# Understanding Low-Value Veteran Care with Natural Experiments

> **NIH VA IK2** · PHILADELPHIA VA MEDICAL CENTER · 2024 · —

## Abstract

Background: Low-value medical services are common and costly. Veterans often receive services that offer
little or no clinical benefit while generating costs and unnecessary risks. Gaps in research have hindered
effective policies to address low-value Veteran care. First, the causes of low-value service use are uncertain.
For example, through the VA Community Care program (VACC), Veterans are treated by non-VA clinicians
who face few incentives to avoid unnecessary tests and procedures. However, it is unclear whether VACC has
increased Veterans’ risk of receiving low-value services. Our research has shown an association between
greater use of VACC and increased rates of low-value care. Rigorous quasi-experimental research could
confirm whether this association is causal, guiding appropriate policy responses. Second, policies addressing
low-value care have been hindered by a lack of evidence on what constitutes low-value care and how to
translate evidence into effective clinical decision-making. To address these research gaps, first, I will test
whether VACC under Choice/MISSION has increased low-value care. Second, I will study strategies to
address low-value care via evidence development and evidence translation.
Significance/Impact: Addressing low-value health care use is of crucial importance to Veterans, aligning with
multiple dimensions of HSR&D priority domains including priority research areas (health care value, quality and
safety of health care), priority HSR methods (advancing HSR methods in areas that cut across conditions or
care settings), and priority policy/legislative areas (MISSION Act).
Innovation: This research applies innovative methods to novel research questions. The quantitative methods
have wide potential applications across VA HSR, though they have been rarely applied in this setting.
Specific Aims: This Career Development Award (CDA) would support the following research aims:
Aim 1 Quantify the effect of VACC under Choice/MISSION on Veterans’ low-value service use and spending.
Aim 2a Convene an expert panel to identify and prioritize “gray zone” services ideal for evidence development.
Aim 2b Conduct focus groups to identify barriers and facilitators to translating new evidence on service value
into high-value practices
Methodology: Aim 1: Using 33 measures of low-value services applied to national clinical data, we will test the
effect of outpatient VACC on low-value service use and spending. A regression discontinuity (RD) analysis will
examine a natural experiment that arose because VACC eligibility can differ for otherwise similar Veterans who
live slightly different distances from VA facilities. Machine learning covariate selection techniques will optimize
statistical power. Aim 2a: Via an expert consensus building process, clinicians, researchers and Veterans will
prioritize “gray zone” services, which have unclear value, for evidence development. Services will be prioritized
based on incidence among Veterans, exp...

## Key facts

- **NIH application ID:** 10749478
- **Project number:** 1IK2HX003634-01A2
- **Recipient organization:** PHILADELPHIA VA MEDICAL CENTER
- **Principal Investigator:** Aaron Lawrence Schwartz
- **Activity code:** IK2 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2023-10-01 → 2027-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10749478

## Citation

> US National Institutes of Health, RePORTER application 10749478, Understanding Low-Value Veteran Care with Natural Experiments (1IK2HX003634-01A2). Retrieved via AI Analytics 2026-05-28 from https://api.ai-analytics.org/grant/nih/10749478. Licensed CC0.

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