Increased ED Visits Among Veterans Utilizing Home-Based Primary Care

Researchers recently found that veteran patients in the Veteran Affairs (VA) Home-Based Primary Care (HBPC) program had increased emergency department (ED) visits and ambulatory care sensitive condition (ACSC) hospitalizations.

According to the study team, VA HBPC “provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients.”

In order to examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death, the researchers conducted a retrospective cohort study. It included VA patients 65 years of age and older who met the following criteria:

• were enrolled in the VA and Medicare;
• whose risk of hospitalization or death was in the top 10%; and
• who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014.

The team measured ED visits and hospitalizations for ACSC from VA records and Medicare claims from October 1, 2014, to September 30, 2015 as the main study outcome.

According to the findings, of the 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity. Additionally, the mean (SD) age was 80.0 (9.02) years, and patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]).

Further findings using adjusted models showed a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]). Further, increased concentrated care with a higher Usual Provider Continuity Index (UPC) was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]).

“Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations,” the authors concluded. “These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.”

Reference:
Edwards ST, Greene L, Chaudhary C, Boothroyd D, Kinosian B, Zulman DM. Outpatient care fragmentation and acute care utilization in Veterans Affairs home-based primary care. JAMA Netw Open. 2022;5(9):e2230036. doi:10.1001/jamanetworkopen.2022.30036