Episode-based (“bundled”) approaches have been promoted for performance measurement to encourage shared accountability for the quality and efficiency of healthcare delivery among all of the providers involved in a patient's care. Most episode-based pilot programs use relatively narrow episode definitions, with the typical episode trigger starting at the time of a hospitalization or surgery. However, little attention has been paid to measuring quality and value of pre-surgical care. Although inpatient and postoperative care are costly, outpatient care accounts for the greatest utilization of health care resources in terms of visits and expenditures. This pre-surgical period, during which patients often have multiple touches with the healthcare system, is an important time to identify opportunities to improve coordination and quality of care for Veterans. The studies proposed as part of this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with carpal tunnel syndrome (CTS), particularly in the pre- surgical period. Treatment for CTS is an ideal context to develop measurement models of care quality and utilization between primary care and specialty providers, given that approximately 40,000 Veterans per year are newly diagnosed with CTS and often receive care from one or more providers from primary care, occupational therapy, orthopedic surgery, plastic surgery, neurosurgery, physical medicine and rehabilitation, or pain management. Although a variety of nonoperative treatments can be appropriate under certain clinical circumstances, these same treatments can be low value if they lead to delays for patients who would benefit from surgery. This series of studies to evaluate and improve quality and utilization of CTS pre-surgical care will advance an understanding of how to optimize coordination of patient-centered surgical care more broadly. This project will have 3 aims: Aim 1: Using VHA national data, facility-level variation in CTS pre-surgical value will be assessed by examining both quality/access (inappropriate delay of surgery) and resource utilization (number of pre-surgical encounters), while evaluating the impact of key structural and process variables, including referral to community providers. Aim 2: Semi-structured interviews with patients and clinicians will be conducted to further identify and better understand factors associated with pre-surgical episode quality and utilization. Clinicians and patients will be recruited from 2 facilities with the highest and 2 facilities with the lowest performance on both pre-surgical measures (quality and utilization) to evaluate perspectives, preferences, organizational factors, and care goals of key stakeholders (patients and providers) who impact decision-making across phases of pre-surgical CTS care. Aim 3: Findings from Aim 1 and Aim 2 will be used to design and pilot a multi-disciplinary CTS clinical care pathway that addresses systemic barriers and processes impacting pre-surgical episode quality/access and utilization of CTS-related care provided across primary care and specialty clinics. Pilot testing will assess the intervention's feasibility, acceptability, and potential to improve facility-level pre-surgical episode value in preparation for an anticipated randomized trial. These methods, refined for CTS, will be applied in future work to examine variation in quality and utilization of pre-surgical care for other conditions, with the goal of optimizing use of health care services and maximizing outcomes for Veterans who receive surgical care. In anticipation of greater Veteran access to community- based care, this initiative will also be beneficial for monitoring and better coordinating the quality and value of care across diverse healthcare settings.

Improving access, quality, and efficiency of care for Veterans, both through VHA and community-based networks, is a top priority. For Veterans receiving surgical care, quality improvement efforts need to focus not only on the time after surgery, but also must consider the care delivered between primary care and specialist providers before surgery. This project will examine the differences in carpal tunnel syndrome-related care across VHA medical centers during the time between diagnosis and surgery, and further understand the factors that are associated with delay of surgery and higher numbers of healthcare visits. These findings will guide the development of organizational changes to help clinicians provide higher quality and efficient care for patients with carpal tunnel syndrome, with the goal of promoting Veteran-centered care and improving patient outcomes. This effort to improve the care prior to surgery for carpal tunnel syndrome, lays the groundwork to improve coordination, access, and quality of care prior to surgery more broadly for other surgical problems.