Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk

Abstract

BackgroundIndividuals 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 ResultsA 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.ConclusionsEpisodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.

An Evaluation of Statin Use Among Patients with Type 2 Diabetes at High Risk of Cardiovascular Events Across Multiple Health Care Systems

“…29 We adjusted for several demographic, clinical, and socioeconomic variables, which were selected after reviewing the literature and variables that we had validated in our previous work. 3,4,15,16,18,[26][27][28]30 Age was treated as continuous and gender as nominal, with males as the reference group. Race/ethnicity was identified from VHA and CMS sources and was classified as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and other, with NHW serving as the reference group.…”

“…Omissions in therapy may also arise, since providers can assume that different systems are providing the necessary therapies for a given indication. Because of these complexities and the association between dual health care system use and suboptimal outcomes among patients with CVD, 3,8,12 we sought to evaluate the effect of dual health care system use on the use of statins in veterans with type 2 diabetes at high risk of cardiovascular events. We hypothesized that a lower degree of VHA utilization would be associated with less statin use.…”

“…1,2 Although visiting multiple providers may be clinically necessary and offer enhanced access, it can also result in fragmentation of care. [1][2][3][4] Lack of care coordination has been associated with increased emergency department visits, hospitalizations, and costs. 2,[5][6][7][8][9] Veterans Health Administration (VHA) patients using health care services from VHA and non-VHA organizations may be at risk of receiving fragmented care.…”

“…This usage, also known as dual health care system use, is increasing among veterans and has been associated with suboptimal outcomes. 3,4,10,11 For instance, dual health care system use has been associated with increased resource utilization and mortality among veterans with cardiovascular disease (CVD). 3,8,12 Over 130 million adults in the United States are projected to have some form of CVD by 2035.…”

“…3,4,10,11 For instance, dual health care system use has been associated with increased resource utilization and mortality among veterans with cardiovascular disease (CVD). 3,8,12 Over 130 million adults in the United States are projected to have some form of CVD by 2035. 13 Among patients with diabetes, atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality and the largest contributor to costs, resulting in $37.3 billion in cardiovascular-related costs each year.…”