{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T15:18:16Z","timestamp":1790349496453,"version":"4.1.0"},"reference-count":34,"publisher":"American Medical Association (AMA)","issue":"8","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA"],"published-print":{"date-parts":[[2025,8,26]]},"abstract":"\n Importance<\/jats:title>\n The Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for veterans to obtain care outside the VA. However, the impact on health care outcomes is uncertain.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To measure the MISSION Act\u2019s impact on travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR).<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This retrospective difference-in-differences cohort study included veterans receiving nonemergent\/nonurgent PCI, CABG, or AVR between October 2016 and September 2022 in non-VA hospitals under MISSION Act coverage or in VA hospitals in the 48 contiguous US states or the District of Columbia. Analyses were conducted in 2023-2024.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Veterans eligible for non-VA care under the MISSION Act by living far from ( &amp;gt;60 minutes) the nearest VA medical center vs veterans living near (\u226460 minutes) a VA medical center.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Major adverse cardiovascular events (MACE), defined as rehospitalization for cardiovascular cause or mortality within 30 days of the procedure, and travel times for care were the primary outcomes.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The cohort comprised veterans receiving PCI (n\u2009=\u200943\u202f000; 42\u202f066 [98%] male; mean [SD] age, 69 [8.8] years), CABG (n\u2009=\u200923\u202f301; 22\u202f197 [98%] male; mean [SD] age, 69 [7.7] years), or AVR (n\u2009=\u200914\u202f682; 14\u202f336 [98%] male; mean [SD] age, 74 [9.6] years). After MISSION implementation, mean PCI travel times increased by 1.3 minutes for near patients and decreased by 29.2 minutes for far patients (difference in differences, \u221230.5 minutes;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). Mean CABG travel times increased by 9.4 minutes for near patients and decreased by 18.1 minutes for far patients (difference in differences, \u221227.4 minutes;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). Mean travel times for AVR increased by 10.0 minutes for near patients and decreased by 23.0 minutes for far patients (difference in differences, \u221233.1 minutes;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). After MISSION implementation, mean PCI MACE rates decreased by 0.5 percentage points for near patients and increased by 2.3 percentage points for far patients (difference in differences, 2.8 percentage points;\n P<\/jats:italic>\n \u2009&amp;lt;.001). Mean CABG MACE rates decreased by 6.5 percentage points for near patients and increased by 1.6 percentage points for far patients (difference in differences, 8.1 percentage points;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). AVR MACE rates were not statistically different between the groups (\n P<\/jats:italic>\n \u2009=\u2009.45).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n MISSION Act implementation was associated with substantial decreases in travel times among veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act implementation was also associated with worsened 30-day MACE rates.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jama.2025.11661","type":"journal-article","created":{"date-parts":[[2025,7,31]],"date-time":"2025-07-31T15:30:49Z","timestamp":1753975849000},"page":"702","source":"Crossref","is-referenced-by-count":8,"title":["Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans"],"prefix":"10.1001","volume":"334","author":[{"given":"Jingyi","family":"Wu","sequence":"first","affiliation":[{"name":"Center for Healthcare Evaluation, Research, and Promotion\/Corporal Michael J. 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Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Todd H.","family":"Wagner","sequence":"additional","affiliation":[{"name":"Veterans Affairs Palo Alto Health Care System, Palo Alto, California"},{"name":"Stanford University, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danny","family":"Chu","sequence":"additional","affiliation":[{"name":"Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania"},{"name":"Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John P.","family":"Cashy","sequence":"additional","affiliation":[{"name":"Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason M.","family":"Prigge","sequence":"additional","affiliation":[{"name":"Center for Healthcare Evaluation, Research, and Promotion\/Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas J.","family":"Glorioso","sequence":"additional","affiliation":[{"name":"Clinical Assessment, Reporting, and Tracking Program, VHA Office of Quality and Patient Safety, Washington DC"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natalia","family":"Rahman","sequence":"additional","affiliation":[{"name":"Denver Research Institute, Denver, Colorado"},{"name":"Rocky Mountain Regional VA Medical Center, Aurora, Colorado"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nandini","family":"Murali","sequence":"additional","affiliation":[{"name":"Denver Research Institute, Denver, Colorado"},{"name":"Rocky Mountain Regional VA Medical Center, Aurora, Colorado"},{"name":"Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jay","family":"Giri","sequence":"additional","affiliation":[{"name":"Center for Healthcare Evaluation, Research, and Promotion\/Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania"},{"name":"Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashwin S.","family":"Nathan","sequence":"additional","affiliation":[{"name":"Center for Healthcare Evaluation, Research, and Promotion\/Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania"},{"name":"Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen W.","family":"Waldo","sequence":"additional","affiliation":[{"name":"Clinical Assessment, Reporting, and Tracking Program, VHA Office of Quality and Patient Safety, Washington DC"},{"name":"Rocky Mountain Regional VA Medical Center, Aurora, Colorado"},{"name":"Section of Cardiology, University of Colorado School of Medicine, Aurora"},{"name":"Cardiology Section, Medicine Service, Rocky Mountain Regional VA Medical Center, Aurora, Colorado"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter W.","family":"Groeneveld","sequence":"additional","affiliation":[{"name":"Center for Healthcare Evaluation, Research, and Promotion\/Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania"},{"name":"Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"5","key":"joi250048r1","doi-asserted-by":"publisher","first-page":"1567","DOI":"10.1007\/s11606-019-05404-w","article-title":"Completing the MISSION: a blueprint for helping veterans make the most of new choices.","volume":"35","author":"Kullgren","year":"2020","journal-title":"J Gen Intern Med"},{"issue":"10","key":"joi250048r5","doi-asserted-by":"publisher","first-page":"1714","DOI":"10.1007\/s11606-018-4574-8","article-title":"Accessing care through the Veterans Choice Program: the veteran experience.","volume":"33","author":"Sayre","year":"2018","journal-title":"J Gen Intern 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