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Kehle SM, Greer N, Rutks I, et al. Interventions to Improve Veterans' Access to Care: A Systematic Review of the Literature [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011 Jan.

Cover of Interventions to Improve Veterans' Access to Care

Interventions to Improve Veterans' Access to Care: A Systematic Review of the Literature [Internet].

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This topic was nominated by the Planning Committee for the 2010 VA Health Services Research & Development State of the Art (SOTA) Conference on “Improving Access to VA Care” in consultation with the VA HSR&D Evidence Synthesis Program. John Fortney, PhD, Maurilio Garcia-Maldonado, MD, and Bonnie Wakefield, PhD, RN, agreed to serve on the Technical Expert Panel (TEP) for the project. The TEP members and the investigators from the Minneapolis VA Evidence-based Synthesis Program (ESP) collaborated to identify and refine the key questions.


We searched MEDLINE (OVID), CINAHL, and PsycINFO for studies published from 1990 to June, 2010. To focus the search on Veterans, we used the following MEDLINE search terms: Health Services Accessibility, access, Veterans, United States Department of Veteran Affairs, and Hospitals, Veterans (see Appendix A). Similar search terms were used in the CINAHL and PsycINFO searches. We limited the searches to articles involving human subjects ages 18 and older published in English language. All publication types were included. Additional references were identified by searching the reference lists of articles identified for inclusion.


Titles and abstracts identified from the search were reviewed by the investigators to identify eligible articles likely related to one or more of the key questions. Exclusion criteria were as follows:

  1. Not English language
  2. Not United States veteran population
  3. Not published from 1990 to present
  4. Not about access to health care
  5. Not about outcomes of interest
  6. Not peer-reviewed (including meeting abstracts and presentations).


For Key Question 1, investigators abstracted data on study design, patient characteristics, dependent and explanatory variables included in analyses, impact of access on system-level and patient-levels outcomes, and interaction terms. For Key Question 2, investigators abstracted data on study design, patient characteristics, intervention, and impact of the intervention on access, system-level, and patient-level outcomes.


Randomized control trials (RCTs) and cohort studies were assigned a rating of good, fair, or poor using the United States Preventive Services Task Force criteria.8 Observational studies were rated in the domains of participant selection (e.g., appropriate recruitment of subjects/ choice of database, response rate, representativeness), outcomes assessment (e.g., valid and reliable measures, no differential or overall high loss to follow-up), and analysis (e.g., potential confounders equally distributed or adjusted for in analysis). If all three of the three criteria were rated as adequate, the study received an overall rating of fair. All other observational studies were rated as poor. For Key Question 2, all intervention types also received a strength of evidence rating (in regards to impact on access, not system- and patient-level outcomes). Interventions for which 80% or greater of the studies received a fair or good quality rating were rated as fair. All other interventions were rating as poor strength of evidence; interventions with two or fewer studies were also rated as poor.


We constructed evidence tables showing the study characteristics and results for all included studies, organized by key question and, for Key Question 2, by intervention. We compiled a summary of findings for each key question and developed conclusions based on qualitative synthesis of the findings. We did not conduct pooled analyses due to marked heterogeneity in study design, patient characteristics, and outcomes assessed.


A draft report was reviewed by our TEP members, by participants at the 2010 “Improving Access to VA Care” State of the Art (SOTA) Conference, and by invited peer-reviewers. Reviewer comments and author responses are summarized in Appendix B.


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