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VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis.

ABSTRACT: Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.This was a retrospective cohort.316,775 community-dwelling Veterans age ? 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009.Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ? 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51).Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.

SUBMITTER: Radomski TR

PROVIDER: S-EPMC4835371 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis.

Radomski Thomas R TR Zhao Xinhua X Thorpe Carolyn T CT Thorpe Joshua M JM Good Chester B CB Mor Maria K MK Fine Michael J MJ Gellad Walid F WF

Journal of general internal medicine 20160222 5

<h4>Background</h4>Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.<h4>Objective</h4>We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.<h4>Design</h4>This was a retrospective cohort.<h4>Participants</h4>316,775 community- ...[more]

PMID: 26902242

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Project description:Background and objectivesMany kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.Design, setting, participants, & measurementsWe conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.ResultsAmong 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).ConclusionsMost dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.

Project description:IntroductionGastrointestinal (GI) symptoms and disorders affect an increasingly large group of veterans. Opioid use may be rising in this population, but this is concerning from a patient safety perspective, given the risk of dependence and lack of evidence supporting opioid use to manage chronic pain. We examined the characteristics of opioid prescriptions and factors associated with chronic opioid use among chronic GI patients dually enrolled in the DVA and Medicare Part D.Materials and methodsIn this retrospective cohort study, we used linked, national patient-level data (from April 1, 2011, to December 31, 2014) from the VA and Centers for Medicare & Medicaid Services to identify chronic GI patients and observe opioid use. Veterans who had a chronic GI symptom or disorder were dually enrolled in VA and Part D and received ≥1 opioid prescription dispensed through the VA, Part D, or both. Chronic GI symptoms and disorders included chronic abdominal pain, chronic pancreatitis, inflammatory bowel diseases, and functional GI disorders. Key outcome measures were outpatient opioid prescription dispensing overall and chronic opioid use, defined as ≥90 consecutive days of opioid receipt over 12 months. We described patient characteristics and opioid use measures using descriptive statistics. Using multiple logistic regression modeling, we generated adjusted odds ratios and 95% CIs to determine variables independently associated with chronic opioid use. The final model included variables outlined in the literature and our conceptual framework.ResultsWe identified 141,805 veterans who had a chronic GI symptom or disorder, were dually enrolled in VA and Part D, and received ≥1 opioid prescription dispensed from the VA, Part D, or both. Twenty-six percent received opioids from the VA only, 69% received opioids from Medicare Part D only, and 5% were "dual users," receiving opioids through both VA and Part D. Compared to veterans who received opioids from the VA or Part D only, dual users had a greater likelihood of potentially unsafe opioid use outcomes, including greater number of days on opioids, higher daily doses, and higher odds of chronic use.ConclusionsChronic GI patients in the VA may be frequent users of opioids and may have a unique set of risk factors for unsafe opioid use. Careful monitoring of opioid use among chronic GI patients may help to begin risk stratifying this group. and develop tailored approaches to minimize chronic use. The findings underscore potential nuances within the opioid epidemic and suggest that components of the VA's Opioid Safety Initiative may need to be adapted around veterans at a higher risk of opioid-related adverse events.

Project description:PurposeWomen Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services.MethodsRural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts.FindingsPrimary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities.ConclusionAlthough VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.

Project description:Importance:Medicare beneficiaries who are also enrolled in Medicaid (dually enrolled beneficiaries) have drawn the attention of policy makers because they comprise the poorest subset of the Medicare population; however, it is unclear how their outcomes have changed over time compared with those only enrolled in Medicare (nondually enrolled beneficiaries). Objective:To evaluate annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among dually enrolled beneficiaries and nondually enrolled beneficiaries. Design, Setting, and Participants:Serial cross-sectional study of Medicare fee-for-service beneficiaries aged 65 years or older between January 2004 and December 2017. The final date of follow-up was September 30, 2018. Exposures:Dual vs nondual enrollment status. Main Outcomes and Measures:Annual all-cause mortality rates; all-cause hospitalization rates; and in-hospital, 30-day, 1-year hospitalization-related mortality rates. Results:There were 71?017?608 unique Medicare beneficiaries aged 65 years or older (mean age, 75.6 [SD, 9.2] years; 54.9% female) enrolled in Medicare for at least 1 month from 2004 through 2017. Of these beneficiaries, 11?697?900 (16.5%) were dually enrolled in Medicare and Medicaid for at least 1 month. After adjusting for age, sex, and race, annual all-cause mortality rates declined from 8.5% (95% CI, 8.45%-8.56%) in 2004 to 8.1% (95% CI, 8.05%-8.13%) in 2017 among dually enrolled beneficiaries and from 4.1% (95% CI, 4.08%-4.13%) in 2004 to 3.8% (95% CI, 3.76%-3.79%) in 2017 among nondually enrolled beneficiaries. The difference in annual all-cause mortality between dually and nondually enrolled beneficiaries increased between 2004 (adjusted odds ratio, 2.09 [95% CI, 2.08-2.10]) and 2017 (adjusted odds ratio, 2.22 [95% CI, 2.21-2.23]) (P?<?.001 for interaction between dual enrollment status and time). All-cause hospitalizations per 100?000 beneficiary-years declined from 49?888 in 2004 to 41?121 in 2017 among dually enrolled beneficiaries (P?<?.001) and from 29?000 in 2004 to 22?601 in 2017 among nondually enrolled beneficiaries (P?<?.001); however, the difference between these groups widened between 2004 (adjusted risk ratio, 1.72 [95% CI, 1.71-1.73]) and 2017 (adjusted risk ratio, 1.83 [95% CI, 1.82-1.83]) (P?<?.001 for interaction). Among hospitalized beneficiaries, the risk-adjusted 30-day mortality rates declined from 10.3% (95% CI, 10.22%-10.33%) in 2004 to 10.1% (95% CI, 10.02%-10.20%) in 2017 among dually enrolled beneficiaries and from 8.5% (95% CI, 8.50%-8.56%) in 2004 to 8.1% (95% CI, 8.06%-8.13%) in 2017 among nondually enrolled beneficiaries. In contrast, 1-year mortality increased among hospitalized beneficiaries from 23.1% (95% CI, 23.05%-23.20%) in 2004 to 26.7% (95% CI, 26.58%-26.84%) in 2017 among dually enrolled beneficiaries and from 18.1% (95% CI, 18.11%-18.17%) in 2004 to 20.3% (95% CI, 20.21%-20.31%) in 2017 among nondually enrolled beneficiaries. The difference in hospitalization-related outcomes between dually and nondually enrolled beneficiaries persisted during the study period. Conclusions and Relevance:Among Medicare fee-for-service beneficiaries aged 65 years or older, dually enrolled beneficiaries had higher annual all-cause mortality, all-cause hospitalizations, and hospitalization-related mortality compared with nondually enrolled beneficiaries. Between 2004 and 2017, these differences did not decrease.

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VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis.

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VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis.

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