Association Between Local Area Unemployment Rates and Use of Veterans Affairs Outpatient Health Services

Wong, Edwin S.; Hebert, Paul L.; Hernandez, Susan E.; Batten, Adam; Lo, Sophie; Lemon, Jaclyn M.; Fihn, Stephan D.; Liu, Chuan Fen

doi:10.1097/mlr.0000000000000079

Cited by 14 publications

(21 citation statements)

References 23 publications

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“…These are consistent with previous findings, despite differences in the unemployment measure used; prior studies used the unemployment rate in the general population (Wong and Liu ; Wong et al. , ; Frakt, Hanchate, and Pizer ). One study found that a 1 percentage point increase in county‐level unemployment rate (equivalent to an approximately 20 percent increase) was associated with a 1.0 to 1.3 percent increase in VA outpatient visits among veterans aged 18–64 during 2004–2012 (Wong et al.…”

Section: Discussionsupporting

confidence: 90%

“…One study found that a 1 percentage point increase in county‐level unemployment rate (equivalent to an approximately 20 percent increase) was associated with a 1.0 to 1.3 percent increase in VA outpatient visits among veterans aged 18–64 during 2004–2012 (Wong et al. ). In contrast, inpatient care utilization was not associated with changes in the overall unemployment rate (Wong et al.…”

Section: Discussionmentioning

confidence: 99%

“…In the context of VA health care utilization, previous models have examined the influence of dual coverage (particularly Medicare and Medicaid), unemployment, housing prices, and Medicaid expansion (Wong et al. , ; Frakt, Hanchate, and Pizer ). Housing price changes have potentially different effects on household financial status and, indirectly, on VA utilization: Increases in housing prices represent a financial gain for homeowners, but likely a financial loss for renters due to a likely increase in rents.…”

Section: Methodsmentioning

confidence: 99%

“…Recent studies have begun to examine the role of unemployment and Medicaid coverage, and their temporal fluctuations, in VA utilization among veterans of all ages (Wong and Liu ; Wong et al. , ; Frakt, Hanchate, and Pizer ).…”

mentioning

confidence: 99%

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External Determinants of Veterans’ Utilization ofVAHealth Care

Hanchate

Frakt

Kressin

et al. 2018

Health Services Research

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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External Determinants of Veterans’ Utilization ofVAHealth Care

Hanchate

Frakt

Kressin

et al. 2018

Health Services Research

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“…Because the observation period coincided with the Great Recession, we also adjusted for the unemployment rate in patients' residence county to account for PCP visit changes influenced by economic conditions. 19,20 The unit of analysis for regression models was patient-quarter.…”

Section: Discussionmentioning

confidence: 99%

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden

et al. 2016

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BACKGROUND:The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. OBJECTIVE: We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. DESIGN, SUBJECTS AND MAIN MEASURES: This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Faceto-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. KEY RESULTS: Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high-and lowcomorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for highcomorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. CONCLUSIONS: Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

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Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

et al. 2019

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BACKGROUND:The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization. OBJECTIVE: To examine the association of patientreported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs). DESIGN: Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects. PARTICIPANTS: A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module. MAIN MEASURES: Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare feefor-service claims. KEY RESULTS: Patients who reported Balways^able to obtain after-hours care compared to Bnever^were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting Busually^getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs. CONCLUSIONS: Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

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Association Between Local Area Unemployment Rates and Use of Veterans Affairs Outpatient Health Services

Abstract: Our findings highlight the importance of the state of the economy in interpreting and forecasting demand for government health programs including VA, particularly during periods focused on deficit reduction.

Cited by 14 publications

References 23 publications

External Determinants of Veterans’ Utilization ofVAHealth Care

External Determinants of Veterans’ Utilization ofVAHealth Care

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

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