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Objective: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them. Data Sources and Study Setting: Qualitative data collected from key informants at 18 geographically diverse VA facilities across 17 Veterans Integrated Services Networks (VISNs). Study Design: We conducted semi-structured interviews from 2019 to 2022 with VISN Patient Safety Officers (PSOs) and VA facility patient safety and quality managers (PSMs and QMs) and VA Facility Community Care (CC) staff to assess lessons learned by examining organizational contextual factors affecting Guidebook implementation based on the Consolidated Framework for Implementation Research (CFIR). Data Collection/Extraction Methods: Interviews were conducted virtually with 45 facility staff and 10 VISN PSOs. Using directed content analysis, we identified CFIR factors affecting implementation. These factors were mapped to the Expert Recommendations for Implementing Change (ERIC) strategy compilation to identify lessons learned that could be useful to our operational partners in improving implementation processes. We met frequently with our partners to discuss findings and plan next steps. Principal Findings: Six CFIR constructs were identified as both facilitators and barriers to Guidebook implementation: (1) planning for implementation; (2) engaging key knowledge holders; (3) available resources; (4) networks and communications; (5) culture; and (6) external policies. The two CFIR constructs that were only barriers included: (1) cosmopolitanism and (2) executing implementation. Conclusions: Our findings suggest several important lessons: (1) engage all collaborators involved in implementation; (2) ensure end-users have opportunities to provide feedback; (3) describe collaborators' purpose and roles/responsibilities clearly at the start; (4) communicate information widely and repeatedly; and (5) identify how multiple high priorities can be synergistic. This evaluation will help our partners and key VA leadership to determine next steps and future strategies for improving Guidebook implementation through collaboration with VA staff. KEYWORDS community care, implementation science, patient safety, veterans, 1 | INTRODUCTION The Veterans Access, Choice and Accountability Act of 2014 ('Choice Act') and the subsequent Veterans Health Administration (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) [...]

1 | INTRODUCTION The Veterans Access, Choice and Accountability Act of 2014 ('Choice') was enacted in direct response to an 'access crisis' involving long waitlists and delays in care. (1)' [...], Objectives: To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act. Data Sources: Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery. Study Design: Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex). Data Collection: We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex). Principal Findings: Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC. Conclusions: As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions." KEYWORDS community health services, postoperative complications, quality of health care, safety, veterans

1I INTRODUCTION Policy makers and researchers increasingly rely on the Medicare Current Beneficiary Survey (MCBS), a nationally representative sample of Medicare beneficiaries, for exploring the potential benefit of policy changes [...], Objective: To develop a cardiovascular disease (CVD) risk score that can be used to quantify CVD risk in the Medicare Current Beneficiary Survey (MCBS). Data Sources: We used 1999-2013 MCBS data. Study Design: We used a backward stepwise approach and cox proportional hazards regressions to build and validate a new CVD risk score, similar to the Framingham Risk Score (FRS), using only information available in MCBS. To assess its performance, we calculated C statistics and examined calibration plots. Data Collection/Extraction Methods: We studied 21 968 community-dwelling Medicare beneficiaries aged 65 years or older without pre-existing CVD. We obtained risk factors from both survey and claims data. We used claims data to derive "CVD event within 3 years" following the FRS definition of CVD. Principal Findings: About five percent of MCBS participants developed a CVD event over a mean follow-up period of 348 days. Our final MCBS-based model added morbidity burden, reported general health status, and functional limitation to the traditional FRS predictors of CVD. This model had relatively fair discrimination (C statistic = 0.69; 95% confidence interval [CI], 0.67-0.71) and performed well on validation (C = 0.68; CI, 0.66-0.70). More importantly, the plot of observed CVD outcomes versus predicted ones showed that this model had a good calibration. Conclusions: Our new CVD risk score can be calculated using MCBS data, thereby extending the survey's ability to quantify CVD risk in the Medicare population and better inform both health policy and health services research. KEYWORDS cardiovascular diseases, health policy, health risk assessment, proportional hazards models, survey methods

The Veterans Access, Choice and Accountability Act ('Choice Act') was passed in August 2014 in direct response to an 'access crisis' involving long waitlists and delays in care (Shulkin 2017; [...], Objective. To assess differences in risk (measured by expected costs associated with sociodemographic and clinical profiles) between Veterans receiving outpatient services through two community care (CC) programs: the Fee program ('Fee') and the Veterans Choice Program ('Choice').Data Sources/Study Setting. Administrative data from VHA's Corporate Data Warehouse in fiscal years (FY) 2014-2015.Study Design. We compared the clinical characteristics of Veterans across three groups (Fee only, Choice only, and Fee & Choice). We classified Veterans into risk groups based on Nosos risk scores and examined the relationship between type of outpatient utilization and risk within each CC group. We also examined changes in utilization of VHA and CC in FY14-FY15. We used chi-square tests, t tests, and ANOVAs to identify significant differences between CC groups.Principal Findings. Of the 1,400,977 Veterans using CC in FY 15, 91.4 percent were Fee-only users, 4.4 percent Choice-only users, and 4.2 percent Fee & Choice users. Mean concurrent risk scores were higher for Fee only and Fee & Choice (1.9, SD = 2.7; 1.8, SD = 2.2) compared to Choice-only users (1.0, SD = 1.2) (p < .0001). Most CC users were 'dual users' of both VHA and CC in FY14-FY15.Conclusions. As care transitions from VHA to CC, VHA should consider how best to coordinate care with community providers to reduce duplication of efforts, improve handoffs, and achieve the best outcomes for Veterans.Key Words. Veterans, risk score, purchased care, Veterans Choice Program, traditional fee basis