The results suggest that access to health care can be improved through structural/organizational interventions. All of the articles reported an association between the intervention and at least one measure of access (either perceived or objective). The evidence was strongest for the implementation of PCMH, which consistently resulted in shorter wait times for both primary care and mental health appointments.14,15,17–19
A finding of particular interest in the PCMH literature was that integration at varying levels (e.g., colocation versus walk in access 1 day per week) resulted in improved access, suggesting that a range of models may yield positive effects.14
The opening of CBOCs and the use telemedicine each had four studies showing that they resulted in improved access for veterans. As would be expected, the opening of CBOCs led to decreased travel time/distance for veterans in CBOC catchment areas.9–11
Researchers examining the use of telemedicine were primarily interested in veterans’ perceived access; they consistently found that veterans reported that specialists were easier to access using telemedicine than traditional in-person meetings.
It is important to note that for many access interventions, it would be impossible for the target access outcome not be impacted. For example, building a VA clinic in a rural area will always decrease the travel distance to the nearest VA clinic for those in that rural community. We required that studies report on the impact of the intervention on either perceived or objective access because we thought that while an access intervention may have a positive impact on the target access outcome, it could negatively impact other aspects of access. For example, while using telemedicine may have a positive impact on geographic access barriers, it could create digital (e.g., connectivity or usability) or cultural (e.g., perceived lack of understanding) barriers. However, few studies included in the review reported on more than the target access outcome. We suggest that future studies include measures on a variety of perceived and objective measures of access. This will provide a more thorough understanding of access barriers and will help researchers identify new barriers that may arise as access interventions are implemented.
All of the 16 unique studies reported process outcomes. The most frequently reported process outcomes were satisfaction with care and utilization. The implementation of CBOCs led to increases in the initiation of care and primary care visits.9–11
PCMH integration also led to an increase in primary care visits and increases in preventative care.16–19
Across the interventions, findings regarding the use of specialty care and hospitalization were mixed.9–11,16,18,19,25
Across interventions, increases in access were associated with satisfaction with care.12,16
The telemedicine studies consistently found that veterans are as satisfied with their care and communication with providers when appointments are delivered via telemedicine as when they are delivered in person.20–22
These findings are important given the accumulating data showing that in-person and telemedicine interventions yield equivalent outcomes for high-priority conditions, such as posttraumatic stress disorder.28
Finally, only 4 of the 16 unique studies reported clinical outcomes.16–19,25
Three found no difference between intervention and control conditions. The RCT by Druss and colleagues was the only study to show that improvements in access led to improvements in clinical outcomes, specifically greater improvements in physical component scores on the SF-36.16
Veterans had a nearly five point increase on their physical component score in the year following integration, while those in the usual care condition had a 0.3 point decrease over the same time period.16
Research on clinical outcomes must be a priority in the future. Such work will be challenging because there are a number of variables that might impact both access and outcomes (e.g., comorbidities). Rigorous, highly controlled research, such as that conducted by Druss et al., will be needed to clarify whether increased access results in improved health for veterans.
In addition to measuring clinical outcomes, we recommend that future research examine process outcomes beyond service utilization. The data regarding utilization are difficult to interpret as it is unclear whether increased utilization led to improved patient outcomes. In one study that did link access and outcomes, increased access to primary care resulted in increased rates and length of hospitalization.25
While the increase in hospitalization was not necessarily a negative outcome, the study highlights the complicated association between utilization and patient health. Thus, we recommend a decreased focus on utilization as an outcome and suggest that if utilization is included as an outcome, it is either specific to the type of care received (e.g., receipt of evidence-based care) or linked to clinical outcomes.
There were important limitations to this study. First, the studies included in this review were primarily of poor to fair methodological quality. Further, we identified a number of well-designed studies that examined access interventions, but they were not included in our review because they did not include data regarding either actual or perceived access outcomes.29–40
Therefore, there are studies that report on the impact of access interventions on downstream outcomes that are not included in this review. As discussed above, we suggest that future research examining access interventions collect and compare a broad range of perceived and actual access outcomes across groups. In conclusion, interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization and satisfaction with care; however, there was a lack of data regarding the link between access and clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.