Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset

Comparing major comorbidity indices as predictors of all-cause mortality in the Veterans Affairs health care system

OBJECTIVES

The Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Index (ECI), and the Functional Comorbidity Index (FCI) are validated clinical measures of comorbidity, but direct comparisons between these measures have rarely been studied especially in high-risk patient populations, such as homeless individuals. The US Department of Veterans Affairs (VA) offers large patient samples to compare these comorbidity measures as predictors of mortality using administrative and clinical records. We examined CCI, ECI, and FCI scores among veterans seeking VA healthcare services, including those experiencing homelessness, and compared their predictive value in relation to all-cause mortality risk.

STUDY DESIGN AND SETTING

Several VA databases from 2017 to 2021 were retrospectively linked, and 4,701,711 U S. veterans [308,553 with homelessness and 4,393,158 without homelessness] were evaluated over a median follow-up of 4.1 years, yielding 917,921 recorded deaths. Regression models were constructed, and Harrell's Concordance Statistic (HCS) was calculated that assessed the ability of z-transformed comorbidity scores to discriminate "high-risk" vs "low-risk" groups of patients for mortality risk, after adjustment for demographic and clinical characteristics.

RESULTS

In adjusted models, ECI (HCS: 0.76-0.77) and CCI (HCS: 0.75-0.76) were better able to discriminate "high-risk" vs "low-risk" groups than FCI (HCS: 0.72-0.75) among homeless and nonhomeless veterans. Compared to ECI and CCI, FCI was more strongly associated with homelessness.

CONCLUSION

CCI and ECI may be more predictive of all-cause mortality risk than FCI, although FCI may be a useful measure of functioning in homeless populations.

PLAIN LANGUAGE SUMMARY

The CCI, ECI, and FCI are clinical measures of comorbidity, but their direct comparisons have been limited, especially in high-risk patient populations like homeless individuals. This study examined CCI, ECI, and FCI scores among veterans seeking health care services at the US Department of Veterans Affairs and found that ECI and CCI were better at discriminating high-risk vs low-risk groups and predicting mortality among homeless and nonhomeless veterans.

Adverse Events Involving Telehealth in the Veterans Health Administration

BACKGROUND

Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.

METHODS

The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.

RESULTS

A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.

CONCLUSION

The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.