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2019 HSR&D/QUERI National Conference Abstract

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1025 — Discontinuity of Care For Patients With Complex Chronic Conditions In An Integrated Healthcare System: A Case Study Of Inflammatory Bowel Disease

Lead/Presenter: Shirley Cohen-Mekelburg,  COIN - Ann Arbor
All Authors: Cohen-Mekelburg SA (Center for Clinical Management Research, Ann Arbor VA), Saini SD (Center for Clinical Management Research, Ann Arbor VA), Wallace, B (Center for Clinical Management Research, Ann Arbor VA) Hollingsworth, JM (Department of Urology, University of Michigan) Bynum, J (Division of Geriatrics, University of Michigan) Burns, J (Center for Clinical Management Research, Ann Arbor VA) Wiitala, W (Center for Clinical Management Research, Ann Arbor VA) Higgins, PD (Division of Gastroenterology, University of Michigan) Waljee1, AK (Center for Clinical Management Research, Ann Arbor VA)

A key advantage of integrated healthcare delivery systems is their ability to maximize care continuity. Traditionally, organizational efforts to maximize care continuity have focused on the role of primary care providers; however, patients with complex medical conditions, who require co-management with specialists, may be missed by such a focus. In the process, these patients may not realize the benefits of clinical integration. We aimed to describe the nature of patient-provider relationships with inflammatory bowel disease (IBD), a chronic inflammatory condition of the gastrointestinal tract, in a large integrated healthcare system that has invested substantial resources in care coordination.

We used the VA Corporate Data Warehouse to identify patients with IBD seen between 2002-2014. Gastroenterologist (GI), primary care (PCP), and surgical outpatient visits were identified for the first three years following the index IBD encounter. Care continuity was calculated using the Bice-Boxerman COC index within the first 3-years of their initial presentation. The association between COC and outcomes (outpatient flare, hospitalization, surgery) was analyzed using a multivariable logistic regression model.

45,100 Veterans with IBD who had a VA PCP were identified. 16.8% had one GI, 33.1% had more than one GI, and 50.8% had no GI provider. For patients with at least 4 visits, the median COC was 0.30 (IQR 0.16, 0.56). A lower COC was associated with younger age, non-White race, moderate-to-severe disease, and having a VA gastroenterologist (Table). Regional variability in COC was also evident. When controlling for disease severity, a lower COC was associated with a higher likelihood of flare requiring corticosteroids, hospitalization, and surgery (Figure). In a secondary analysis accounting for facility fixed-effects, these associations persisted.

Continuity of care for IBD patients is low, even in an integrated system with systematic efforts to enhance continuity of care. Lower COC is also associated with more severe disease and worse outcomes.

Understanding COC in a system that has invested heavily in care coordination is key to understanding and eventually addressing discontinuity of care and fragmentation for patients with complex chronic conditions in the VA and the community.