EVALUATION OF THE VAS PILOT PROGRAM IN INSTITUTIONAL REORGANIZATION TOWARD PRIMARY AND AMBULATORY CARE .1. CHANGES IN-PROCESS AND OUTCOMES OF CARE

Purpose. To evaluate the impact of the reorganization of an academic V eterans Affairs medical center toward primary and ambulatory care-incl uding the implementation of a medical-center-wide interdisciplinary fi rm system and ambulatory care training program-on the quality of prima ry ambulatory care. Method. Randomly selected male veterans visiting t he Veterans Affairs Medical Center in Sepulveda, California, were surv eyed in 1992, early in the implementation of the program, and in 1993, after the program had been fully implemented. Two surveys were used: one before the veterans saw their primary care providers (practice-bas ed survey) and the other immediately after patient visits (visit-based survey). Survey-participant data were then linked to computerized uti lization and mortality data. Survey topics were mapped to the medical center's strategic plan and goals for ambulatory care, and focused on patients' reports about the care they had received in terms of continu ity, access, preventive care, and other aspects of the biopsychosocial model of care. Administrative computer data were then used to evaluat e effects on medical center workload. Statistical analyses included an alysis of variance, analysis of covariance, chi-square, and logistic r egression. Results. For practice based comparisons, complete data were available for 1,262 veterans in 1992 and 1,373 in 1993. For visit-bas ed comparisons, complete data were available for 1,407 veterans in 199 2 and 643 in 1993. Results included statistically significant improvem ents in continuity of care and detection of depression as well as incr eased rates of preventive care counseling (smoking and exercise). The proportion of veterans reporting being seen by physicians increased, a s did the proportion of patients seen for check-ups rather than for ac ute problems. Fewer patients were seen in subspecialty clinics than in general medicine clinics. Patient satisfaction increased, hospitaliza tions decreased, and death rates decreased. Alcohol counseling and acc ess to care for acute symptoms declined. Workload shifted from subspec ialists to generalists and from inpatient care to outpatient care. Con clusion. The institutional reorganization toward primary and ambulator y care succeeded in substantially improving the quality of ambulatory care, reflecting improvements in the system of care and of health care provider training in ambulatory care.