Health Services Research & Development

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2006 HSR&D National Meeting Abstract


3009 — Dual Use of Medicare and the Veterans Health Administration: Are There Adverse Health Outcomes?

Author List:
Wolinsky FD (Iowa City VAMC)
Miller TR (University of Iowa)
An H (University of Iowa)
Brezinski PR (University of Iowa)
Vaughn TR (Iowa City VAMC)
Rosenthal GE (Iowa City VAMC)

Objectives:
Nearly ten million veterans are eligible to use both the Veterans Health Administration (VHA) and Medicare because of their military service and age. While dual use may provide older veterans with broader access, it may also decrease the continuity of their care. This study evaluates whether dual use is associated with mortality.

Methods:
We conducted a secondary analysis of the Survey of Assets and Health Dynamics among the Oldest Old (AHEAD), a nationally representative sample of adults 70 years old or older in 1993-94. Baseline survey data were linked to Medicare claims and the National Death Index for the analytic sample of 1,566 self-responding men, 864 (55.2%) of whom were veterans. Because the AHEAD cannot be linked to VHA claims, we used an indirect measure of dual use. In this study, dual use was indicated when a given veteran’s self-reported number of hospital episodes in the 12 months prior to baseline was greater than that observed in his Medicare claims for the same period. Proportional hazards models were fitted.

Results:
97 (11.2%) of the veterans were classified as dual users. 817 (52.2%) of the 1,566 AHEAD men had died by December 31, 2002, including 67.3% of the dual users and 51.2% of all others (p < .001). Adjusting for age, race, self-rated health, ADLs, IADLs, socioeconomic status, comorbidity, cognitive status, depressive symptoms, hospitalization status, and a propensity score reflecting potential selection bias in the assembly of the cohort at baseline, as well as subsequent hospitalization for ambulatory care sensitive conditions, the independent effect of dual use was a 62.3% increased risk of mortality (AHR =1.623; p = .022). The risk of mortality was not increased among veterans who were not dual users.

Implications:
Using an indirect measure, dual use of VHA and Medicare services by veterans was associated with a substantially increased risk of death.

Impacts:
These results warrant a formal request from VA HSR&D to the AHEAD and its primary sponsor, the National Institute on Aging, to link the AHEAD data with VHA claims to directly examine the potential adverse effects of dual use among older veterans.