0026thinsp;=\u0026thinsp;10).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eNavigation and Care Management between VA and VA-CC Providers\u003c/h2\u003e \u003cp\u003eCoordination of care comprised a wide definitional scope. Studies addressed scheduling assistance \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e, assistance with resolving billing issues \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e and communication issues \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e\u003c/sup\u003e, as well as perceptions of hassles following referrals from VA to VA-CC and perceived long wait times for follow-up \u003csup\u003e35\u003c/sup\u003e, and interventions implementing new staff to assist with medication management across VA and non-VA care \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMost studies used qualitative data \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan additionalcitationids=\"CR49 CR50 CR51 CR52 CR53\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e\u003c/sup\u003e collected from Veterans, providers, and support staff and brought to light issues and possible leverage points to alleviate coordination challenges for better system functioning \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. One implementation of a referral coordination initiative \u003csup\u003e\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e\u003c/sup\u003e in Michigan found improved process efficiency through a nurse-led process that combined the roles of care coordinator and care navigator \u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e. This process, which included early Veteran engagement that informed Veterans of their VA and VA-CC options, increased retention in VA care by streamlining inter-VA facility services \u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e. Some of the suggested changes included creating new roles specifically for coordination of care, such as a record tracker, patient liaison, and provider point-of-contact \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, as well as creating more role clarity \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e and improving communication technologies used by Veterans, VA providers, and VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmong the nine articles addressing primary care \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e, the burden of coordinating care between VA and VA-CC providers under the Choice Act was highlighted \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e and communication challenges under both Acts were a frequent theme \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Notably, a qualitative observational study focused on coordination of care between VA-CC home health aides and VA primary care teams and showed limited communication between the VA care team and home health providers \u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. In another study including surveys of Veterans and providers, Veterans reported that VA and VA-CC providers were informed about the others\u0026rsquo; care more than half the time \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Rural Veterans reported better overall health and ease of managing care \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Both VA and VA-CC providers reported problems with managing medications, sharing test results, communicating with specialists, and sharing discharge summaries \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eVeteran and Provider Experiences\u003c/h2\u003e \u003cp\u003eTwo studies addressing primary and specialty care highlighted the \u0026ldquo;Survey of Healthcare Experiences of Patients\u0026rdquo; (SHEP) results showing Veterans rated VA care better in the areas of communication, coordination of care, and provider ratings \u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e. Other studies discussed the burden on providers of coordinating care, hesitancies that providers have with the VA-CC system, \u003csup\u003e33,34\u003c/sup\u003e and communication issues \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Data collected from Veterans who used VA and VA-CC showed that communication between VA and VA-CC providers was variable \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Similarly, VA-CC providers reported sending communications to VA providers less often than their VA counterparts sent to VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. In many cases, Veterans transferred documents between providers, acting as necessary go-betweens due to gaps in coordination of care. This finding was echoed in semi-structured interviews with Veterans who revealed successes and challenges with interorganizational coordination of care relaying workarounds they had found to help overcome such challenges \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, as well as by Veterans and their families who discussed how they had to fill in gaps in coordinating the care for their Veterans \u003csup\u003e\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmong articles addressing coordination of care, two addressed health-related social needs: one focused on homeless Veterans \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e and another addressed those with poor health status \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Veterans experiencing homelessness who used VA and VA-CC services, compared to those using the VA without community care, were more likely to endorse unfavorable coordination experiences in primary care. Veterans experiencing homelessness who were more likely to use VA-CC were female, older, had higher education levels, experienced more financial hardship, had three or more chronic conditions, and had higher rates of psychological distress, depression, or posttraumatic stress disorder (PTSD) \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Additionally, Veterans experiencing homelessness who had travel barriers, psychological distress, or lower social support were more likely to have lower satisfaction with VA-CC \u003csup\u003e36\u003c/sup\u003e. Both studies recommended improving communication between VA and VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eVA-CC Program Implementation\u003c/h2\u003e \u003cp\u003eThe Program Implementation domain included 26 articles (Supplementary Table\u0026nbsp;3). The primary difference between articles included in the Access vs. Program Implementation domains was whether they addressed outcomes or processes. For example, articles in the Access domain evaluated access as an outcome of Choice and MISSION implementation, while articles related to access in the Implementation domain described activities and processes that facilitated or impeded access to care under Choice and MISSION. Early findings for the Choice Act suggested that the program was implemented without adequate preparation \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Multiple studies identified issues with scheduling \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e, care coordination \u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e, and billing confusion \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. Studies identified critical information missing from patient records for VA-CC services (e.g., pathology results) \u003csup\u003e\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e\u003c/sup\u003e, challenges with health information exchange interoperability \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, and differences in utilization by rurality \u003csup\u003e\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e. Implementation was hampered by a steep learning curve for leadership and staff and a lack of VA-CC adaptability to local processes \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e. Some VA providers expressed reservations about sending Veterans to VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA common difficulty during Choice Act implementation was engaging VA-CC providers, resulting in VA-CC provider networks not being sufficiently developed, that is having enough providers and the right type of providers in the right locations to ensure adequate access to VA-CC \u003csup\u003e30,37,42,59\u003c/sup\u003e. Community providers most interested in participating tended to be Veterans themselves, those already providing care to Veterans or who had pre-established working relationships with the VA \u003csup\u003e30,32,34\u003c/sup\u003e, and those interested in the mission of providing care to Veterans \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGAO conducted numerous evaluations of VA-CC program implementation noting the limitations of projecting future costs \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, providing oversight of VA and third-party administrator processes \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e without having sufficient metrics and processes in place \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eResearch has shown that as more Veterans use non-VA hospitals, the technical efficiency of VA hospitals decreases considerably \u003csup\u003e\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u003c/sup\u003e. Additionally, Veterans who go to a VA-CC Emergency Department (ED) have a greater proportion of subsequent specialty care visits from VA-CC providers than Veterans with a VA ED visit \u003csup\u003e\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e. However, researchers have shown that supplementing VA-CC with additional VA programs (e.g., management of specialty care referrals, telemedication management) improves VA care retention and reduces costs \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eQuality of Care\u003c/h2\u003e \u003cp\u003eQuality of Care included 22 articles (Supplementary Table\u0026nbsp;4) summarized into three themes: 1) VA and VA-CC comparisons (n\u0026thinsp;=\u0026thinsp;13), 2) VA-CC quality of practice (n\u0026thinsp;=\u0026thinsp;5), and 3) other evaluations of quality of care (n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eVA and VA-CC Quality of Care Comparisons\u003c/h2\u003e \u003cp\u003eComparisons of the quality of care provided by VA and VA-CC were mixed depending on the type of care examined \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e,\u003cspan additionalcitationids=\"CR110 CR111\" citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e\u003c/sup\u003e. No differences between VA-delivered and VA-CC quality were found in hernia surgeries \u003csup\u003e\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e\u003c/sup\u003e, cataract surgeries \u003csup\u003e\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e, inpatient mortality \u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e, post-operative mortality, readmissions, or emergency department visits for a set of 40 different surgical procedures \u003csup\u003e\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e\u003c/sup\u003e, or hepatitis C infection treatment failure rates and reasons for treatment failure \u003csup\u003e\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e. While studies on total knee arthroplasties have found better overall quality in VA with respect to lower readmissions (83) and lower complication rates (85), quality of total knee arthroplasty was also found not to be associated with care setting (79). Patients who received VA Telemental health or were referred to VA-CC had similar ratings of satisfaction with patient-centeredness of care \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. One study found VA-CC was associated with increased receipt of certain preventive care services \u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/sup\u003e. Three studies identified VA providing better quality for colonoscopy care and patient experiences, as well as lower mortality following elective percutaneous revascularization \u003csup\u003e\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e,\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eVA-CC Quality of Care\u003c/h2\u003e \u003cp\u003eOther studies focused on VA-CC quality of care without direct comparisons to VA. Women Veterans receive their maternity care through VA-CC where rates of Cesarean-section were 35%, which is slightly higher than the national average of 32% \u003csup\u003e26\u003c/sup\u003e. Women Veterans of color were significantly more likely to deliver by Cesarean-section than White women Veterans \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Relatively few VA-CC primary care and mental health providers in Texas and Vermont reported using guideline-recommended psychotherapy or prescribing practices for PTSD \u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e. In cases of VA-CC suicide-related safety events, poor communication between VA and VA-CC providers led to inadequate treatment or follow-up care, and VA providers were concerned that VA-CC providers and their environments were not adequately prepared to address patient safety (e.g., access to methods of strangulation in VA-CC emergency rooms and rehabilitation units) \u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e. Further, there may have been ineffective controls used by VA and its contracts to identify health care providers eligible to participate in VA-CC, resulting in the inclusion of potentially ineligible providers \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Some VA providers believed that some VA-CC providers did not have the specific experience required to treat more advanced cases of hepatitis C virus or to manage common Veteran comorbidities such as mental illnesses and traumatic brain injury \u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eOther Evaluations of Quality of Care\u003c/h2\u003e \u003cp\u003eTwo studies found Veterans were generally satisfied with their VA-CC care \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Veterans identified (a) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (b) a positive environment or \u0026ldquo;eco-system of care\u0026rdquo; as integral to their decisions about where to receive care; both VA-delivered care and VA-CC sometimes performed well on these factors and sometimes did not, influencing Veterans\u0026rsquo; engagement with VA and VA-CC \u003csup\u003e38\u003c/sup\u003e. Finally, one study examined variation in VA facilities\u0026rsquo; rates of low-value service use, with higher rates among VA facilities with a greater use of VA-CC, however, this association did not hold when adjusting for other facility characteristics \u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCosts\u003c/h2\u003e \u003cp\u003eEleven articles in total addressed costs (Supplementary Table\u0026nbsp;5), with all but one examining health care costs incurred by the VA health care system \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e,\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e\u003c/sup\u003e. We have summarized the Costs domain into two themes: 1) VA and VA-CC comparisons (n\u0026thinsp;=\u0026thinsp;3) and 2) other evaluations of costs (n\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eVA and VA-CC Comparisons\u003c/h2\u003e \u003cp\u003eAmong comparative studies, whether VA or VA-CC services were more costly depended on the service in question \u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e. For example, in one California region, VA-CC was more costly than VA-direct care for hepatitis C treatment \u003csup\u003e\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e, while nationally, VA-direct care was more costly than VA-CC for total knee arthroplasties and cataract surgeries \u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u003c/sup\u003e. Many of these studies may not account for all costs for VA-CC, including administrative costs for program administration and costs incurred by individual facilities to authorize and coordinate community care. In addition, a national study found that sleep studies were more costly in VA-CC than in VA due to lower rates of home testing and higher rates of in-laboratory sleep testing in VA-CC \u003csup\u003e107\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eOther Evaluations of Costs\u003c/h2\u003e \u003cp\u003eThree studies examined costs of VA-CC care without comparing them to VA \u003csup\u003e14,65,115\u003c/sup\u003e. For example, prescription medication costs during the first year of the Veterans Choice Program totaled \u003cspan\u003e$\u003c/span\u003e27\u0026nbsp;million \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, and in 2018, \u003cspan\u003e$\u003c/span\u003e205.8\u0026nbsp;million was spent on low-value or potentially inappropriate services across VA and VA-CC \u003csup\u003e65\u003c/sup\u003e. However, the latter study \u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e did not separate out VA-CC from VA costs of care. Another study compared VA-CC and Medicare reimbursement for 10 common ophthalmic procedures in FY2020, finding that negotiated VA-CC fees regularly exceeded Medicare reimbursements for the same procedures \u003csup\u003e\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOne study examined perceptions of VA-CC costs and found that VA-CC medical billing problems for VA-CC emergency care contributed to Veterans\u0026rsquo; perceptions of financial hardship \u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. In addition, two reports published by the GAO found that VA data and processes used to develop VA-CC budget estimates underestimated VA-CC costs \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTwo studies found that interventions to address aspects of VA-CC medication prescribing could produce cost savings to the VA health care system \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u003c/sup\u003e. For example, a pharmacist-led tele-medication management intervention at three VA medical centers produced cost savings from a reduction in VA-CC medication-related costs for oral antineoplastic therapies (i.e., oral chemotherapy) \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Similarly, a medication authorization review program was associated with significant savings to VA resulting from reductions in Veterans\u0026rsquo; use of VA-CC prescribed non-approved prescription drugs \u003csup\u003e\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe Choice Act\u0026rsquo;s aim was to improve Veterans\u0026rsquo; temporal and geographic access to care by employing a contracted network of community providers, thus expanding Veterans\u0026rsquo; care options beyond VA facilities and providers \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. This scoping review included numerous studies on access to care, finding that, in most cases, appointments with VA-CC were no timelier, and often less timely, than appointments within the VA. However, VA-CC did improve Veterans\u0026rsquo; geographic access to care via reduced drive times. Yet, a subgroup of Veterans still drove further to VA-CC than their nearest VA facility for care, suggesting geographic access is only one of several considerations impacting Veterans\u0026rsquo; decisions about where to seek care. This scoping review also identified additional aspects of access, including network capacity/provider shortages, program utilization, and program satisfaction, highlighting VA-CC impacts such as changes in Veterans\u0026rsquo; reliance on VA care.\u003c/p\u003e \u003cp\u003eMany rural Veterans became eligible for VA-CC under the Choice Act due to living farther than 40 miles from their nearest VA facility; however, VA-CC has not been able to improve geographic access for many rural Veterans \u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e. This was not unexpected given well-documented and long-standing national rural health care workforce shortages \u003csup\u003e\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e\u003c/sup\u003e. Fortunately, distance to care is not the primary or sole factor rural Veterans use in deciding whether and where to seek health care. Research has found that rural Veterans consider distance alongside other factors such as care urgency, patient resources, and patient-provider relationships \u003csup\u003e\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e,\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e\u003c/sup\u003e. Evaluating improvements in Veterans\u0026rsquo; access to health care may need more nuanced approaches that consider Veterans\u0026rsquo; priorities and preferences, similar to VA\u0026rsquo;s Whole Health approach. (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.va.gov/wholehealth/\u003c/span\u003e\u003cspan address=\"https://www.va.gov/wholehealth/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) The Whole Health approach focuses on \u003cem\u003ewhat matters to the Veteran\u003c/em\u003e, considering Veterans\u0026rsquo; values, needs, and goals. VA-CC demonstrates the limits of expanding VA\u0026rsquo;s network of providers to improve geographic access for rural Veterans.\u003c/p\u003e \u003cp\u003eImproving access for Veterans requires the VA \u0026ndash;the largest integrated health care system in the U.S. -- to further incorporate an expanded network of contracted community providers. The VA had 90 days to implement this legislated program under the Choice Act \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e within its health care system serving more than 9.5\u0026nbsp;million enrolled Veterans and eligible family members, made up of 172 medical centers and 1,100 outpatient clinics, supported by 371,000 health care professionals and support staff \u003csup\u003e\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e\u003c/sup\u003e. Issues with VA-CC program implementation included difficulties finding providers to participate in the VA-CC network, scheduling with VA-CC providers, and communicating with VA-CC providers about Veterans\u0026rsquo; care. The authors caution that these prior studies should be considered within their historical context and in light of the current context. VA-CC continues to evolve and these studies have directly and indirectly informed its evolution \u003csup\u003e\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e,\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e\u003c/sup\u003e. For example, when VA-CC was initially implemented, third-party administrators who managed VA-CC provider networks were responsible for scheduling VA-CC appointments. However, when this approach proved ineffective, the VA established local Community Care Departments, which are currently responsible for managing consults, referrals, authorizations, scheduling appointments, coordinating health information exchange and care, and answering Veteran and provider questions, and have developed initiatives to help Veterans navigate the CNN \u003csup\u003e\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOverall, quality findings were mixed and provide a less conclusive picture than that provided in prior reviews. Prior systematic reviews have shown that VA care is as good or better than non-VA care \u003csup\u003e\u003cspan additionalcitationids=\"CR124\" citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u003c/sup\u003e. However, these prior works preceded the Choice Act \u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u003c/sup\u003e or were not limited to assessments of VA-CC quality \u003csup\u003e\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e,\u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e124\u003c/span\u003e\u003c/sup\u003e. In this scoping review, which focused solely on the quality of VA-delivered care and VA-CC, quality of care was measured in terms of health outcomes, such as clinical quality measures and adverse health care events (e.g., post-surgical complications); receipt of preventive services; and satisfaction with care. A unique area of \u0026lsquo;quality\u0026rsquo; among the literature was VA-CC provider expertise, or lack thereof, related to the specific health care needs of the Veteran population served by the VA \u003csup\u003e126\u003c/sup\u003e. Veterans who use VA healthcare tend to report poorer health, to have less education and lower household incomes, to have served longer in the military and in combat, and to have a disability, more medical conditions as well as mental health disorders \u003csup\u003e\u003cspan citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e,\u003cspan citationid=\"CR128\" class=\"CitationRef\"\u003e128\u003c/span\u003e\u003c/sup\u003e. VA is different from non-VA healthcare in that it has systemwide clinical expertise to address service-connected conditions and disorders, including multiple co-morbid physical and mental health conditions \u003csup\u003e\u003cspan additionalcitationids=\"CR130\" citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e\u003c/sup\u003e. In non-VA healthcare settings, for example, providers may not be knowledgeable about the specific healthcare needs of the Veteran population and/or lack the training necessary to provide quality care to Veterans. As part of the MISSION Act, the VA provides optional no-cost continuing medication education (CME) training to VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e\u003c/sup\u003e. However, it is unknown whether providers are willing to participate in these trainings, particularly if they see few Veterans or are unaware of the Veteran status of their patients or the VA engagement of their patients \u003csup\u003e\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e\u003c/sup\u003e. We found no research examining the use of these training materials or their impact on quality of Veterans\u0026rsquo; care.\u003c/p\u003e \u003cp\u003eThe top three priorities in evaluating the coordination of VA care and VA-CC include: 1) identifying which Veterans would benefit most from additional care coordination support; 2) determining who is responsible for coordinating care for Veterans receiving VA-CC; and 3) developing measurement systems to assess the effectiveness of VA-CC coordination efforts for Veterans \u003csup\u003e\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e\u003c/sup\u003e. This scoping review identified some research on Veterans\u0026rsquo; experience and satisfaction with coordination of care, including with referral coordination \u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e. In 2019, the VA began the Referral Coordination Initiative (RCI) \u003csup\u003e\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e\u003c/sup\u003e to improve coordination of care for patients requiring VA-CC, however, due to pandemic-related disruptions, national implementation of the RCI was stalled, so it was not surprising that there were no studies that examined care coordination that identified Veterans who could benefit most from additional care coordination support. This VA-CC scoping review found a recurring theme of the process challenges that aligned with the SOTA\u0026rsquo;s second priority - role clarity. Lastly, there were no articles that proposed measurement systems to assess the effectiveness of VA-CC coordination efforts. This may be a direct consequence of the issues noted in the Program Implementation section, which outlined challenges with the interoperability of Health Information Exchanges, which is arguably essential to coordination of care across VA and VA-CC settings.\u003c/p\u003e \u003cp\u003eThe U.S. population of Veterans is declining, but the number of Veterans using VA health care is increasing \u003csup\u003e\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e\u003c/sup\u003e, as are the costs to provide care. From 2012 to 2022, there was an approximately 400% increase in costs in VA-purchased community care, largely due to the passage of the Choice and MISSION Acts; in 2012, VA spent approximately \u003cspan\u003e$\u003c/span\u003e4.5\u0026nbsp;billion dollars on VA-CC compared to the estimated VA-CC obligations of \u003cspan\u003e$\u003c/span\u003e21.3\u0026nbsp;billion in 2022 \u003csup\u003e22\u003c/sup\u003e. This trend in VA\u0026rsquo;s medical care budget is expected to continue with increases of 23% in 2023 and 25% in 2024 \u003csup\u003e135\u003c/sup\u003e. Comparisons including VA versus non-VA costs can inform VA decisions on what types of care VA should provide and what types of care to refer to the community (i.e., \u0026ldquo;make vs. buy\u0026rdquo;) \u003csup\u003e136\u003c/sup\u003e. However, only two studies thus far have compared costs of care in VA and VA-CC settings \u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e. In addition, two studies evaluated medication management interventions aimed at managing VA-CC prescription medication costs \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u003c/sup\u003e, but no studies have investigated cost savings related to other types of care delivery or value-based care, which are important for policy-related initiatives. We anticipate more research on these and related topics will be published in the future because of the MISSION Act, which established the VA Center for Care and Payment Innovation (CCPI) to improve Veteran care while reducing costs (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.innovation.va.gov/careandpayment/\u003c/span\u003e\u003cspan address=\"https://www.innovation.va.gov/careandpayment/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough many studies addressed more than one domain, few studies investigated the potential synergistic benefits or trade-offs in improving one aspect of care delivery at the cost of another (e.g., expanding access without addressing quality of care). However, one research study conducted under the Choice Act found improved wait times for colonoscopies but lower surveillance guideline compliant care from VA-CC providers \u003csup\u003e\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e\u003c/sup\u003e. Another study found longer wait times and higher costs for VA-CC versus VA care \u003csup\u003e\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e. A recent publication, not included in this scoping review, identified a potential unanticipated consequence of the MISSION Act\u0026mdash;a shift in financing of care between VA and Medicare \u003csup\u003e\u003cspan citationid=\"CR137\" class=\"CitationRef\"\u003e137\u003c/span\u003e\u003c/sup\u003e. Overall non-VA ED utilization among Veterans may not have changed, but the payor of those visits is increasingly the VA and less likely Medicare, suggesting shifts in reliance to VA-CC \u003csup\u003e137\u003c/sup\u003e. These novel approaches at examining VA-CC in addition to studies that concurrently examine multiple aspects of the VA-CC program are needed to guide future evolutions of the program and inform policy.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe chose a scoping review to summarize the topics and findings related to VA-CC programs to inform research and policy. An inherent limitation of any scoping review is that it does not grade the evidence, and therefore we cannot provide definitive recommendations \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, given the breadth of the scoping review, we anticipate it will serve as a precursor to several domain-specific systematic reviews, particularly as the program under the MISSION Act becomes more established and the research more extensive. Second, there is the possibility that we may have excluded research that should have been included due to \u0026lsquo;community care\u0026rsquo; being a phrase that is used in many contexts and not specific to VA\u0026rsquo;s expanded purchased care programs under the Choice and MISSION Acts. We attempted to prevent inaccurate exclusions through multiple review processes, however, a few may still have been missed. Lastly, this scoping review represents the literature available at a point in time. Research continues to be published, and we anticipate extending this work through future systematic reviews of individual domains and knowledge syntheses across domains.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe challenge with evaluating VA-CC, understanding its strengths and weaknesses, and providing evidence-based guidance for future improvements lies in synthesizing disparate findings into a coherent composite. As VA advances its vision of an integrated learning health system, this scoping review brings together the evidence needed to inform clinical and Congressional priorities and drive continued improvement in Veteran care and outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVeterans Health Administration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eChoice Act\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVeterans Access, Choice, and Accountability Act\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVA-CC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVA-purchased Community Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMISSION Act\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaintaining Internal Systems and Strengthening Integrated Outside Networks Act\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eU.S. Government Accountability Office\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHEP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSurvey of Healthcare Experiences of Patients\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eState-Of-The-Art\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter for Care and Payment Innovation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was supported by Award # VA HSR\u0026amp;D COR 23\u0026ndash;190, VA SDR 20\u0026ndash;390 from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service. Dr. Vanneman was also supported in part by VA HSR\u0026amp;D CDA 15\u0026ndash;259 from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service. Dr. Govier was supported in part by career development awards from the VHA Office of Rural Health (NOMAD PROJ-04269) and VA Health Systems Research Service (IK2RD000662). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.\u003c/p\u003e \u003cp\u003eRole of the Funder/Sponsor:\u003c/p\u003e \u003cp\u003eThe funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/p\u003e\u003ch2\u003eAuthors' contributions:\u003c/h2\u003e \u003cp\u003eMAM, DJG, AL, and DMH worked to conceptualize the scoping review, had full access to all the data. MAM, DJG, SPY, MEV, KMM, AKR, DMH critically revised the manuscript for important intellectual content and approved the final version to be submitted for publication. HH designed the specific protocol of the scoping review literature pull. MAM, DJG, and DMH were involved in drafting the article and took responsibility for the accuracy of the data analysis. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eThe authors would like to thank Shylo Ward (SW) for her management of the articles throughout the scoping review process; Senta Wiederholt (SW), Holly McCready (HM), Abby Moss (AM), Rachel Sears (RS), and Liz Mace (LM) for helping with article extraction; and Rachel Sears for creating the manuscript\u0026rsquo;s figures.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eAll data analyzed during this study can be recreated using the search strategy provided in Supplementary File 2.\u003c/p\u003e \u003cp\u003eCompeting interests:\u003c/p\u003e \u003cp\u003eAll authors are employed by the Department of Veterans Affairs (VA) and received VA funding to conduct this scoping review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFact Sheet 20\u0026thinsp;\u0026ndash;\u0026thinsp;01: Overview of Non-VA Medical Care. 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Med Care 55(7 Suppl 1):S4\u0026ndash;S12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MLR.0000000000000683\u003c/span\u003e\u003cspan address=\"10.1097/MLR.0000000000000683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMengeling MA, Mattocks KM, Hynes DM, Vanneman ME, Matthews KL, Rosen AK (2021) Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care. 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J Gen Intern Med 38(9):2179\u0026ndash;2188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-023-08207-2\u003c/span\u003e\u003cspan address=\"10.1007/s11606-023-08207-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShekelle P, Maggard-Gibbons M, Blegen M et al (2023) VA versus Non-VA Quality of Care: A Systematic Review. Department of Veterans Affairs (US); Accessed August 26, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK591851/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK591851/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Hanlon C, Huang C, Sloss E et al (2017) Comparing VA and Non-VA Quality of Care: A Systematic Review. 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Rand Health Q 5(4):13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://ovidsp.ovid.com/ovidweb.cgi?T=JS\u003c/span\u003e\u003cspan address=\"http://ovidsp.ovid.com/ovidweb.cgi?T=JS\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u0026amp;PAGE=reference\u0026amp;D=pmnm3\u0026amp;NEWS=N\u0026amp;AN=28083423\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose L, Schmidt A, Gehlert E, Graham LA, Aouad M, Wagner TH (2023) Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees. JAMA Netw Open 6(7):e2323884. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2023.23884\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2023.23884\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUS Veterans Who Do and Do Not Utilize Veterans Affairs Health Care Services: Demographic, Military, Medical, and Psychosocial Characteristics. Psychiatrist.com. 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Med Care 52(2):172. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MLR.0000000000000059\u003c/span\u003e\u003cspan address=\"10.1097/MLR.0000000000000059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreech SK, Pulverman,Carey S, Crawford, Jennifer N et al (2021) Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities. Behav Med 47(1):69\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08964289.2019.1644283\u003c/span\u003e\u003cspan address=\"10.1080/08964289.2019.1644283\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Department of Veterans Affiars. Provider Education and Training. 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Accessed May 30, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147251/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147251/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMattocks KM, Cunningham K, Elwy AR et al (2019) Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care. J Gen Intern Med 34(Suppl 1):18\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-019-04972-1\u003c/span\u003e\u003cspan address=\"10.1007/s11606-019-04972-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasmussen P, Farmer CM (2022) The Promise and Challenges of VA Community Care: Veterans\u0026rsquo; Issues in Focus. RAND Corporation. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7249/PEA1363-5\u003c/span\u003e\u003cspan address=\"10.7249/PEA1363-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForum (2019) : Specialty Care and the MISSION Act. Accessed May 30, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hsrd.research.va.gov/publications/forum/spring19/default.cfm?ForumMenu=Spring19-1\u003c/span\u003e\u003cspan address=\"https://www.hsrd.research.va.gov/publications/forum/spring19/default.cfm?ForumMenu=Spring19-1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose L, Tran D, Wu S, Dalton A, Kirsh S, Vashi A (2023) Payer shifting after expansions in access to private care among veterans. Health Serv Res 58(6):1189\u0026ndash;1197. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1475-6773.14162\u003c/span\u003e\u003cspan address=\"10.1111/1475-6773.14162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"51165001-7928-4057-9709-fc9a7cf84ed9","identifier":"10.13039/100006379","name":"Office of Research and Development","awardNumber":"VA HSR\u0026D COR 23-190, VA SDR 20-390,VA HSR\u0026D CDA 15-259,NOMAD PROJ-04269,IK2RD000662","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Department of Veterans Affairs, Veterans Health Administration","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"policy making, case management, delivery of health care, quality of health care, health services research","lastPublishedDoi":"10.21203/rs.3.rs-9657762/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9657762/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eIn 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.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eFour 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.\u003c/p\u003e\n\u003cp\u003eFifteen 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).\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eOf 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).\u003c/p\u003e\n\u003cp\u003eOverall, 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.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e","manuscriptTitle":"Increasing Veterans’ Access to Health Care After Legislated Expansion of VA Community CarePrograms: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 17:19:04","doi":"10.21203/rs.3.rs-9657762/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"331bdfc9-fbaa-4aaa-aeee-cc4408af2256","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T17:19:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 17:19:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9657762","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9657762","identity":"rs-9657762","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}