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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Care cascades following low-value cervical cancer screening in dually enrolled Veterans. J Am Geriatr Soc 2024; 72:2091-2099. [PMID: 38721922 PMCID: PMC11226371 DOI: 10.1111/jgs.18956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare. METHODS This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting. RESULTS Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare. CONCLUSIONS Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.
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Affiliation(s)
- Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Burke RE, Pelcher L, Tjader A, Linsky AM, Thorpe CT, Turner JP, Rose L. Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations. J Gen Intern Med 2023; 38:3509-3516. [PMID: 37349639 PMCID: PMC10713889 DOI: 10.1007/s11606-023-08250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. OBJECTIVE We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). DESIGN Retrospective cohort study from 2015 to 2019. PARTICIPANTS Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). MAIN MEASURES Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. KEY RESULTS The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. CONCLUSIONS The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lindsay Pelcher
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Andrew Tjader
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
- Centre de Recherche, Institut Universiaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Liam Rose
- Health Economics Resource Center, Palo Alto VA Medical Center, Palo Alto, CA, USA
- Stanford Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA, USA
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3
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Shepherd-Banigan M, Miller KEM, Hastings SN, Schleiden LJ, Thorpe JM. Use of high cost care among Veterans with comorbid mental illness and Alzheimer's Disease and related dementias. PLoS One 2023; 18:e0282071. [PMID: 37172031 PMCID: PMC10180599 DOI: 10.1371/journal.pone.0282071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/07/2023] [Indexed: 05/14/2023] Open
Abstract
INTRODUCTION/OBJECTIVE Alzheimer's Disease and Other Related Dementias (AD/ADRD) leads to frequent emergency department (ED) and inpatient use. Mental health symptoms among persons with AD/ADRD increases cognitive and functional disabilities and could contribute to these high rates of intensive health care use. The objective of this paper is to assess the relationship of mental illness on 12-month patterns in hospitalization and ED use among Veterans aged 65 and over with a new AD/ADRD diagnosis. METHODS We used an existing dataset of administrative electronic health record data of Veterans with AD/ADRD from the US Veterans Health Administration linked with Medicare claims data from 2011-2015. We use multivariable logistic regression to examine the association between no pre-existing mental illness, pre-existing mental illness (e.g., major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder), and pre-existing severe mental illness-or SMI-(e.g., bipolar disorder, major depressive disorder with psychosis, or schizophrenia) and 12- month ED and hospitalization use and readmissions among Veterans who had an initial hospitalization visit. We estimated predicted probabilities, differential effect, and associated 95% confidence intervals. RESULTS In our sample, 1.4% had SMI and 11% had non-SMI mental illness. The unadjusted percentage with inpatient and ED use was higher among Veterans with SMI (34% and 26%, respectively) and Veterans with non-SMI mental illness (20%, 16%) compared with Veterans without pre-existing mental illness (12%, 9%). Compared to individuals with no pre-existing mental illness, having a pre-existing mental illness (1.27 percentage points, 95% CI: 0.76, 1.78) and a pre-existing SMI (7.17 percentage points, 95% CI: 5.66, 8.69) were both associated with an increased likelihood of ED use. The same pattern was observed for any inpatient use (mental illness 2.18, 95% CI: 1.59, 2.77; SMI 9.91, 95% CI: 8.21, 11.61). Only pre-existing SMI was associated higher hospitalization readmission. DISCUSSION Pre-existing mental illness increases use of high cost, intensive health care and this association is higher of more severe mental health conditions. We also show that pre-existing mental illness exerts a unique influence, above and beyond other comorbidities, such as diabetes, on ED and inpatient visits. More needs to be done to increase recognition of the unique risks of this combination of health conditions and encourage strategies to address them. Developing, testing, and implementing comprehensive strategies that address the intersection of ADRD and mental illness is promising approach that requires more focused attention.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham, NC, United States of America
- Duke-Margolis Center for Health Policy, Durham, NC, United States of America
- Hopkins Economics of Alzheimer's Disease and Services Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine E M Miller
- Hopkins Economics of Alzheimer's Disease and Services Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - S Nicole Hastings
- Durham VA Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham, NC, United States of America
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, United States of America
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States of America
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Oakes AH, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems. JAMA Netw Open 2022; 5:e2247180. [PMID: 36520431 PMCID: PMC9856440 DOI: 10.1001/jamanetworkopen.2022.47180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
Importance Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades. Objective To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services. Design, Setting, and Participants This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022. Exposures Receipt of low-value PSA testing. Main Outcomes and Measures Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates. Results This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA. Conclusions and Relevance The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.
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Affiliation(s)
- Aimee N. Pickering
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medical Ethics Health Policy, University of Pennsylvania, Philadelphia
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Trilliant Health, Birmingham, Alabama
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Thomas R. Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Esumi S, Ushio S, Zamami Y. Polypharmacy in Older Adults with Alzheimer’s Disease. Medicina (B Aires) 2022; 58:medicina58101445. [PMID: 36295605 PMCID: PMC9608980 DOI: 10.3390/medicina58101445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
The number of patients with Alzheimer’s disease is increasing annually. Most of these patients are older adults with comorbid physical illnesses, which means that they are often treated with a combination of medications for the disease they have and those for Alzheimer’s disease. Thus, older adults with Alzheimer’s disease are potentially at risk for polypharmacy. In addition, the drug interactions between Alzheimer’s disease medications and those for the treatment of physical illnesses may reduce their efficacy and increase side effects. This article reviews polypharmacy and drug interactions in elderly patients with Alzheimer’s disease, with a focus on psychotropic drugs.
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Affiliation(s)
- Satoru Esumi
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
- The Faculty of Pharmaceutical Science, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe 650-8586, Japan
- Correspondence: ; Tel.: +81-78-974-1551
| | - Soichiro Ushio
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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Datta R, Fried T, O’Leary JR, Zullo AR, Allore H, Han L, Juthani-Mehta M, Cohen A. National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship. Open Forum Infect Dis 2022; 9:ofac453. [PMID: 36147594 PMCID: PMC9487603 DOI: 10.1093/ofid/ofac453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Over 7 million older Americans are homebound. Managing infections in homebound persons presents unique challenges that are magnified among persons living with dementia (PLWD). This work sought to characterize antibiotic use in a national cohort of PLWD who received home-based primary care (HBPC) through the Veterans Health Administration. Methods Administrative data identified veterans aged ≥65 years with ≥2 physician home visits in a year between 2014 and 2018 and a dementia diagnosis 3 years before through 1 year after their initial HBPC visit. Antibiotics prescribed orally, intravenously, intramuscularly, or by enema within 3 days of an HBPC visit were assessed from the initial HBPC visit to death or December 31, 2018. Prescription fills and days of therapy (DOT) per 1000 days of home care (DOHC) were calculated. Results Among 39 861 PLWD, the median age (interquartile range [IQR]) was 85 (78-90) years, and 15.0% were Black. Overall, 16 956 (42.5%) PLWD received 45 122 prescription fills. The antibiotic use rate was 20.7 DOT per 1000 DOHC. Telephone visits and advanced practice provider visits were associated with 30.9% and 42.0% of fills, respectively. Sixty-seven percent of fills were associated with diagnoses for conditions where antibiotics are not indicated. Quinolones were the most prescribed class (24.3% of fills). The overall median length of therapy (IQR) was 7 (7-10) days. Antibiotic use rates varied across regions. Within regions, the median annual antibiotic use rate decreased from 2014 to 2018. Conclusions Antibiotic prescriptions were prevalent in HBPC. The scope, appropriateness, and harms of antibiotic use in homebound PLWD need further investigation.
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Affiliation(s)
- Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri Fried
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R O’Leary
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Heather Allore
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Manisha Juthani-Mehta
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Edwards ST, Greene L, Chaudhary C, Boothroyd D, Kinosian B, Zulman DM. Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care. JAMA Netw Open 2022; 5:e2230036. [PMID: 36066895 PMCID: PMC9449785 DOI: 10.1001/jamanetworkopen.2022.30036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. Objective To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. Design, Setting, and Participants This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022. Exposures Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner. Main Outcomes and Measures Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015. Results Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]). Conclusions and Relevance Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.
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Affiliation(s)
- Samuel T. Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Camila Chaudhary
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Derek Boothroyd
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruce Kinosian
- Geriatrics Extended Care Data Analysis Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, Division of Geriatrics, University of Pennsylvania, Philadelphia
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Sjoberg H, Liu W, Rohs C, Ayele RA, McCreight M, Mayberry A, Battaglia C. Optimizing care coordination to address social determinants of health needs for dual-use veterans. BMC Health Serv Res 2022; 22:59. [PMID: 35022053 PMCID: PMC8754195 DOI: 10.1186/s12913-021-07408-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/13/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Veterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. METHODS ACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran's VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 - 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. RESULTS When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13-30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). CONCLUSION We developed and implemented a program addressing dual-users' SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
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Affiliation(s)
- Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Wenhui Liu
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Carly Rohs
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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9
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Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study. J Gen Intern Med 2021; 36:3689-3696. [PMID: 34047924 PMCID: PMC8642498 DOI: 10.1007/s11606-021-06780-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There has been a reduction in BZD prescribing in the Veterans Affairs (VA) health care system since 2013. It is unknown whether the decline in VA-dispensed BZDs has been offset by Medicare Part D prescriptions. OBJECTIVES To examine (1) whether, accounting for Part D, declines in BZD prescribing to older Veterans remain; (2) patient characteristics associated with obtaining BZDs outside VA and facility variation in BZD source (VA only, VA and Part D, Part D only). DESIGN Retrospective cohort study with mixed effects multinomial logistic model examining characteristics associated with BZD source. PATIENTS A total of 1,746,278 Veterans aged ≥65 enrolled in VA and Part D, 2013-2017. MAIN MEASURES BZD prescription prevalence and source. KEY RESULTS From January 2013 to June 2017, the quarterly prevalence of older Veterans with Part D filling BZD prescriptions through the VA declined from 5.2 to 3.1% (p<0.001) or, accounting for Part D, from 10.0 to 7.7% (p<0.001). Among those prescribed BZDs between July 2016 and June 2017, 37.0%, 10.2%, and 52.8% received prescriptions from VA only, both VA and Part D, or Part D only, respectively. Older age was associated with higher odds of obtaining BZDs through Part D (e.g., compared to those 65-74, Veterans ≥85 had adjusted odds ratio [AOR] for Part D vs. VA only of 1.8 [95% highest posterior density interval (HPDI), 1.69, 1.86]). Veterans with substance use disorders accounted for few BZD prescriptions from any source but were associated with higher odds of prescriptions through Part D (e.g., alcohol use disorder AOR for Part D vs. VA alone: 1.9 [95% HPDI, 1.63, 2.11]) CONCLUSIONS: The decline in BZD use by older Veterans with Part D coverage remained after accounting for Part D, but the majority of BZD prescriptions came from Medicare. Further reducing BZD prescribing to older Veterans should consider prescriptions from community sources.
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10
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Schleiden LJ, Zickmund SL, Roman KL, Kennedy K, Thorpe JM, Rossi MI, Niznik JD, Springer SP, Thorpe CT. Caregiver and provider perspectives on dual VA and Medicare Part D medication use in veterans with suspected dementia or cognitive impairment. Am J Health Syst Pharm 2021; 79:94-101. [PMID: 34453437 DOI: 10.1093/ajhp/zxab343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Many older veterans with dementia fill prescriptions through both Veterans Affairs (VA) and Medicare Part D benefits. Dual VA/Part D medication use may have unintended negative consequences on prescribing safety and quality. We aimed to characterize benefits and drawbacks of dual VA/Part D medication use in veterans with dementia or cognitive impairment from the perspectives of caregivers and providers. METHODS This was a qualitative study based on semistructured telephone interviews of 2 group: (1) informal caregivers accompanying veterans with suspected dementia or cognitive impairment to visits at a VA Geriatric Evaluation and Management clinic (n = 11) and (2) VA healthcare providers of veterans with dementia who obtained medications via VA and Part D (n = 12). We conducted semistructured telephone interviews with caregivers and providers about benefits and drawbacks of dual VA/Part D medication use. Interview transcripts were subjected to qualitative content analysis to identify key themes. RESULTS Caregivers and providers both described cost and convenience benefits to dual VA/Part D medication use. Caregivers reported drawbacks including poor communication between VA and non-VA providers and difficulty managing medications from multiple systems. Providers reported potential safety risks including communication barriers, conflicting care decisions, and drug interactions. CONCLUSION Results of this study allow for understanding of potential policy interventions to better manage dual VA/Part D medication use for older veterans with dementia or cognitive impairment at a time when VA is expanding access to non-VA care.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Susan L Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, and Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie Lynn Roman
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Kayla Kennedy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle I Rossi
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Geriatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sydney P Springer
- University of New England School of Pharmacy Westbrook College of Health Professions, Portland, ME, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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11
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Growdon ME, Gan S, Yaffe K, Steinman MA. Polypharmacy among older adults with dementia compared with those without dementia in the United States. J Am Geriatr Soc 2021; 69:2464-2475. [PMID: 34101822 DOI: 10.1111/jgs.17291] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 05/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States. DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014-2016. MEASUREMENTS PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti-dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications). RESULTS The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1-4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0-4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6-3.9). CONCLUSION In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross-cutting and multidisciplinary approaches.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Departments of Neurology, Psychiatry, and Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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12
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Jones AL, Gordon AJ, Gabrielian SE, Montgomery AE, Blosnich JR, Varley AL, deRussy AJ, Austin EL, Hoge AE, Kim YI, Gelberg L, Kertesz SG. Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey. Med Care 2021; 59:504-512. [PMID: 33827108 PMCID: PMC8119353 DOI: 10.1097/mlr.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. OBJECTIVE Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. RESEARCH DESIGN Cross-sectional analysis of responses to a 2018 mailed survey. SUBJECTS VHA outpatients with homeless experiences. MEASURES Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. RESULTS Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). CONCLUSIONS Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Health Care System
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Health Care System
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Sonya E Gabrielian
- VA Greater Los Angeles Health Care System
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Ann Elizabeth Montgomery
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | - John R Blosnich
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA
| | | | | | - Erika L Austin
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | | | - Young-Il Kim
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Lillian Gelberg
- VA Greater Los Angeles Health Care System
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Stefan G Kertesz
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
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13
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Cashion W, Gellad WF, Sileanu FE, Mor MK, Fine MJ, Hale J, Hall DE, Rogal S, Switzer G, Ramkumar M, Wang V, Bronson DA, Wilson M, Gunnar W, Weisbord SD. Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare. Clin J Am Soc Nephrol 2021; 16:437-445. [PMID: 33602753 PMCID: PMC8011004 DOI: 10.2215/cjn.10020620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. RESULTS Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). CONCLUSIONS Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.
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Affiliation(s)
- Winn Cashion
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Hale
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Departments of Surgery, Anesthesia and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shari Rogal
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Galen Switzer
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mohan Ramkumar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina,Department of Population Health Sciences and Department of Medicine, Duke University, Durham, North Carolina
| | - Douglas A. Bronson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - Mark Wilson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - William Gunnar
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.,Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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14
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Abstract
As a recently retired Army Nurse Corps officer with almost 30 years of service to my country, I want to ensure that my fellow nurse practitioners (NPs) are aware of their role in ensuring high quality and safe patient care to all veterans who are accessing care outside of the Veterans Health Administration (VHA). Specifically, NPs who work outside the VHA have an opportunity to participate in patient safety efforts aimed at reducing veteran suicide. On June 6, 2018, Congress passed Public Law 115-182 or the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. A goal of the MISSION Act is to ensure that veterans have access to health care by streamlining eligibility criteria for community care. A veteran who drives more than 30 minutes or waits more than 20 days for a primary care or mental health appointment may be eligible to be sent to a community care provider such as an NP. Therefore, NPs and other providers who work in community settings have an obligation to know more about the mental and physical health care needs of veterans as well as the resources that have been developed by the VHA to assist them.
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15
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Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-Community Dual Care: Veteran and Clinician Perspectives. J Community Health 2020; 45:795-802. [PMID: 32112237 PMCID: PMC7319870 DOI: 10.1007/s10900-020-00795-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Many veterans receive care in both community settings and the VA. Recent legislation has increased veteran access to community providers, raising concerns about safety and coordination. This project aimed to understand the benefits and challenges of dual care from the perceptions of both the Veterans their clinicians. We conducted surveys and focus groups of veterans who use both VA and community care in VT and NH. We also conducted a web-based survey and a focus group involving primary care clinicians from both settings. The main measures included (1) reasons that veterans seek care in both settings; (2) problems faced by veterans and clinicians; (3) association of health status and ease of managing care with sites of primary care; and (4) association of veteran rurality with dual care experiences. The primary reasons veterans reported for using both VA and community care were (1) for convenience, (2) to access needed services, and (3) to get a second opinion. Veterans reported that community and VA providers were informed about the others' care more than half the time. Veterans in isolated rural towns reported better overall health and ease of managing their care. VA and community primary care clinicians reported encountering systems problems with dual-care including communicating medication changes, sharing lab and imaging results, communicating with specialists, sharing discharge summaries and managing medication renewals. Both Veterans and their primary clinicians report substantial system issues in coordinating care between the VA and the community, raising the potential for significant patient safety and Veteran satisfaction concerns.
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Affiliation(s)
- James Schlosser
- VA New England Healthcare System, the Manchester VA Medical Center, Manchester, USA.
- , Concord, USA.
| | - Donald Kollisch
- VA New England Healthcare System, the White River Junction VA Medical Center, White River Junction, USA
- Geisel School of Medicine At Dartmouth, Hanover, USA
| | | | - Troi Perkins
- Nicholas School of the Environment, Duke University, Durham, USA
| | - Ardis Olson
- Geisel School of Medicine At Dartmouth, Hanover, USA
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16
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Gillmeyer KR, Rinne ST, Glickman ME, Lee KM, Shao Q, Qian SX, Klings ES, Maron BA, Hanlon JT, Miller DR, Wiener RS. Factors Associated With Potentially Inappropriate Phosphodiesterase-5 Inhibitor Use for Pulmonary Hypertension in the United States, 2006 to 2015. Circ Cardiovasc Qual Outcomes 2020; 13:e005993. [PMID: 32393128 DOI: 10.1161/circoutcomes.119.005993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of phosphodiesterase-5 inhibitors (PDE5i) for groups 2 and 3 pulmonary hypertension (PH) is rising nationally, despite guidelines recommending against this low-value practice. Although receiving care across healthcare systems is encouraged to increase veterans' access to specialists critical for PH management, receiving care in 2 systems may increase risk of guideline-discordant prescribing. We sought to identify factors associated with prescribing of PDE5i for group 2/3 PH, particularly, to test the hypothesis that veterans prescribed PDE5i for PH in the community (through Medicare) will have increased risk of subsequently receiving potentially inappropriate treatment in Veterans Health Administration (VA). METHODS AND RESULTS We constructed a retrospective cohort of 34 775 Medicare-eligible veterans with group 2/3 PH by linking national patient-level data from VA and Medicare from 2006 to 2015. We calculated adjusted odds ratios (ORs) of receiving daily PDE5i treatment for PH in VA using multivariable models with facility-specific random effects. In this cohort, 1556 veterans received VA prescriptions for PDE5i treatment for group 2/3 PH. Supporting our primary hypothesis, the variable most strongly associated with PDE5i treatment in VA for group 2/3 PH was prior treatment through Medicare (OR, 6.5 [95% CI, 4.9-8.7]). Other variables strongly associated with increased likelihood of VA treatment included more severe disease as indicated by recent right heart failure (OR, 3.3 [95% CI, 2.8-3.9]) or respiratory failure (OR, 3.7 [95% CI, 3.1-4.4]) and prior right heart catheterization (OR, 3.8 [95% CI, 3.4-4.3]). CONCLUSIONS Our data suggest a missed opportunity to reassess treatment appropriateness when pulmonary hypertension patients seek prescriptions from VA-a relevant finding given policies promoting shared care across VA and community settings. Interventions are needed to reinforce awareness that pulmonary vasodilators are unlikely to benefit group 2/3 pulmonary hypertension patients and may cause harm.
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Affiliation(s)
- Kari R Gillmeyer
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Seppo T Rinne
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Mark E Glickman
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Statistics, Harvard University, Cambridge, MA (M.E.G.)
| | - Kyung Min Lee
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Qing Shao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Shirley X Qian
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Elizabeth S Klings
- Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Bradley A Maron
- Department of Cardiology, Veterans Affairs Boston Healthcare System, MA (B.A.M.)
| | - Joseph T Hanlon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.A.M.).,Center for Health Equity Research and Promotion (J.T.H.), Veterans Affairs Pittsburgh Healthcare System, PA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
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17
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Thorpe JM, Thorpe CT, Schleiden L, Cashy J, Carico R, Gellad WF, Van Houtven CH. Association Between Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits and Potentially Unsafe Prescribing. JAMA Intern Med 2019; 179:1584-1586. [PMID: 31329215 PMCID: PMC6646996 DOI: 10.1001/jamainternmed.2019.2788] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This observational study evaluates the association of dual prescribing for Veterans Affairs and Medicare Part D benefits with unsafe prescription exposure in a national cohort of older veterans.
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Affiliation(s)
- Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, UNC-Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, UNC-Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Loren Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Cashy
- Corporal Michael J. Crescenz Veterans Affairs Medical Center and the Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
| | - Ronald Carico
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Courtney Harold Van Houtven
- Center Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Miller LB, Sjoberg H, Mayberry A, McCreight MS, Ayele RA, Battaglia C. The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care. BMC Health Serv Res 2019; 19:734. [PMID: 31640673 PMCID: PMC6805730 DOI: 10.1186/s12913-019-4582-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans' social determinants of health (SDOH) to facilitate Veterans' transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care. METHODS The ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams. We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping. DISCUSSION The ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans' SDOH. This intervention will provide an essential service for effective care coordination.
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Affiliation(s)
- Lindsay B Miller
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Marina S McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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19
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Patient Possession of Excess Medication Supply in the VA: A Retrospective Database Study. Med Care 2019; 57:898-904. [PMID: 31634269 DOI: 10.1097/mlr.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medication overlap leading to medication excess is a form of therapeutic duplication, itself a type of potentially inappropriate prescribing. OBJECTIVE To determine the prevalence of potential medication excess in the Veterans Health Administration (VHA) and identify associated medication-level, patient-level, and system-level factors. RESEARCH DESIGN A retrospective database study. SUBJECTS All veterans who received ≥1 prescription dispensed by a VHA pharmacy in fiscal year 2014. MEASURES The primary outcome of "medication excess" was defined for each patient as the number of excess days' worth of medications for all overlap episodes (concurrently dispensed medications with the same name for >10 d). Predictors included medication-level, patient-level, and system-level factors. Multivariable negative binomial regression analyses estimated the rate ratio of each predictor with medication excess. RESULTS Among 4,687,453 veterans, 64% had ≥1 medication overlap episodes. Patients were prescribed a median of 7 [interquartile range (IQR), 3-12] unique medications, had a median of 2 (IQR, 0-5) overlap episodes, and a median of 27 (IQR, 0-96) days of medication excess. In adjusted regression models, factors associated with greater risk of medication excess included having more comorbidities, multiple prescribers, a combination of filling locations (consolidated mail-order pharmacy vs. local pharmacy), and multiple prescription durations (≥90 d vs. less). CONCLUSIONS Medication excess was high among VHA users, with nearly two-thirds of patients experiencing at least 1 duplicative medication. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and potentially inappropriate prescribing.
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20
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study. Ann Intern Med 2019; 170:433-442. [PMID: 30856660 PMCID: PMC6736692 DOI: 10.7326/m18-2574] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems. OBJECTIVE To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose. DESIGN Nested case-control study. SETTING VA and Medicare Part D. PARTICIPANTS Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions. MEASUREMENTS The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications. RESULTS Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005). LIMITATION Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems. CONCLUSION Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Joseph T Hanlon
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (W.F.G.)
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21
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Nash DB. Pharmacy Integration. AMERICAN HEALTH & DRUG BENEFITS 2019; 12:64-65. [PMID: 31057692 PMCID: PMC6485649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- David B Nash
- Editor-in-Chief, American Health & Drug Benefits Founding Dean, Jefferson College of Population Health, Philadelphia, PA
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Abstract
IMPORTANCE Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse. OBSERVATIONS A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits). CONCLUSIONS AND RELEVANCE Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore
| | - Sanket S Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut.,Department of Veterans Affairs West Haven, West Haven, Connecticut
| | - Eric R Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Scott M Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
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23
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Pope CA, Davis BH, Wine L, Nemeth LS, Haddock KS, Hartney T, Axon RN. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn 2018; 14:283-296. [PMID: 28906129 DOI: 10.1177/1742395317729887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.
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Affiliation(s)
- Charlene A Pope
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,2 Division General Pediatrics, Department of Pediatrics, College of Medicine, Medical University of South Carolina (MUSC), Charleston, USA
| | - Boyd H Davis
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,3 University of North Carolina-Charlotte, Charlotte, NC, USA
| | - Leticia Wine
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Lynne S Nemeth
- 4 College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - K Sue Haddock
- 5 William J.B. Dorn VA Medical Center, Columbia, SC, USA
| | - Tom Hartney
- 6 Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - R Neal Axon
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,7 Department of Internal Medicine, College of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
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24
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Carico R, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Hausmann LRM, Donohue JM, Suda KJ, Stroupe K, Hanlon JT, Good CB, Fine MJ, Gellad WF. Receipt of Overlapping Opioid and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs: A Cross-sectional Study. Ann Intern Med 2018; 169:593-601. [PMID: 30304353 PMCID: PMC6219924 DOI: 10.7326/m18-0852] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap. OBJECTIVE To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions. DESIGN Cross-sectional. SETTING VA and Medicare. PARTICIPANTS All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891). MEASUREMENTS Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use). RESULTS Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]). LIMITATION Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study. CONCLUSION Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Ron Carico
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Katie J Suda
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; Edward Hines, Jr. VA Hospital and University of Illinois at Chicago College of Pharmacy, Chicago, Illinois (K.J.S.)
| | - Kevin Stroupe
- Edward Hines, Jr. VA Hospital, Chicago, Illinois (K.S.)
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
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25
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans. Res Social Adm Pharm 2018; 15:1007-1013. [PMID: 30385111 DOI: 10.1016/j.sapharm.2018.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. OBJECTIVES To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. METHODS In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. RESULTS Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. CONCLUSIONS Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.
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Affiliation(s)
- Patience Moyo
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie M Donohue
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Value Based Pharmaceutical Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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26
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Thorpe CT, Gellad WF, Mor MK, Cashy JP, Pleis JR, Van Houtven CH, Schleiden LJ, Hanlon JT, Niznik JD, Carico RL, Good CB, Thorpe JM. Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia. Health Serv Res 2018; 53 Suppl 3:5375-5401. [PMID: 30328097 DOI: 10.1111/1475-6773.13055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,School of Medicine and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - John R Pleis
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Courtney H Van Houtven
- Durham Veterans Affairs Health Care System, VA Medical Center (152), Durham, NC.,Duke University School of Medicine, VA Medical Center (152), Durham, NC
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ronald L Carico
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Center for High Value Pharmaceutical Purchasing, UPMC Health Plan, Pittsburgh, PA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
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Lei L, Cooley SG, Phibbs CS, Kinosian B, Allman RM, Porsteinsson AP, Intrator O. Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization. Health Serv Res 2018; 53 Suppl 3:5331-5351. [PMID: 30246404 DOI: 10.1111/1475-6773.13048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data. DATA SOURCES VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013. STUDY DESIGN Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions. DATA COLLECTION Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million). PRINCIPAL FINDINGS VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data. CONCLUSIONS Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.
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Affiliation(s)
- Lianlian Lei
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Susan G Cooley
- VHA Office Geriatrics & Extended Care, U.S. Dept. Veterans Affairs, Washington, DC
| | - Ciaran S Phibbs
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,Department of Pediatrics-Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bruce Kinosian
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Division of Geriatrics, University of Pennsylvania, Philadelphia, PA
| | | | - Anton P Porsteinsson
- Department of Psychiatry, University of Rochester School ofMedicine and Dentistry, Rochester, NY
| | - Orna Intrator
- VHA Office Geriatrics & Extended Care Data Analysis Center (GECDAC), Washington, DC.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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28
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Schleiden LJ, Thorpe CT, Cashy JP, Gellad WF, Good CB, Hanlon JT, Mor MK, Niznik JD, Pleis JR, Van Houtven CH, Thorpe JM. Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D. Res Social Adm Pharm 2018; 15:701-709. [PMID: 30236896 DOI: 10.1016/j.sapharm.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States.
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States
| | - John P Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States
| | - Chester B Good
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States; Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center, 600 Grant St, Pittsburgh, PA, 15219, United States
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, United States
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - John R Pleis
- National Center for Health Statistics, Centers for Disease Control and Prevention, Division of Research and Methodology, 3311 Toledo Road, Hyattsville, MD, 20782, United States
| | - Courtney H Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, VA Medical Center (152), 508 Fulton St., Durham, NC, 27705, United States; Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Imperial Center, Durham, NC, 27713, United States
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States; Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Annex Suite 202, Philadelphia, PA, 19104, United States
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Trivedi AN, Jiang L, Johnson EE, Lima JC, Flores M, O'Toole TP. Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team. Health Serv Res 2018; 53 Suppl 3:5219-5237. [PMID: 30151996 DOI: 10.1111/1475-6773.13034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Amal N Trivedi
- Providence VA Medical Center, Providence, RI.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Lan Jiang
- Providence VA Medical Center, Providence, RI
| | | | - Julie C Lima
- Providence VA Medical Center, Providence, RI.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
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30
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Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk. J Am Heart Assoc 2018; 7:e009054. [PMID: 30371248 PMCID: PMC6201461 DOI: 10.1161/jaha.118.009054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2 weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30 days after initial visit, and ended 30 days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30 days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.
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Affiliation(s)
- R. Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Division of General Internal MedicineDepartment of MedicineThe Medical University of South CarolinaCharlestonSC
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
| | - Charles J. Everett
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
| | - Paul Heidenreich
- Division of CardiologyVA Palo Alto Healthcare SystemStanford University Medical CenterPalo AltoCA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
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31
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Gunnar W, Bronson DA, Cupples SA. Access to Transplant Care and Services Within the Veterans Health Administration. Fed Pract 2018; 35:12-21. [PMID: 30766376 PMCID: PMC6263447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The VHA provides timely solid organ transplant care and services with outcomes comparable to that of nationally reported estimates.
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Affiliation(s)
- William Gunnar
- is National Director of Surgery, is Chief Biostatistician, and is Director of Clinical Services, all at the National Surgery Office, Veterans Health Administration in Washington, DC. Dr. Gunnar also is a Clinical Professor of Surgery at George Washington University in Washington, DC
| | - Douglas A Bronson
- is National Director of Surgery, is Chief Biostatistician, and is Director of Clinical Services, all at the National Surgery Office, Veterans Health Administration in Washington, DC. Dr. Gunnar also is a Clinical Professor of Surgery at George Washington University in Washington, DC
| | - Sandra A Cupples
- is National Director of Surgery, is Chief Biostatistician, and is Director of Clinical Services, all at the National Surgery Office, Veterans Health Administration in Washington, DC. Dr. Gunnar also is a Clinical Professor of Surgery at George Washington University in Washington, DC
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32
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Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. A narrative review of problems with medicines use in people with dementia. Expert Opin Drug Saf 2018; 17:825-836. [DOI: 10.1080/14740338.2018.1497156] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tesfahun C. Eshetie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H. Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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Yoon J, Vanneman ME, Dally SK, Trivedi AN, Phibbs CS. Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans. Health Serv Res 2018; 53:1539-1561. [PMID: 28608413 PMCID: PMC5980176 DOI: 10.1111/1475-6773.12727] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care. DATA SOURCES Veterans Affairs utilization data and Medicaid Analytic Extract Files. STUDY DESIGN A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors. PRINCIPAL FINDINGS In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality. CONCLUSION Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCA
- Department of General Internal MedicineUCSF School of MedicineSan FranciscoCA
| | - Megan E. Vanneman
- Informatics, Decision‐Enhancement and Analytic Sciences CenterVA Salt Lake City Health Care SystemSalt Lake CityUT
- Department of Internal MedicineDivision of EpidemiologyUniversity of Utah School of MedicineSalt Lake CityUT
- Department of Population Health SciencesDivision of Health System Innovation and ResearchUniversity of Utah School of MedicineSalt Lake CityUT
| | - Sharon K. Dally
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
| | - Amal N. Trivedi
- Providence VA Medical CenterProvidenceRI
- Department of Health Services, Policy and PracticeBrown UniversityProvidenceRI
| | - Ciaran S. Phibbs
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCA
- Department of PediatricsStanford University School of MedicineStanfordCA
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34
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Kurella Tamura M, Thomas IC, Montez-Rath ME, Kapphahn K, Desai M, Gale RC, Asch SM. Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs. JAMA Intern Med 2018; 178:657-664. [PMID: 29630695 PMCID: PMC6583073 DOI: 10.1001/jamainternmed.2018.0411] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain. Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known. OBJECTIVE To compare initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs the Department of Veterans Affairs (VA). DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients from the US Medicare and VA health care systems evaluated 11 215 veterans aged 67 years or older with incident kidney failure between January 1, 2008, and December 31, 2011. Data analysis was performed March 15, 2016, through September 20, 2017. EXPOSURES Pre-ESRD nephrology care in Medicare vs VA health care systems. MAIN OUTCOME AND MEASURES Dialysis treatment and death within 2 years. RESULTS Of the 11 215 patients included in the study, 11 085 (98.8%) were men; mean (SD) age was 79.1 (6.9) years. Within 2 years of incident kidney failure, 7071 (63.0%) of the patients started dialysis and 5280 (47.1%) died. Patients who received pre-ESRD nephrology care in Medicare were more likely to undergo dialysis compared with patients who received pre-ESRD nephrology care in VA (82% vs 53%; adjusted risk difference, 28 percentage points; 95% CI, 26-30 percentage points). Differences in dialysis initiation between Medicare and VA were more pronounced among patients aged 80 years or older and patients with dementia or metastatic cancer, and less pronounced among patients with paralysis (P < .05 for interaction). Two-year mortality was higher for patients who received pre-ESRD care in Medicare compared with VA (53% vs 44%; adjusted risk difference, 5 percentage points; 95% CI, 3-7 percentage points). The findings were similar in a propensity-matched analysis. CONCLUSIONS AND RELEVANCE Veterans who receive pre-ESRD nephrology care in Medicare receive dialysis more often yet are also more likely to die within 2 years compared with those in VA. The VA's integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a concomitant increase in mortality.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Kristopher Kapphahn
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California
| | - Randall C Gale
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of General Medicine, Stanford School of Medicine, Palo Alto, California
| | - Steven M Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of General Medicine, Stanford School of Medicine, Palo Alto, California
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35
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Gellad WF, Thorpe JM, Zhao X, Thorpe CT, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Hausmann LRM, Donohue JM, Gordon AJ, Suda KJ, Stroupe KT, Hanlon JT, Cunningham FE, Good CB, Fine MJ. Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use. Am J Public Health 2017; 108:248-255. [PMID: 29267065 DOI: 10.2105/ajph.2017.304174] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Walid F Gellad
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Joshua M Thorpe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Xinhua Zhao
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Carolyn T Thorpe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Florentina E Sileanu
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - John P Cashy
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Jennifer A Hale
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Maria K Mor
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Thomas R Radomski
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Leslie R M Hausmann
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Julie M Donohue
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Adam J Gordon
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Katie J Suda
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Kevin T Stroupe
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Joseph T Hanlon
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Francesca E Cunningham
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Chester B Good
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
| | - Michael J Fine
- Walid F. Gellad, Joshua M. Thorpe, Xinhua Zhao, Carolyn T. Thorpe, Florentina E. Sileanu, John P. Cashy, Jennifer A. Hale, Maria K. Mor, Thomas R. Radomski, Leslie R. M. Hausmann, Adam J. Gordon, Joseph T. Hanlon, and Michael J. Fine are with the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. Julie M. Donohue is with the Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh. Katie J. Suda and Kevin T. Stroupe are with the Center of Innovation for Complex Chronic Care, Hines VA Hospital, Chicago, IL. Francesca E. Cunningham and Chester B. Good are with the Department of Veterans Affairs, Pharmacy Benefits Management Services, VA Center for Medication Safety, Chicago
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Hanson BJ, Shaukat A. Not Too Hot, Not Too Cold, but "Just Right". Am J Gastroenterol 2017; 112:1686-1688. [PMID: 29109494 DOI: 10.1038/ajg.2017.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022]
Abstract
When ordering diagnostic tests, physicians are faced with a problem of not too many tests, not too few, but 'just right'. However, in medical diagnostics 'just right' may be very difficult to identify. Such is the conundrum presented in study by Rubenstein and colleagues regarding appropriate use of repeat esophagogastroduodenoscopy (EGD) in Veterans Health Administration (VHA) medical facilities. The important message of this paper is that out of 235,855 patients with an index EGD, 36% underwent repeat EGD over 5 years, of which only 9% (range 3-18%a cross VHA facilities) were classified as probable overuse.
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Affiliation(s)
- Brian J Hanson
- Division of Gastroenterology (B.J.H., A.S.), Minneapolis VA Healthcare system and Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aasma Shaukat
- Division of Gastroenterology (B.J.H., A.S.), Minneapolis VA Healthcare system and Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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37
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Lyons TW, Olson KL, Palmer NP, Horwitz R, Mandl KD, Fine AM. Patients Visiting Multiple Emergency Departments: Patterns, Costs, and Risk Factors. Acad Emerg Med 2017; 24:1349-1357. [PMID: 28861915 DOI: 10.1111/acem.13304] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/23/2017] [Accepted: 08/27/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We sought to characterize the population of patients seeking care at multiple emergency departments (EDs) and to quantify the proportion of all ED visits and costs accounted for by these patients. METHODS We performed a retrospective, cohort study of deidentified insurance claims for privately insured patients with one of more ED visits between 2010 and 2016. We measured the number of EDs visited by each patient and determined the overall proportion of all ED visits and ED costs accounted for by patients who visit multiple EDs. We identified factors associated with visiting multiple EDs. RESULTS A total of 8,651,716 patients made 16,390,676 ED visits over the study period, accounting for $26,102,831,740 in ED costs. A significant minority (20.5%) of patients visited more than one ED over the study period. However, these patients accounted for a disproportionate amount of all ED visits (41.4%) and all ED costs (39.2%). A small proportion (0.4%) of patients visited five or more EDs but accounted for 2.8% of ED visits and costs. Among patients with two ED visits within 30 days, 32% were to different EDs. Having at least one ED visit for mental health or substance abuse-related diagnosis was associated with increased odds of visiting multiple EDs. CONCLUSIONS A substantial minority of patients visit multiple EDs, but account for a disproportionate burden of overall ED utilization and costs. Future work should evaluate the impact of visiting multiple EDs on care utilization and outcomes and explore systems for improving access to patient records across care centers.
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Affiliation(s)
- Todd W. Lyons
- Computational Health Informatics Program; Boston Children's Hospital; Boston MA
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
| | - Karen L. Olson
- Computational Health Informatics Program; Boston Children's Hospital; Boston MA
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
| | - Nathan P. Palmer
- Department of Biomedical Informatics; Harvard Medical School; Boston MA
| | - Reed Horwitz
- Computational Health Informatics Program; Boston Children's Hospital; Boston MA
| | - Kenneth D. Mandl
- Computational Health Informatics Program; Boston Children's Hospital; Boston MA
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
- Department of Biomedical Informatics; Harvard Medical School; Boston MA
| | - Andrew M. Fine
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
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38
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Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration. Med Care 2017; 55 Suppl 7 Suppl 1:S45-S52. [DOI: 10.1097/mlr.0000000000000707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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