Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics

Pharmacy use by dual-eligible non-elderly veterans with private healthcare insurance

Background

Utilization of private sector healthcare services among dual enrolled veterans with private healthcare insurance plans (PHIP) has not been well-characterized. Concurrent use of Veterans Health Administration (VHA) and non-VHA pharmacies may increase risk for adverse outcomes. Thus, the objectives of this study were to determine the extent to which dual VHA-PHIP enrollees obtain medications through VHA and non-VHA pharmacies and to characterize medications obtained through non-VHA pharmacies.

Methods

This observational study used merged administrative data from VHA and a predominant regional PHIP to select veterans < 65 years of age, residing in two Midwestern US states, and simultaneously enrolled in both VHA and the PHIP during fiscal years (FY) 2001–2010. Primary outcome measures included counts of prescriptions dispensed from VHA and non-VHA pharmacies, and frequencies of medications dispensed by non-VHA pharmacies based on PHIP claims.

Results

Of 5783 veterans who filled ≥ 1 prescription in FY10, 2935 (50.8 %) used non-VHA pharmacies exclusively, 1165 (20.2 %) used VHA pharmacies exclusively and 1683 (29.1 %) were dual users. Health services utilization was higher for dual users compared to exclusive users of either VHA or non-VHA pharmacies across multiple measures, including total prescriptions, outpatient encounters, and inpatient admissions. The most common medications dispensed by non-VHA pharmacies, by proportion of veterans treated, were hydrocodone (20.9 %), amoxicillin (18.5 %), simvastatin (17.5 %), azithromycin (17.4 %), and lisinopril (15.1 %). Antidepressants comprised 3 of 10 most common medications dispensed by VHA, but none of the most common medications dispensed to exclusive non-VHA pharmacy users.

Conclusions

Our findings align with VHA-Medicare dual enrolled veterans where only a minority of veterans used VHA services exclusively. Younger veterans relied disproportionately on VHA for mental health medications.

Did Massachusetts Health Reform Affect Veterans Affairs Primary Care Use?

Massachusetts Health Reform (MHR), implemented in 2006, introduced new health insurance options that may have prompted some veterans already enrolled in the Veterans Affairs Healthcare System (VA) to reduce their reliance on VA health services. This study examined whether MHR was associated with changes in VA primary care (PC) use. Using VA administrative data, we identified 147,836 veterans residing in Massachusetts and neighboring New England (NE) states from October 2004 to September 2008. We applied difference-in-difference methods to compare pre–post changes in PC use among Massachusetts and other NE veterans. Among veterans not enrolled in Medicare, VA PC use was not significantly different following MHR for Massachusetts veterans relative to other NE veterans. Among VA–Medicare dual enrollees, MHR was associated with an increase of 24.5 PC visits per 1,000 veterans per quarter ( p = .048). Despite new non-VA health options through MHR, VA enrollees continued to rely on VA PC.

Insured Veterans' Use of VA and Non-VA Health Care in a Rural State

PURPOSE

To understand how working-age VA-enrolled veterans with commercial insurance use both VA and non-VA outpatient care, and how rural residence affects dual use, for common diagnoses and procedures.

METHODS

We analyzed VA and non-VA outpatient treatment records for any months during 2005-2010 that New Hampshire veterans ages <65 were simultaneously enrolled in VA health care and commercial insurance (per NH's mandatory claims database). Controlling for covariates, we used analysis of variance to compare urban and rural VA users, non-VA users, and dual users on travel burden, diagnosis counts, duration in outpatient care, and visit frequencies, and logistic regressions to assess whether rural veterans were as likely to be seen for common conditions and procedures.

FINDINGS

More than half of patients were non-VA users and another third were dual users; rural residents were slightly more likely than urban residents to be dual users. For nearly any common diagnosis or procedure, dual users were more likely to have it at some time during treatment than other patients in either VA or non-VA care, but they seldom had it listed in both care systems. Dual users also were seen most often overall, although within either care system they were seen less often than other patients, particularly if they were rural residents living far from care. Rural residence reduced chances of treatment for a wide variety of conditions, though it also was associated with more musculoskeletal and connective tissue diagnoses. It also reduced chances that patients had some diagnostic and treatment procedures but increased the odds of others that may require fewer visits.

CONCLUSIONS

Dual users living in rural areas may have less continuity in their health care. Ensuring that rural dual users are identified in primary care should improve access and care coordination.

Patient and Facility Variation in Costs of VA Heart Failure Patients

OBJECTIVES

This study sought to determine the variation in annual health care costs among patients with heart failure in the Veterans Affairs (VA) system.

BACKGROUND

Heart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs.

METHODS

We obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone, VA facility alone, and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences.

RESULTS

There were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD 49,180) with more than one-half of their costs from inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all p < 0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses, patient factors alone explained more of the variation in health care costs (R(2) = 0.116) compared with the facility where the patient was treated (R(2) = 0.018).

CONCLUSIONS

A large variation in costs of heart failure patients was observed across facilities, although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients.

Corticosteroid Use and Complications in a US Inflammatory Bowel Disease Cohort

Background and Aims

Corticosteroids are effective for the short-term treatment of inflammatory bowel disease (IBD). Long-term use, however, is associated with significant adverse effects. To define the: (1) frequency and duration of corticosteroid use, (2) frequency of escalation to corticosteroid-sparing therapy, (3) rate of complications related to corticosteroid use, (4) rate of appropriate bone density measurements (dual energy X-ray absorptiometry [DEXA] scans), and (5) factors associated with escalation and DEXA scans.

Methods

Retrospective review of Veterans Health Administration (VHA) data from 2002–2010.

Results

Of the 30,456 Veterans with IBD, 32% required at least one course of corticosteroids during the study time period, and 17% of the steroid users had a prolonged course. Among these patients, only 26.2% underwent escalation of therapy. Patients visiting a gastroenterology (GI) physician were significantly more likely to receive corticosteroid-sparing medications. Factors associated with corticosteroid-sparing medications included younger age (OR = 0.96 per year,95%CI:0.95, 0.97), male gender (OR = 2.00,95%CI:1.16,3.46), GI visit during the corticosteroid evaluation period (OR = 8.01,95%CI:5.85,10.95) and the use of continuous corticosteroids vs. intermittent corticosteroids (OR = 2.28,95%CI:1.33,3.90). Rates of complications per 1000 person-years after IBD diagnosis were higher among corticosteroid users (venous thromboembolism [VTE] 9.0%; fragility fracture 2.6%; Infections 54.3) than non-corticosteroid users (VTE 4.9%; fragility fracture 1.9%; Infections 26.9). DEXA scan utilization rates among corticosteroid users were only 7.8%.

Conclusions

Prolonged corticosteroid therapy for the treatment of IBD is common and is associated with significant harm to patients. Patients with prolonged use of corticosteroids for IBD should be referred to gastroenterology early and universal efforts to improve the delivery of high quality care should be undertaken.

Medicare-VHA dual use is associated with poorer chronic wound healing

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Veterans’ Pharmacy and Health Care Utilization Following Implementation of the Medicare Part D Pharmacy Benefit

We examined associations between enrollment in Medicare Part D pharmacy benefits and changes in medication acquisition from Department of Veterans Affairs (VA) pharmacies. We included all women and a random 10% sample of men who were VA enrollees, ≥65 years old as of January 1, 2004, and alive through December 2007. We used difference-in-differences models with propensity score weighting to examine changes in medication acquisition between 2005 (before Part D was implemented) and 2007 (after Part D implementation) for veterans who were or were not Part D enrolled. Of 231,716 veterans meeting inclusion criteria, 49,881 (21.5%) were enrolled. While 30-day medication supplies decreased from 26.2 to 23.4 for enrolled veterans, they increased from 36.6 to 37.4 for nonenrolled veterans (difference-in-differences: −4.0, p < .001). Reductions in 30-day supplies were greater among veterans who were required to pay VA copayments for some or all medications and who used VA and Medicare outpatient services.

Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

Dissemination of a Care Collaboration Project

A core project team was able to identify essential implementation components for a successful dual-care program aimed at improving communication and collaboration with non-VA health care providers.

Treating Dual-Use Patients Across Two Health Care Systems: A Qualitative Study

Improved communication and increased education may enhance the experience and outcomes for veterans using multiple health care systems, according to this qualitative assessment of health care provider views.

Mental Health Disorders and Treatment Seeking Among Veterans in Non-VA Facilities: Results and Implications from the Veterans' Health Study

We surveyed 700 veterans who were outpatients in a non-Veterans Affairs (VA) multihospital system. Our objective was to assess the prevalence of mental disorders and service use among these veterans. The majority were Vietnam veterans (72.0%), and male (95.9%), and 40.4% reported recently using the VA for care. The prevalence of lifetime post-traumatic stress disorder (PTSD) was 9.6%, lifetime depression 18.4%, and lifetime mental health service use 50.1%. In multivariate analyses, significant factors associated with PTSD, depression, and mental health service use were low self-esteem, use of alcohol/drugs to cope, history of childhood adversity, high combat exposure, and low psychological resilience. VA service use was associated with greater mental health service use and combat exposure. With the exception of alcohol misuse, the mental health status of veterans seen in non-VA facilities appeared to be better than reported in past studies. Because most veterans have access to both VA and non-VA services, these findings have implications for veterans and outcomes research.

Clinical and economic burden of community-acquired pneumonia in the Veterans Health Administration, 2011: a retrospective cohort study

Purpose

The burden of community-acquired pneumonia (CAP) is not well described in the US Veterans Health Administration (VHA).

Methods

CAP was defined as having a pneumonia diagnosis with evidence of chest X-ray, and no evidence of prior (90 days) hospitalization/long-term care. We calculated incidence rates of adult CAP occurring in inpatient or outpatient VHA settings in 2011. We also estimated the proportion of VHA CAP patients who were hospitalized, were readmitted within 30 days of hospital discharge, and died (any cause) in the year following diagnosis. Incremental costs during the 90 days following a CAP diagnosis were estimated from the perspective of the VHA.

Results

In 2011, 34,101 Veterans developed CAP (35,380 episodes) over 7,739,757 VHA person-years. Median age of CAP patients was 65 years (95 % male). CAP incidence rates were higher for those aged ≥50 years. A majority of Veterans aged 50–64 (53 %) and ≥65 (66 %) years had ≥1 chronic medical (moderate risk) or immunocompromising (high risk) condition. Compared to those at low-risk (healthy), moderate- and high-risk Veterans were >3 and >6 times more likely to develop CAP, respectively. The percentage of CAP patients who were hospitalized was 45 %, ranging from 12 % (age 18–49, low risk) to 57 % (age ≥65, high risk). One-year all-cause mortality rates ranged from 1 % (age 18–49, low risk) to 36 % (age ≥65, high risk). Annual VHA medical expenditure related to CAP was estimated to be $750 million (M) ($415M for those aged ≥65 years).

Conclusion

A focus on CAP prevention among older Veterans and those with comorbid or immunocompromising conditions is important.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-015-0789-3) contains supplementary material, which is available to authorized users.

The Continuity and Quality of Primary Care

Patients who have access to different health care systems, such as Medicare-eligible veterans, may obtain services in either or both health systems. We examined whether quality of diabetes care was associated with care continuity or veterans’ usual source of primary care in a retrospective cohort study of 1,867 Medicare-eligible veterans with diabetes in 2001 to 2004. Underprovision of quality of diabetes care was more common than overprovision. In adjusted analyses, veterans who relied only on Medicare fee-for-service (FFS) for primary care were more likely to be underprovided HbA1c testing than veterans who relied only on Veteran Affairs (VA) for primary care. Dual users of VA and Medicare FFS primary care were significantly more likely to be overprovided HbA1c and microalbumin testing than VA-only users. VA and Medicare providers may need to coordinate more effectively to ensure appropriate diabetes care to Medicare-eligible veterans, because VA reliance was a stronger predictor than care continuity.

Comparison of colorectal cancer screening in veterans based on the location of primary care clinic

OBJECTIVES

To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs).

METHODS

The VA Outpatient Care Files were used to identify 2 837 770 patients ≥ 50 years with ≥ 2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms.

RESULTS

CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years.

CONCLUSIONS

Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.

The relationship between local area labor market conditions and the use of Veterans Affairs health services

Background

In the U.S., economic conditions are intertwined with labor market decisions, access to health care, health care utilization and health outcomes. The Veterans Affairs (VA) health care system has served as a safety net provider by supplying free or reduced cost care to qualifying veterans. This study examines whether local area labor market conditions, measured using county-level unemployment rates, influence whether veterans obtain health care from the VA.

Methods

We used survey data from the Behavioral Risk Factor Surveillance System in years 2000, 2003 and 2004 to construct a random sample of 73,964 respondents self-identified as veterans. VA health service utilization was defined as whether veterans received all, some or no care from the VA. Hierarchical ordered logistic regression was used to address unobserved state and county random effects while adjusting for individual characteristics. Local area labor market conditions were defined as the average 12-month unemployment rate in veterans’ county of residence.

Results

The mean unemployment rate for veterans receiving all, some and no care was 5.56%, 5.37% and 5.24%, respectively. After covariate adjustment, a one percentage point increase in the unemployment rate in a veteran’s county of residence was associated with an increase in the probability of receiving all care (0.34%, p-value = 0.056) or some care (0.29%, p-value = 0.023) from the VA.

Conclusions

Our findings suggest that the important role of the VA in providing health care services to veterans is magnified in locations with high unemployment.

Budget impact analysis of HIV testing in the VA healthcare system

OBJECTIVES

The long-term cost effectiveness of routine HIV testing is favorable relative to other medical interventions. Facility-specific costs of expanded HIV testing and care for newly identified patients, however, are less well defined. To aid in resource allocation decisions, we developed a spreadsheet-based budget-impact tool populated with estimates of facility-specific HIV testing and care costs incurred with an expanded testing program.

METHODS

We modeled intervention effects on quarterly costs of antiretroviral therapy (ART), outpatient resource utilization, and staff expenditures in the Department of Veterans Affairs over a 2-year period of increasing HIV testing rates. We used HIV prevalence estimates, screening rates, counseling, positive tests, Veterans Affairs treatment, and published sources as inputs. We evaluated a single-facility cohort of 20,000 patients and at baseline assumed a serodiagnostic rate of 0.45%.

RESULTS

Expanding testing from 2% to 15% annually identified 21 additional HIV-positive patients over 2 years at a cost of approximately $290,000, more than 60% of which was due to providing ART to newly diagnosed patients. While quarterly testing costs decreased longitudinally as fewer persons required testing, quarterly ART costs increased from $10,000 to more than $60,000 over 2 years as more infected patients were identified and started on ART. In sensitivity analyses, serodiagnostic and annual HIV testing rates had the greatest cost impact.

CONCLUSIONS

Expanded HIV testing costs are greatest during initial implementation and predominantly due to ART for new patients. Cost determinations of expanded HIV testing provide an important tool for managers charged with allocating resources within integrated systems providing both HIV testing and care.

Service utilization of veterans dually eligible for VA and Medicare fee-for-service: 1999-2004

OBJECTIVE

To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services.

DATA SOURCES

VA and Medicare FFS enrollment and outpatient utilization databases in 1999 and 2004.

STUDY DESIGN

Multinomial logistic regression was used to examine odds of VA-only and Medicare-only utilization, relative to dual utilization, in 1999 and 2004. Observational cohort comprising a 5% random sample of dually-eligible Veterans: 73,721 in 1999 and 125,042 in 2004.

PRINCIPAL FINDINGS

From 1999 to 2004, persons with the highest HCC risk scores had decreasing odds of exclusive VA reliance (OR=0.26 in 1999 and 0.17 in 2004, p<0.05), but had increasing odds of exclusive Medicare reliance (OR=0.43 in 1999 and 0.56 in 2004, p<0.05).Persons in high VA priority groups had decreasing odds of exclusive VA reliance, as well as decreasing odds of exclusive Medicare reliance, indicating increasing odds of dual use. Newly eligible Veterans with the highest HCC risk scores had higher odds of dual system use, while newly eligible Black Veterans had lower odds of dual system use.

CONCLUSIONS

Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.

Reduced overall and event-free survival among colon cancer patients using dual system care

BACKGROUND

Many veterans have dual Veterans Administration (VA) and Medicare healthcare coverage. We compared 3-year overall and cancer event-free survival (EFS) among patients with nonmetastatic colon cancer who obtained substantial portions of their care in both systems and those whose care was obtained predominantly in the VA or in the Medicare fee-for-service system.

METHODS

We conducted a retrospective observational cohort study of patients older than 65 years with stages I to III colon cancer diagnosed from 1999 to 2001 in VA and non-VA facilities. Dual use of VA and non-VA colon cancer care was categorized as predominantly VA use, dual use, or predominantly non-VA use. Extended Cox regression models evaluated associations between survival and dual use.

RESULTS

VA and non-VA users (all stages) had reduced hazard of dying compared with dual users [e.g., for stage I, VA HR 0.40, 95% confidence interval (CI): 0.28-0.56; non-VA HR 0.54, 95% CI: 0.38-0.78). For EFS, stage I findings were similar (VA HR 0.47, 95% CI: 0.35-0.62; non-VA HR 0.64, 95% CI: 0.47-0.86). Stage II and III VA users, but not non-VA users, had improved EFS (stage II: VA HR 0.74, 95% CI: 0.56-0.97; non-VA HR 0.92, 95% CI: 0.69-1.22; stage III: VA HR 0.73, 95% CI: 0.56-0.94; non-VA HR 0.81, 95% CI: 0.62-1.06).

CONCLUSIONS

Improved survival among VA and non-VA compared with dual users raises questions about coordination of care and unmet needs.

IMPACT

Additional study is needed to understand why these differences exist, why patients use both systems, and how systems may be improved to yield better outcomes in this population.

Trends in rates and attributable costs of conditions among female VA patients, 2000 and 2008

RESEARCH OBJECTIVE

We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.

METHODS

Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.

RESULTS

The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.

CONCLUSION

Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.

Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients

Background

More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time.

Objectives

To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare.

Methods

A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations.

Results

Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics.

Conclusions

Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.

Tailoring VA primary care to women veterans: association with patient-rated quality and satisfaction

BACKGROUND

Primary care delivery models tailored to women's needs and preferences are associated with higher quality and satisfaction. Therefore, the U.S. Department of Veterans Affairs (VA) recommends adoption of designated providers for women in primary care clinics or women's health centers as the optimal models for women's primary care. We assessed women veterans' ratings of their VA health care quality, gender-related satisfaction, gender appropriateness, and VA provider skills in treating women, in relation to primary care model at VA sites nationwide.

METHODS

Health care ratings were obtained from VA users in the 2008-2009 National Survey of Women Veterans. VA administrative data identified the site for each respondent's primary care. Facility data identified the site's primary care model for women. We conducted multilevel modeling to compare health care ratings for sites serving 300 or more women veterans who had adopted VA recommendations for women's primary care models (adopter sites), with non-adopter sites, and with small sites serving fewer women veterans, adjusting for patient characteristics.

RESULTS

Adopter sites received higher adjusted ratings of gender-related satisfaction and perceptions of VA provider skills than non-adopter and small sites. Adopter sites also received higher adjusted ratings of gender appropriateness than small sites. Adjusted ratings of quality of care did not differ by type of site.

CONCLUSION

VA sites with primary care models tailored to women were rated higher on most dimensions of care. Facilitating establishment of these optimal care models at other sites is one strategy for improving women veterans' experiences with VA care. Research to identify other features of care associated with quality could inform ongoing VA quality transformation efforts.

Defining core issues in utilizing information technology to improve access: evaluation and research agenda

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

Recent trends in Veterans Affairs chronic condition spending

The change in prevalence and total Veterans Affairs (VA) spending were estimated for 16 chronic condition categories between 2000 and 2008. The drivers of changes in spending also were examined. Chronic conditions were identified through diagnoses in encounter records, and treatment costs per patient were estimated using VA cost data and regression models. The estimated differences in total VA spending between 2000 and 2008 and the contributions of population increase, differences in prevalence, and differences in treatment costs were evaluated. Most of the spending increases during the study period were driven by the increase in the VA patient population from 3.3 million in 2000 to 4.9 million in 2008. Spending on renal failure increased the most, by more than $1.5 billion, primarily because of higher prevalence. Higher treatment costs did not contribute much to higher spending; lower costs per patient for several conditions may have helped to slow spending for diabetes, chronic obstructive pulmonary disease, heart conditions, renal failure, dementia, and stroke. Lowering treatment costs per patient for common conditions can help slow spending for chronic conditions, but most of the increase in spending in the study period was the result of more patients seeking care from VA providers and the higher prevalence of conditions among patients. As the VA patient population continues to age and to develop more co-morbidities, and as returning veterans seek care for service-related problems, higher spending on chronic conditions will become a more prominent issue for the VA health care system.

Nurse staffing and patient care costs in acute inpatient nursing units

OBJECTIVE

Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration.

METHODS

Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day.

RESULTS

The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P<0.001), but not among surgical admissions. Total nursing HPPD and RN skill mix were associated with higher costs per hospital day for both medical admissions ($79.02 per additional HPPD and $5.64 per 1% point increase in nursing skill mix, both P<0.001) and surgical admissions ($112.47 per additional HPPD and $13.31 per 1% point increase in nursing skill mix, both P<0.001). Patients experiencing complications or transferring to an intensive care unit had higher inpatient costs than other patients.

CONCLUSIONS

The association of nurse staffing level with costs per admission differed for medical versus surgical admissions.

The impact of primary care dual-management on quality of care

BACKGROUND

Discontinuity is common in US healthcare. Patients access multiple systems of care and in the nation's largest integrated healthcare system, Veteran's Administration (VA) patients frequently use non-VA primary care providers. The impact of this "dual-management" on quality is unknown. The authors' objective was to identify dual-management and associations with markers of care quality for hypertension and associated conditions.

METHODS

Data was collected via surveys and chart reviews of primary care patients with hypertension from six VA clinics in Iowa and Minnesota. Clinical measures abstracted included the following: goal blood pressure (BP) and use of guideline-concordant therapy, low-density lipoprotein (LDL) cholesterol, hemoglobin A1C, and body mass index (BMI). Dual-management data was obtained through self-report.

RESULTS

Of 189 subjects (mean age = 66), 36% were dual-managed by non-VA providers. There was no difference in hypertension quality of care measures by dual-management status. A total of 51% were at BP goal and 58% were on guideline-concordant therapy. Dual-managed patients were more likely to use thiazide diuretics (43% vs 29%; P = .03) and angiotensin receptor blockers (13% vs 3%; P < .01), but less likely to use angiotensin-converting enzyme inhibitors (43% vs 61%; P = .02). There was no difference in LDL cholesterol (97.1 mg/dl vs 100.1 mg/dl; P = .55), hemoglobin A1C (7% vs 6%; P = .74), or BMI (29.8 vs 30.9; P = .40) for dual-managed versus VA managed patients, respectively.

CONCLUSIONS

Although dual-management may decrease continuity, VA/private sector dual-management did not impact quality of care, though some medication differences were observed. With the high prevalence of dual-management, future work should further address quality and evaluate redundancy of services.

Statins and prostate cancer diagnosis and grade in a veterans population

BACKGROUND

Although prostate cancer is commonly diagnosed, few risk factors for high-grade prostate cancer are known and few prevention strategies exist. Statins have been proposed as a possible treatment to prevent prostate cancer.

METHODS

Using electronic and administrative files from the Veterans Affairs New England Healthcare System, we identified 55,875 men taking either a statin or antihypertensive medication. We used age- and multivariable-adjusted Cox proportional hazard models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for prostate cancer incidence among patients taking statins (n = 41,078) compared with patients taking antihypertensive medications (n = 14,797). We performed similar analyses for all lipid parameters including total cholesterol examining each lipid parameter as a continuous variable and by quartiles. All statistical tests were two-sided.

RESULTS

Compared with men taking an antihypertensive medication, statin users were 31% less likely (HR = 0.69, 95% CI = 0.52 to 0.90) to be diagnosed with prostate cancer. Furthermore, statin users were 14% less likely (HR = 0.86, 95% CI = 0.62 to 1.20) to be diagnosed with low-grade prostate cancer and 60% less likely (HR = 0.40, 95% CI = 0.24 to 0.65) to be diagnosed with high-grade prostate cancer compared with antihypertensive medication users. Increased levels of total cholesterol were also associated with both total (HR = 1.02, 95% CI = 1.00 to 1.05) and high-grade (HR = 1.06, 95% CI = 1.02 to 1.10) prostate cancer incidence but not with low-grade prostate cancer incidence (HR = 1.01, 95% CI = 0.98 to 1.04).

CONCLUSIONS

Statin use is associated with statistically significantly reduced risk for total and high-grade prostate cancer, and increased levels of serum cholesterol are associated with higher risk for total and high-grade prostate cancer. These findings indicate that clinical trials of statins for prostate cancer prevention are warranted.