ORIGINAL RESEARCH
Jonathan Staloff, MD, MSc; Eric Gunnink, MS; Jorge Rojas Jr., MS; Edwin S. Wong, PhD; Jacqueline M. Ferguson, PhD; Donna M. Zulman, MD, MS; Karin Nelson, MD, MSHS; Ashok Reddy, MD, MSc
Corresponding Author: Jonathan Staloff, MD, MSc; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System; Department of Family Medicine, University of Washington.
Email: jon.staloff@gmail.com
DOI: 10.3122/jabfm.2025.250282R1
Keywords: Latent Class Analysis, Logistic Regression, Primary Health Care, Retrospective Studies, Telemedicine, Veterans Health
Dates: Submitted: 07-24-2025; Revised: 12-15-2025; Accepted: 01-02-2026
Status: In Press.
INTRODUCTION: Veterans receive primary care through in-person, video, and telephone visits, but little is known about how the number and mix of visit modalities affect care quality. This study assessed differences in quality based on Veterans’ primary care visit volume and modality mix.
METHODS: We conducted a retrospective cohort analysis using multivariable logistic regression. The cohort included all Veterans Health Administration (VHA) patients empaneled to primary care in Fiscal Years 2022–2023. Visit exposure was categorized as: “Few Visits, Telephone Only,” “Intermediate Visits, All Modalities,” and “Many Visits, All Modalities” based on a previously published latent class analysis. Outcomes included influenza vaccination, hypertension control, statin therapy and adherence, tobacco use screening and cessation counseling, alcohol misuse screening, and depression screening.
RESULTS: Among 6,430,423 Veterans, those with “Many Visits, All Modalities” had higher adjusted odds of meeting most quality metrics compared to those with “Few Visits, Telephone Only”: influenza vaccination (aOR 1.76 for ages 19–65; aOR 1.88 for 66+), hypertension control (aOR 1.12), statin therapy (aOR 1.44) and adherence (aOR 1.20), tobacco use screening (aOR 1.28) and cessation counseling (aOR 2.26), and alcohol misuse screening (aOR 1.13), all p<0.05.
CONCLUSIONS: Veterans with higher primary care use across all modalities receive better quality care on most metrics than those with fewer telephone-only visits. Nonetheless, for some services, quality differences were modest, supporting the feasibility of high-quality care via telephone. Health systems should take a selective approach in identifying primary care services that are amenable to telephone or video care.