Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1005 — Health Status Changes with Onsite vs. Referral Primary Care for Veterans in Addictions Treatment

Author List:
Kivlahan DR (CESATE VA Puget Sound/Univ of WA)
Malte CA (CESATE VA Puget Sound)
Hawkins EJ (CESATE VA Puget Sound)
Baer JS (CESATE VA Puget Sound/Univ of WA)
Sloan KL (CESATE VA Puget Sound/Univ of WA)
Calsyn DA (Univ of WA)
Saxon AJ (CESATE VA Puget Sound/Univ of WA)

Objectives:
Patients entering treatment for substance use disorders (SUDs) often have medical comorbidities that affect health status. Providing primary care within SUD clinics (onsite care) may improve health in this population. This study evaluated whether onsite care leads to clinically important changes in physical health status, compared to usual care.

Methods:
Veterans (N=720) entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) in the VA SUD clinic (onsite); or 2) in the VA general medicine clinic (referral). We evaluated as an outcome a change of 5 or more points, often considered a clinically meaningful change, in SF-36 Physical Component Summary (PCS) scores between randomization and 12-month follow-up. Among subjects completing the 12-month assessment (n=525, 72.9%), we used logistic regression to evaluate the odds of a 5+ point change in PCS in patients randomized to onsite versus referral care, adjusting for age, race, current psychiatric condition, primary SUD, Addiction Severity Index, and baseline SF-36 PCS and Mental Component Summary score.

Results:
Overall, significantly more onsite subjects reported clinically meaningful improvement (onsite=25.4% and referral=17.4%; ORadj=1.76; 95% CI=1.09-2.86; p=0.021). Unexpectedly, nearly one of three subjects in both conditions demonstrated clinically meaningful deterioration (onsite=36.5% and referral=30.9%; ns). In subgroup analyses limited to 428 subjects attending >1 primary care appointment during follow-up, those with onsite care had significantly higher likelihood of both clinically meaningful improvement (ORadj=2.12; 1.24-3.64; p=0.006) and deterioration (ORadj=1.64; 1.01-2.66; p=0.047).

Implications:
Patients in SUD treatment who were randomized to receive onsite primary care were more likely to show a 5+ point improvement in PCS over 12 month follow-up, compared to those who received primary care as usual in the general medicine clinic. However, >30% of subjects, irrespective of site of primary care, had a 5+ point deterioration in PCS during the 12 month study.

Impacts:
Further study is needed to identify specific patient, provider, and system characteristics that mediate clinically meaningful change in physical health status among SUD patients and to identify patient subgroups that respond more favorably to onsite vs. referral care.