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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3045 — Does Improved Continuity of Primary Care Reduce Emergency Visits in VA?

Katz DA (Iowa City VAMC), McCoy KD (Iowa City VAMC), Sarrazin MS (Iowa City VAMC)

Recent changes in healthcare delivery, including the movement toward more team-based care, have reduced the likelihood of patients seeing the same primary care provider (PCP) at repeated visits. Decreased continuity of care (COC) has also been associated with increased healthcare utilization in some studies. The aim of this study is to evaluate the association between longitudinal COC and use of emergency department (ED) care in VA outpatients.

We conducted a retrospective cohort study of all VA outpatients who were assigned to a VISN 23 PCP and had at least two primary care visits to physicians or physician extenders during FY2008-2009 (N = 214,141). To do this, we linked data in the 2008 Patient Care Management Module (PCMM) to VA outpatient data. Clinic stop codes were used to identify ED visits. Telephone contacts, home-based contacts, or contacts with a non-PCP were excluded. We estimated longitudinal COC using three measures: Usual Provider of Continuity (UPC), Modified Modified Continuity Index (MMCI), and Known Provider Continuity (K index). Multivariable random effects logistic regression models were used to predict VA emergency department use. Separate models were fit for each COC measure, controlling for demographics, chronic conditions (Elixhauser comorbidity index), and usual site of care (random effect).

The study population was elderly (mean age 66) and predominantly male (96%). The mean number of primary care outpatient visits was 4.2, and 22% visited the VA ED during the 2 year follow-up period. The mean for UPC, MMCI, and K-index was 0.75, 0.74, and 0.73, respectively (on a scale of 0-1, where 1 is perfect continuity). In multivariable models, the lowest and middle tertiles of UPC were associated with an increased odds of any ED use: adjusted OR (95%CI) = 1.44 (1.42-1.46) and 1.30 (1.28-1.32), respectively. Similar results were obtained for the other COC measures.

Longitudinal continuity of VA primary care compares favorably to that reported in non-VA settings. Reductions in PCP continuity may significantly increase utilization of VA ED services.

Innovative models of care such as the Patient Centered Medical Home need to be monitored for untoward reductions in continuity with the patient’s PCP.

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