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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
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Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
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Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
Do Health Systems Respond to the Quality of Their Competitors?
Daniel J. Crespin, PhD; Jon B. Christianson, PhD; Jeffrey S. McCullough, PhD; and Michael D. Finch, PhD
Impact of Clinical Training on Recruiting Graduating Health Professionals
Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
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Does Care Consultation Affect Use of VHA Versus Non-VHA Care?
Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH

Does Care Consultation Affect Use of VHA Versus Non-VHA Care?

Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH
Uncoordinated multisystem use is problematic for Veterans Health Administration (VHA) patients with dementia. The Partners in Dementia Care intervention is successful in changing the pattern of VHA versus non-VHA use.

Signed consent forms were received for 508 veterans and 486 caregivers who completed the baseline interview and were randomized. During the 1-year follow-up period, 36 of 316 (11.4%) PDC participants and 18 of 192 (9.4%) UC participants died. This difference was not significant. Of the 454 remaining participants, 328 veterans with caregivers completed the follow-up interviews. Of these, 17 had missing information on the cognitive, behavioral, or personal care dependency scores. Another 17 observations were removed due to missing information on other covariates. Our final data set had a sample size of 294. With 6 observations per participant, we had 1764 observations in our analysis data set.

Table 1 describes the baseline characteristics of PDC and UC participants. There were no differences in participant ages between the PDC and UC groups, although the spouses of PDC participants were younger than those of UC participants (mean [SD], 69.0 [12.4] vs 72.0 [10.3]; P ≤.02). PDC participants had a higher percentage of spouse caregivers (86% vs 72%; P ≤.001) and higher mean (SD) prebaseline Charlson-Deyo Index scores (2.5 [2.3] vs 1.8 [1.6]; P ≤.01). The PDC group had a lower proportion of white participants than the control group (81% vs 94%) and, on average, lived closer to the nearest VHA medical center (mean [SD] distance in miles, 20.9 [16.5] vs 36.9 [34.6]; P ≤.01).

Overall, the PDC group had a higher proportion of participants with at least 1 VHA hospital admission over the study period (24% vs 14%; P ≤.04) but a lower proportion with at least 1 VHA ED encounter (35% vs 52%; P ≤.01) than the UC group over the 3 periods. A higher percentage of non-VHA ED encounters occurred in the PDC group versus the UC group (39% vs 28%; P ≤.05).

There were no differences between PDC and UC participants in any of the 3 periods in terms of the ADLs that they needed assistance with, their behavior problem scores, or their levels of cognitive impairment.

GEE Models

Hospital admissions. The results from our GEE logistic models are shown in Table 2. There was no overall intervention effect on site of hospital admissions. However, we found a significant 4-way interaction among time, intervention, distance from VHA facility, and site of care for hospital admissions (P ≤.01). This interaction indicated that the likelihood of a VHA versus non-VHA admission changed over time, depending on whether the veteran was in the PDC or UC group and how far from the closest VHA medical center the veteran lived (Figure 1). During the prebaseline period, PDC participants appeared more likely to use non-VHA inpatient services than VHA services, with this likelihood decreasing as distance from the closest VHA facility increased. By months 7 to 12, this pattern changed. VHA admissions became more likely compared with non-VHA admissions for the PDC group veterans living closest to the nearest VHA facility, with the likelihood of VHA admissions declining with distance. The pattern of hospital admissions did not change over time for the UC veterans.

Increasing ADL scores (P ≤.01), Charlson-Deyo Index scores (P ≤.03), and patient age (P ≤.03) were each associated with a higher likelihood of overall inpatient utilization. We also found a significant negative association in inpatient utilization for caregivers with midlevel education (some post–high school education) compared with those with a lower level of education (P ≤.01). We did not see significant associations for the remainder of our covariates.

ED visits. There was a significant intervention effect for site (VHA vs non-VHA) of ED care at baseline. However, there was not a significant site (VHA vs non-VHA) × intervention × time interaction, nor a significant 4-way interaction including distance, indicating that the PDC versus UC differences in VHA versus non-VHA use that existed at baseline remained throughout the follow-up period. There was also a significant interaction between patient age and site of care (Table 2). As Figure 2 indicates, as veterans aged, the likelihood of a non-VHA ED visit increased, whereas the likelihood of a VHA ED visit remained stable. The relationship did not vary by intervention status. Other covariates, such as patient age (P ≤.01), having a spouse caregiver (P ≤.01), number of ADLs (P ≤.01), and living in the North PDC region (P ≤.01), displayed a positive association with ED utilization, whereas caregiver age (P ≤.02) displayed a negative association.

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