Importance of health system context for evaluating utilization patterns across systems

Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era

OBJECTIVE

To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation.

DATA SOURCES AND STUDY SETTING

VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets.

STUDY DESIGN

Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation.

DATA COLLECTION/EXTRACTION METHODS

Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021.

PRINCIPAL FINDINGS

Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively.

CONCLUSIONS

MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.

Growth of Community Outpatient Care in the Veterans Affairs System After the MISSION Act

BACKGROUND

The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 authorized a major expansion of purchased care in the community for Veterans experiencing access barriers in the Veterans Affairs (VA) health care system.

OBJECTIVE

To estimate changes in primary care, mental health, and emergency/urgent care visits in the VA and community fiscal years (FY) 2018-2021 and differences between rural and urban clinics.

DESIGN

A national, longitudinal study of VA clinics and outpatient utilization. Clinic-level analysis was conducted to estimate changes in number and proportion of clinic visits provided in the community associated with the MISSION Act adjusting for clinic characteristics and underlying time trends.

PARTICIPANTS

In total, 1050 VA clinics and 6.6 million Veterans assigned to primary care.

MAIN MEASURES

Number of primary care, mental health, and emergency/urgent care visits provided in the VA and community and the proportion provided in the community.

KEY RESULTS

Nationally, community primary care visits increased by 107% (50,611 to 104,923), community mental health visits increased by 167% (100,701 to 268,976), and community emergency/urgent care visits increased by 129% (142,262 to 325,407) from the first quarter of 2018 to last quarter of 2021. In adjusted analysis, after MISSION Act implementation, there was an increase in community visits as a proportion of total clinic visits for emergency/urgent care and mental health but not primary care. Rural clinics had larger increases in the proportion of community visits for primary care and emergency/urgent care than urban clinics.

CONCLUSIONS

After the MISSION Act, more outpatient care shifted to the community for emergency/urgent care and mental health care but not primary care. Community care utilization increased more in rural compared to urban clinics for primary care and emergency/urgent care. These findings highlight the challenges and importance of maintaining provider networks in rural areas to ensure access to care.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time

BACKGROUND

Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care.

OBJECTIVE

To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status.

DESIGN

Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering.

APPOINTMENTS

13,720 CCN and 40,638 comparison appointments.

MAIN MEASURES

Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment.

KEY RESULTS

Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively.

CONCLUSIONS

After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals

BACKGROUND

Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage.

METHODS

We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit. Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics.

RESULTS

A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit.

CONCLUSIONS

Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.

Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization

OBJECTIVE

To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.

DATA SOURCES

Veterans Affairs (VA) and Medicare data.

STUDY DESIGN

We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental health care utilization.

DATA EXTRACTION METHODS

We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year.

PRINCIPAL FINDINGS

The mean (SD) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).

CONCLUSIONS

Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers, and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization

U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice

BACKGROUND

The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers.

OBJECTIVES

The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider.

RESEARCH DESIGN

This was a retrospective, observational over fiscal years (FY) 2015-2018.

SUBJECTS

Veterans receiving primary care services paid for by the VA.

MEASURES

Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year.

RESULTS

There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care.

CONCLUSION

As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care

OBJECTIVE

To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients.

DATA SOURCES

Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012.

STUDY DESIGN

We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment.

PRINCIPAL FINDINGS

Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant.

CONCLUSIONS

Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.

Predicting Primary Care Use Among Patients in a Large Integrated Health System: The Role of Patient Experience Measures

OBJECTIVE

Most Veterans Affairs (VA) Health Care System enrollees age 65+ also have the option of obtaining care through Medicare. Reliance upon VA varies widely and there is a need to optimize its prediction in an era of expanding choice for veterans to obtain care within or outside of VA. We examined whether survey-based patient-reported experiences improved prediction of VA reliance.

METHODS

VA and Medicare claims in 2013 were linked to construct VA reliance (proportion of all face-to-face primary care visits), which was dichotomized (=1 if reliance >50%). We predicted reliance in 83,143 Medicare-eligible veterans as a function of 61 baseline characteristics in 2012 from claims and the 2012 Survey of Healthcare Experiences of Patients. We estimated predictive performance using the cross-validated area under the receiver operating characteristic (AUROC) curve, and assessed variable importance using the Shapley value decomposition.

RESULTS

In 2012, 68.9% were mostly VA reliant. The AUROC for the model including claims-based predictors was 0.882. Adding patient experience variables increased AUROC to 0.890. The pseudo R for the full model was 0.400. Baseline reliance and patient experiences accounted for 72.0% and 11.1% of the explained variation in reliance. Patient experiences related to the accessibility of outpatient services were among the most influential predictors of reliance.

CONCLUSION

The addition of patient experience variables slightly increased predictive performance. Understanding the relative importance of patient experience factors is critical for informing what VA reform efforts should be prioritized following the passage of the 2018 MISSION Act.

Healthcare Utilization and Costs for Patients With Parkinson's Disease After Deep Brain Stimulation

Objective

To compare the complications, healthcare utilization and costs following DBS or medical management for patients with Parkinson's disease (PD).

Methods

We examined healthcare utilization and costs for up to 5 years between veterans with DBS and those with medical management for PD. Veterans who received DBS between 2007 and 2013 were matched with veterans who received medical management using propensity score approaches. Healthcare utilization and costs were obtained from national VA and Medicare data sources and compared using procedures to adjust for potential differences in length of follow-up.

Results

We identified 611 veterans who had received DBS and a matched group of 611 veterans who did not undergo DBS. Among DBS patients, 59% had the electrodes and generator implanted during separate admissions. After 5 years of follow-up, average total healthcare costs, including DBS procedures and complications, were $77,131 (95% confidence interval: $66,095-$88,168; P < 0.001) higher per person for patients who received DBS ($162,489) than patients who received medical management ($85,358). In contrast, excluding the costs of the DBS procedures and complications, average total costs were not significantly different between patients who received DBS and patients who received medical management after 5 years of follow-up.

Conclusions

Healthcare costs over 5 years were higher for veterans who received DBS. These higher healthcare costs may reflect the costs of DBS procedures and any follow-up required plus greater surveillance by healthcare professionals following DBS as well as unobserved differences in the patients who received medical management or DBS.

Statin use among Veterans with dialysis-dependent chronic kidney disease

INTRODUCTION

The benefits of statin medications in patients receiving maintenance dialysis remains controversial and clinical trials overall have shown no benefit. Potential side effects of statin medications include myalgias, myopathy, and memory loss and risk of side effects associated with statin medications increase with higher statin doses. We examined statin use and statin dose among Veterans with dialysis dependent CKD. Such information may help clinicians modulate medication use and reduce pill burden in appropriate patients.

METHODS

This cross-sectional analysis ascertained medication utilization by linking records from the U.S. Department of Veteran's Affairs (VA) Managerial Cost Accounting Pharmacy National Data Extracts and Medicare Part D during calendar year 2013 for Veterans with dialysis-dependent CKD enrolled in and/or using VA healthcare. The venue of dialysis and patient characteristics were ascertained by linking VA Medical SAS datasets, VA Fee Basis datasets (for non-VA care paid for by VA), Medicare claims and the United States Renal Data Systems patient core files.

FINDINGS

We identified 18,494 Veterans with dialysis-dependent CKD who were enrolled in and/or used VA healthcare, had no history of kidney transplantation, and were alive on January 1, 2014. More than half (58.1%) of Veterans with dialysis-dependent CKD used statins and 35.7% of statin utilization was high dose. Statins were the third most commonly prescribed medication after beta blockers (64.8%) and phosphate binders (64.5%).

DISCUSSION

Statins are a commonly prescribed medication among Veterans receiving maintenance dialysis and approximately one-third of statin utilization is high dose in this population. Future studies should examine patient preferences, comorbidities, and dialysis characteristics that impact the risks and benefits of statin use in order to identify those patients who will or will not benefit from continued statin use.

Veterans' Reliance on VA Care by Type of Service and Distance to VA for Nonelderly VA-Medicaid Dual Enrollees

BACKGROUND

Not much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.

OBJECTIVES

To estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.

RESEARCH DESIGN

Retrospective, longitudinal analysis of Medicaid claims data and VA administrative data to compare patients' utilization of VA and Medicaid services 12 months before and for up to 12 months after Medicaid enrollment began.

SUBJECTS

Nonelderly veterans (below 65 y) receiving VA care and newly enrolled in Medicaid, calendar years 2006-2010 (N=19,890).

MEASURES

VA reliance (proportion of care received in VA) for major categories of outpatient and inpatient care.

RESULTS

Patients used VA outpatient care at similar levels after enrolling in Medicaid with the exceptions of emergency department (ED) and obstetrics/gynecology care, which decreased. VA inpatient utilization was similar after Medicaid enrollment for most types of care. VA-adjusted outpatient reliance was highest for mental health care (0.99) and lowest for ED care (0.02). VA-adjusted inpatient reliance was highest for respiratory (0.80) and cancer stays (0.80) and lowest for musculoskeletal stays (0.20). Associations between VA reliance and distance to VA providers varied by type of care.

CONCLUSIONS

Veterans dually enrolled in Medicaid received most of their outpatient care from the VA except ED, obstetrics/gynecology, and dental care. Patients received most of their inpatient care from Medicaid except mental health, respiratory, and cancer care. Sensitivity to travel distance to VA providers explained some of these differences.

Reliance on Medicare Providers by Veterans after Becoming Age-Eligible for Medicare is Associated with the Use of More Outpatient Services

OBJECTIVE

To estimate the effect of Medicare use on the receipt of outpatient services from 2001 through 2015 for a cohort of Veterans Administration (VA) users who became age-eligible for Medicare in 1998-2000.

DATA SOURCES/STUDY SETTING

VA administrative data linked with Medicare claims for veterans who participated in the 1999 Large Health Survey of Enrolled Veterans.

STUDY DESIGN

We coded each veteran as VA-reliant or Medicare-reliant based on the number of visits in each system and compared the health and social risk factors between VA-reliant and Medicare-reliant veterans. We used bivariate probit and instrumental variables models to estimate the association between a veteran's reliance on Medicare and the receipt of outpatient procedures in Medicare and the VA.

PRINCIPAL FINDINGS

Veterans who chose to rely on the VA (n = 4,317) had substantially worse social and health risk factors than Medicare-reliant veterans (n = 2,567). Medicare reliance was associated with greater use of outpatient services for 24 of the 28 types of services considered. Instrumental variable estimates found significant effects of Medicare reliance on receipt of advanced imaging and cardiovascular testing.

CONCLUSIONS

Expanded access to fee-for-service care in the community may be expensive, while the VA will likely continue to care for the most vulnerable veterans.

Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003-2014

OBJECTIVE

To examine the long-term reliance on outpatient care at the population (i.e., system) level among fee-for-service Medicare-enrolled elderly veterans in the Department of Veterans Affairs (VA) health care system and Medicare from 2003 to 2014.

DATA SOURCES/STUDY SETTING

We analyzed a 5 percent random sample, stratified by facility, age, gender, and race, of Medicare-enrolled veterans enrolled in a VA primary care panel using VA administrative data and Medicare claims.

STUDY DESIGN

We performed a repeated cross-sectional analysis over 48 quarters. VA reliance was defined at the system level as the proportion of total visits (VA + Medicare) that occurred in VA. We examined four visit types and seven high-volume medical subspecialties. We applied direct standardization adjusting for age, gender, and race using the 2010 population distribution of Medicare-enrolled veterans.

PRINCIPAL FINDINGS

Over the 12-year period, VA provided the vast majority of mental health care. Conversely, veterans received slightly more than half of their primary care and most of their specialty care, surgical care, and seven high-volume medical subspecialties through Medicare. However, reliance on VA outpatient care steadily increased over time for all categories of care.

CONCLUSIONS

Despite the controversies about VA access to care, Medicare-enrolled veterans, who have a choice of using VA or Medicare providers, appear to increase their use of VA care prior to the Choice Act.

The Physician Shortage: A Red Herring in American Health Care Reform

Although the USA spends more on health care than any other comparable nation, Americans are less healthy than citizens of high-income countries that spend far less. Over the past 12 years, the number of physicians per capita in the USA has been a concerning problem that may contribute to the disparity between health care costs and health status. Some have argued that remediating the shortage of primary care physicians will improve patient health. Others assert that the relationship between health care costs and health outcomes is more complex, influenced by a broad range of variables intrinsic to health care (i.e., provider availability, continuity, coordination); patient factors (ethnicity, socioeconomic status, health behaviors, health literacy, and other social factors); and systems factors (health information management, health information technology and health care measurement itself). This article contends that increasing the physician supply will not improve the health of Americans. Rather, solutions which lower health care costs while concomitantly improving health status will. Aside from community-level actions, health can improve at lower costs by increasing the prevalence of and proficiency in team-based care models, that address individual patient determinants of health, and poorly coordinated care. Future directions for this research and policy development are discussed.

Spillover Effects of Massachusetts Health Reform on Mental Health Use by VA and Medicare Dual Enrollees

Older veterans can obtain care from the Veterans Affairs Health System (VA), Medicare or both. We examined whether their use of mental health care was impacted by capacity effects stemming from younger, uninsured veterans' enrolling in VA to satisfy the individual mandate within Massachusetts Health Reform (MHR). Using administrative data, we applied a difference-in-difference approach to compare pre-post changes in mental health use following MHR implementation. Findings indicated MHR was associated with increases in use through Medicare and the probability of dual VA-Medicare use. These results provide support for the possibility that limited capacity led to care seeking outside VA.

Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team

OBJECTIVE

It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.

DATA SOURCE

Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.

STUDY DESIGN

Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.

PRINCIPAL FINDINGS

A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits.

CONCLUSIONS

In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.

Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team

OBJECTIVE

To examine the association between reliance on VA outpatient care and hospital admissions among Medicare-eligible Veterans enrolled in the Homeless Patient Aligned Care Team (H-PACT).

DATA SOURCES/STUDY SETTING

Registry of H-PACT enrollees linked to VA and Medicare utilization data for 2013.

STUDY DESIGN

After assigning Veterans to two groups according to whether they received >90 percent of outpatient care in VA (higher reliance) or <90 percent of outpatient care in VA (lower reliance), generalized linear models with inverse probability of treatment weights were used to estimate the association of reliance with Medicare and VA-financed hospital admissions.

PRINCIPAL FINDINGS

Compared with higher reliance Veterans, lower reliance Veterans had an equivalent number of annual VA hospitalizations (0.63 vs. 0.50; p = .14) but substantially greater Medicare hospitalizations (0.85 vs. 0.08; p < .001). Among Veterans in the highest tertile of outpatient visits, we observed statistically similar rates of VA hospital use but over 10-fold greater rates of Medicare-financed hospitalizations (1.31 for lower reliance vs. 0.15 for high reliance; p < .001).

CONCLUSIONS

Among Veterans receiving integrated care in VA's H-PACT, dual use of Medicare and VA outpatient care is strongly associated with acute hospitalizations financed by Medicare. Linking VA and non-VA data may identify a subset of homeless Veterans with fragmented outpatient care who are at increased risk of poor outcomes.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans

OBJECTIVE

Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care.

METHODS

The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset.

RESULTS

Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA.

CONCLUSIONS

VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Relational Climate and Health Care Costs: Evidence From Diabetes Care

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.

Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use

OBJECTIVES

To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D.

METHODS

Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source.

RESULTS

Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR] = 3.0; 95% confidence interval [CI] = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3).

CONCLUSIONS

Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

Longer wait times affect future use of VHA primary care

BACKGROUND

Improving access to the Veterans Health Administration (VHA) is a high priority, particularly given statutory mandates of the Veterans Access, Choice and Accountability Act. This study examined whether patient-reported wait times for VHA appointments were associated with future reliance on VHA primary care services.

METHODS

This observational study examined 13,595 VHA patients dually enrolled in fee-for-service Medicare. Data sources included VHA administrative data, Medicare claims and the Survey of Healthcare Experiences of Patients (SHEP). Primary care use was defined as the number of face-to-face visits from VHA and Medicare in the 12 months following SHEP completion. VHA reliance was defined as the number of VHA visits divided by total visits (VHA+Medicare). Wait times were derived from SHEP responses measuring the usual number of days to a VHA appointment with patients' primary care provider for those seeking immediate care. We defined appointment wait times categorically: 0 days, 1day, 2-3 days, 4-7 days and >7 days. We used fractional logistic regression to examine the relationship between wait times and reliance.

RESULTS

Mean VHA reliance was 88.1% (95% CI = 86.7% to 89.5%) for patients reporting 0day waits. Compared with these patients, reliance over the subsequent year was 1.4 (p = 0.041), 2.8 (p = 0.001) and 1.6 (p = 0.014) percentage points lower for patients waiting 2-3 days, 4-7 days and >7 days, respectively.

CONCLUSIONS

Patients reporting longer usual wait times for immediate VHA care exhibited lower future reliance on VHA primary care.

IMPLICATIONS

Longer wait times may reduce care continuity and impact cost shifting across two federal health programs.

Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care

OBJECTIVE

To assess the influence of relational climate on quality of diabetes care.

DATA SOURCES/STUDY SETTING

The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets.

STUDY DESIGN

Multilevel panel data (2008-2012) with patients nested into clinics.

DATA COLLECTION/EXTRACTION METHODS

Diabetic patients were identified using ICD-9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all-or-none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure).

PRINCIPAL FINDINGS

The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline-compliant care than those with the lowest relational climate (OR for a 1-unit increase: 1.02, p-value <.001). Among insulin-dependent diabetic veterans, this effect was twice as large. Contrary to that expected, relational climate did not influence intermediate outcomes.

CONCLUSIONS

Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care.

Impact of Patient-Centered Care Innovations on Access to Providers, Ambulatory Care Utilization, and Patient Clinical Indicators in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration piloted patient-centered care (PCC) innovations beginning in 2010 to improve patient and provider experience and environment in ambulatory care. We use secondary data to look at longitudinal trends, evaluate system redesign, and identify areas for further quality improvement.

METHODS

This was a retrospective, observational study using existing secondary data from multiple US Department of Veteran Affairs sources to evaluate changes in veteran and facility outcomes associated with PCC innovations at 2 innovation and matched comparison sites between FY 2008-2010 (pre-PCC innovations) and FY 2011-2012 (post-PCC innovations). Outcomes included access to primary care providers (PCPs); primary, specialty, and emergency care use; and clinical indicators for chronic disease.

RESULTS

Longitudinal trends revealed a different story at each site. One site demonstrated better PCP access, decrease in emergency and primary care use, increase in specialty care use, and improvement in diabetic glucose control. The other site demonstrated a decrease in PCP access and primary care use, no change in specialty care use, and an increase in diastolic blood pressure in relation to the comparison site.

CONCLUSION

Secondary data analysis can reveal longitudinal trends associated with system changes, thereby informing program evaluation and identifying opportunities for quality improvement.

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.

Implications for informatics given expanding access to care for Veterans and other populations

Recent investigations into appointment scheduling within facilities operated by the US Department of Veterans Affairs (VA) illuminate systemic challenges in meeting its goal of providing timely access to care for all Veterans. In the wake of these investigations, new policies have been enacted to expand access to care at VA facilities as well as non-VA facilities if the VA is unable to provide access within a reasonable timeframe or a Veteran lives more than 40 miles from a VA medical facility. These policies are similar to broader health reform efforts that seek to expand access to care for other vulnerable populations. In this perspective, we discuss the informatics implications of expanded access within the VA and its wider applicability across the US health system. Health systems will require robust health information exchange, to maintain coordination while access to care is expanded. Existing informatics research can guide short-term implementation; furthermore, new research is needed to generate evidence about how best to achieve the long-term aim of expanded access to care.

Hospital diagnostic aggregation and risk-adjusted quality

OBJECTIVE

To demonstrate the importance of diagnostic aggregation when assessing hospitals.

DATA SOURCES

Patient data from the Victorian Admitted Episodes Database (VAED), 1999/2000 to 2004/2005. Financial statements from public hospitals, 2002/2003 to 2004/2005.

STUDY DESIGN

Risk-adjusted quality computed for each hospital using two aggregation levels. Each is then used to estimate the relationship between hospital efficiency and quality using two-stage DEA/Tobit model by Wilson and Simar (2006).

DATA COLLECTION

Selected variables from the VAED were obtained from the Department of Health in Victoria, then linked anonymously with financial statements.

PRINCIPAL FINDINGS

Hospital quality and, in some cases, its relationship with efficiency differs depending on aggregations.

CONCLUSIONS

Patient risk adjustment should be conducted using more than one aggregation level whenever possible.

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.

Beta-binomial regression and bimodal utilization

OBJECTIVE

To illustrate how the analysis of bimodal U-shaped distributed utilization can be modeled with beta-binomial regression, which is rarely used in health services research.

DATA SOURCES/STUDY SETTING

Veterans Affairs (VA) administrative data and Medicare claims in 2001-2004 for 11,123 Medicare-eligible VA primary care users in 2000.

STUDY DESIGN

We compared means and distributions of VA reliance (the proportion of all VA/Medicare primary care visits occurring in VA) predicted from beta-binomial, binomial, and ordinary least-squares (OLS) models.

PRINCIPAL FINDINGS

Beta-binomial model fits the bimodal distribution of VA reliance better than binomial and OLS models due to the nondependence on normality and the greater flexibility in shape parameters.

CONCLUSIONS

Increased awareness of beta-binomial regression may help analysts apply appropriate methods to outcomes with bimodal or U-shaped distributions.

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.

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

OBJECTIVE

To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients.

DATA SOURCES/STUDY SETTING

VA administrative and Medicare claims data from 2001 to 2004.

STUDY DESIGN

Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients.

PRINCIPAL FINDINGS

A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80).

CONCLUSIONS

Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.