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Hebert PL, Kumbier KE, Smith VA, Hynes DM, Govier DJ, Wong E, Kaufman BG, Shepherd-Banigan M, Rowneki M, Bohnert ASB, Ioannou GN, Boyko EJ, Iwashyna TJ, O’Hare AM, Bowling CB, Viglianti EM, Maciejewski ML. Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans. JAMA Netw Open 2024; 7:e2355387. [PMID: 38334995 PMCID: PMC10858406 DOI: 10.1001/jamanetworkopen.2023.55387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
Importance The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. Objective To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. Design, Setting, and Participants In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. Exposure COVID-19 infection. Main Outcomes and Measures The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. Results The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). Conclusions and Relevance This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.
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Affiliation(s)
- Paul L. Hebert
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, Health Data and Informatics Program, Center for Quantitative Life Sciences, College of Health, Oregon State University, Corvallis
| | - Diana J. Govier
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- School of Nursing, Oregon Health & Science University, Portland
| | - Edwin Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Amy S. B. Bohnert
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - George N. Ioannou
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, University of Washington, Seattle
| | - Edward J. Boyko
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Ann M. O’Hare
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health & Science University, Portland
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Nguyen CB, Kobe C, Kumbier KE, Bauman J, Burns JA, Tsao PA, Sparks JB, Skolarus TA, Caram ME. Determinants of Bone-Modifying Agent Prescribing for Metastatic Castration-Resistant Prostate Cancer in a National Health Care Delivery System. JCO Oncol Pract 2024; 20:59-68. [PMID: 38085028 PMCID: PMC10827294 DOI: 10.1200/op.23.00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Despite guidelines recommending bone-modifying agents (BMAs) to decrease skeletal-related events (SREs) in men with metastatic castration-resistant prostate cancer (mCRPC), BMAs are underutilized. In this retrospective cohort study, we report the factors associated with BMA use in a national health care delivery system. METHODS We used the Veterans Affairs Corporate Data Warehouse to identify men with mCRPC between 2010 and 2017. BMA prescribing frequency was evaluated, and the association between patient- and disease-specific factors with BMA use was assessed using multivariable logistic regression. RESULTS Among 3,980 men identified with mCRPC (mean age 73.5 years, 29% Black), 47% received a BMA; median time to BMA from start of mCRPC treatment was 102 days. Factors associated with BMA use included previous BMA use (adjusted odds ratio [aOR], 7.81 [95% CI, 6.48 to 9.47]), diagnosis code for bone metastases (aOR, 1.26 [95% CI, 1.08 to 1.46]), and concomitant corticosteroid use (aOR, 1.53 [95% CI, 1.29 to 1.82]). Decreased BMA use was associated with advancing age (aOR, 0.85 per 10 years [95% CI, 0.78 to 0.92]), Charlson comorbidity index ≥2 (aOR, 0.76 [95% CI, 0.63 to 0.93]), Black race (aOR, 0.83 [95% CI, 0.70 to 0.98]), and decreased estimated glomerular filtration rate (eGFR; aOR, 0.19 [95% CI, 0.11 to 0.32] for eGFR 0-29 mL/minutes; aOR, 0.76 [95% CI, 0.64 to 0.91] for 30-59 mL/minutes). CONCLUSION Patients who are older, Black, or have more comorbidities are less likely to receive guideline concordant care to prevent SREs. These observations highlight the unique challenges of caring for patients with mCRPC and the need for future studies to increase BMA use in these populations.
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Affiliation(s)
- Charles B. Nguyen
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher Kobe
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan Bauman
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer A. Burns
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Phoebe A. Tsao
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ted A. Skolarus
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Megan E.V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Read AJ, Waljee AK, Chen CS, Holleman R, Kumbier KE, Saini SD. Prevalence of Appropriate Testing for Incident Anemia in the US Department of Veterans Affairs. JAMA Netw Open 2021; 4:e2034406. [PMID: 33496793 PMCID: PMC7838922 DOI: 10.1001/jamanetworkopen.2020.34406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study assesses the prevalence of appropriate testing for incident anemia in a large cohort from a national integrated health care system.
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Affiliation(s)
- Andrew J. Read
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Akbar K. Waljee
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- VA Health Services Research and Development Service, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Charity S. Chen
- VA Health Services Research and Development Service, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Robert Holleman
- VA Health Services Research and Development Service, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Kyle E. Kumbier
- VA Health Services Research and Development Service, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer D. Saini
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- VA Health Services Research and Development Service, Center for Clinical Management Research, Ann Arbor, Michigan
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