Multiple System Utilization and Mortality for Veterans With Stroke

Abstract

Background and Purpose-Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. Methods-Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. Results-The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7%VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). Conclusions-Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Cost differences in VHA acute and subacute rehabilitation units: Implications for VHA resource planning

“…The fact that nursing costs account for $3,500 of these lower costs is consistent with reduced lengths of stay as the primary driver of these results. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work [10,19] * suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.…”

“…To the extent that improved guideline compliance improves functional outcomes, this suggests that higher rates of guideline compliance may be desirable not only from a clinical perspective but also from a financial perspective. This suggestion is tempered, however, by several limitations in the present study: (1) we were unable to detect statistically significant differences is short-term, long-term, or 2-year annual VHA costs, leaving open the question of whether possible postdischarge increases in costs for patients treated in ARBUs offset the lower costs observed during the index rehabilitation stay (the results remained inconclusive when we examined these longer-term costs excluding the costs of the index stay); (2) our data pertain only to VHA stroke patients and are therefore limited in their scope, since both ARBUs and SRBUs treat a wide variety of rehabilitation patients, including those with spinal cord injuries, amputations, and traumatic brain injuries; (3) this study, by necessity, only examined the costs associated with VHA use and omitted any use of non-VHA care, thereby making this analysis more of a business case analysis from the VHA perspective rather than societal perspective (prior research among stroke patients has shown substantial amounts of poststroke Medicare utilization among Medicare-enrolled veterans [19]); and (4) our use of observational data raises the possibility that our results may exhibit statistical selection bias whereby those patients who are selected for treatment in a particular type of unit (ARBU or SRBU) differ from other patients in unobserved ways that influence the outcomes under study. (For example, if clinicians tend to direct more motivated stroke patients to ARBUs and less motivated stroke patients to SRBUs, our failure to measure motivation directly could bias our results in favor of ARBUs.)…”

Veterans and the Affordable Care Act

“…Some data suggest that veterans receiving care from both VA and non-VA sources are more likely to be rehospitalized and to die within a year compared with VA-only users, although the reasons for the disproportionate mortality have not been studied. 2 VA/Medicare dual-eligible veterans with myocardial infarctions who use both plans undergo more invasive cardiac procedures without gaining a survival advantage over VA-only users, but adverse events associated with greater use of invasive procedures by non-VA clinicians have again not been analyzed. 3 More health care choices may adversely affect the quality of care for some veterans in ways other than fragmenting care.…”

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

“…However, our findings add to evidence on the association between dual use measured at the individual level and increased healthcare utilization as well as adverse outcomes. For example, Jia and colleagues observed higher hospital readmission rates and mortality among dual users after stroke, and Tarlov and colleagues observed higher mortality among dual users of colon cancer care 28, 29. More recently, Bolden and colleagues found that dual system care was associated with lower likelihood of wound healing in patients with chronic pressure ulcer 30…”