1141 — Ambulatory Care Coordination Issues of Dual Use Solid Organ Transplant Recipients

Thrall SA, Ralph H. Johnson VAMC; Taber DJ, Ralph H. Johnson VAMC;

Objectives:
To describe coordination issues in ambulatory care provided to dual use solid organ transplant recipients at a VAMC.

Methods:
Retrospective, longitudinal, single-center study; 103 veterans identified by ICD-9 code (solid organ transplant recipient) or active immunosuppressive prescription, 46 met inclusion criteria of transplant prior to 06/01/2012 and attendance at one or more clinic visits with both a VA provider and a provider from local academic medical transplant center (AMTC) between 06/01/2013 - 05/31/2014. Data collection included clinic notes, laboratory tests, and medication lists from both facilities' electronic medical records. Data was reviewed to ascertain care coordination issues including duplication, omissions, co-management, and medication record discrepancies.

Results:
At baseline, mean age at transplant was 57±10 years; 93% male, 33% black, and 61% kidney transplants. During the year studied, the average patient had 7 ambulatory care visits (4 at the VAMC, 3 at the AMTC) with 3 different providers (1 VA primary care, 1 VA specialty, and 1 AMTC provider). At least 39% had documentation of ambulatory care provided outside of either system. The incidence of over-provision of laboratory tests was 85% for CBCs and chemistry panels, 57% for drug levels, and 61% for lipid panels. The incidence of drug level under-provision was 39%. The percentage of veterans with at least two providers caring for the same comorbidity was 63% for hypertension, 30% for diabetes and 24% for hyperlipidemia. Conversely, care omission was noted for 4% of hypertensive patients, 4% of diabetics, and 26% of hyperlipidemia patients. Few patients had documentation of care provided by the other institution (30-37%). 93% of patients had discrepancies in medication lists between health care systems, with 52% of patients with a immunosuppressant medication discrepancy. The median number of medication list discrepancies per patient was 4 (IQR 3-7).

Implications:
Most veteran organ transplant recipients receive care across multiple healthcare systems, with significant care coordination issues. Poor communication across these systems leads to gaps and duplications in care, coupled with substantial medication list discrepancies.

Impacts:
Improved coordination and communication between health systems is imperative to optimize efficient care and outcomes in dual users, such as organ transplant recipients.