# Optimizing Access, Appropriateness, and Quality of Minimally Invasive Procedures for Veterans

> **NIH VA IK2** · VETERANS ADMIN PALO ALTO HEALTH CARE SYS · 2020 · —

## Abstract

The last five years have seen a paradigm shift in healthcare: new minimally invasive treatments are
now available that can effectively replace surgery for elderly, comorbid patients. The most striking example is
Transcatheter Aortic Valve Replacement (TAVR), the first major minimally invasive structural heart disease
treatment to be disseminated nationally. TAVR is a life-saving option for the approximately 87,000 Veterans
nationwide who suffer from severe aortic stenosis, and thereby face a 50% mortality rate within two years if
left untreated. Preliminary data suggest that the novel complexities associated with TAVR diffusion significantly
impact vulnerable patient populations. Based on prior data, one key mechanism for these disparities may be
that vulnerable patient populations are less equipped to make informed decisions about treatment.
 Driven by the hypothesis that vulnerable Veteran populations experience unequal treatment with
TAVR, but that decision support to routinely assess appropriateness and reduce barriers to care for Veterans
can reduce these differences, the aims of this proposal are to: (1) Identify patient level factors that
influence cardiovascular procedural treatment on the spectrum from minimally invasive (newer: TAVR and
older: PCI) to invasive (older: CABG, SAVR) within the VA, categorizing high and low access groups, with non-
VA data comparison. Multivariate, hierarchical logistic regression will be used to determine the association of
patient level factors, including demographic and VA-specific contextual factors (e.g., percent service
connection, proximity to VA procedure site, use of Veterans Choice or Medicare) with procedural use,
identifying “low” and “high” access profile groups. I hypothesize that older, established cardiovascular
procedures will show fewer inequities in care compared to the newest paradigm of care, TAVR. (2) Identify
decisional needs and barriers to achieving appropriate TAVR treatment from the perspectives of Veterans
(stratified into low and high access groups as defined by Aim 1) and their healthcare providers. I will use an
explanatory mixed methods design to conduct semi-structured interviews with a stratified sample of low and
high access profile Veterans referred for TAVR from multiple states and their providers to inform development
of a pilot intervention in Aim 3. I hypothesize that poor understanding of individualized risks and benefits are a
major limitation to appropriate TAVR referrals, with geographic barriers and difficulty using Veterans Choice
options particularly identified among low access profile Veterans. (3) Build and pilot a novel individualized
decision-making tool and patient facing website to improve both appropriateness and access to care, along
with a strategy for implementation into routine VA care. Using TAVR as a model, I will develop and validate
the feasibility of a prototype physician-facing decision aid for incorporation into routine VA care that predicts
i...

## Key facts

- **NIH application ID:** 9933953
- **Project number:** 5IK2HX002236-02
- **Recipient organization:** VETERANS ADMIN PALO ALTO HEALTH CARE SYS
- **Principal Investigator:** Celina M Yong
- **Activity code:** IK2 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2019-02-01 → 2024-01-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9933953

## Citation

> US National Institutes of Health, RePORTER application 9933953, Optimizing Access, Appropriateness, and Quality of Minimally Invasive Procedures for Veterans (5IK2HX002236-02). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9933953. Licensed CC0.

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