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2019 HSR&D/QUERI National Conference Abstract

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4100 — Impact of dual healthcare system use on lipid management among Veterans with diabetes

Lead/Presenter: Erin Weeda,  COIN - Charleston
All Authors: Weeda ER (COIN Charleston, MUSC), Ward,RC [Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center] Taber, DJ [Health Equity and Rural Outreach Innovation Center (HEROIC) Ralph H. Johnson Department of Veterans Affairs Medical Center] Axon, RN [Health Equity and Rural Outreach Innovation Center (HEROIC) Ralph H. Johnson Department of Veterans Affairs Medical Center] Gebregziabher, M [Health Equity and Rural Outreach Innovation Center (HEROIC) Ralph H. Johnson Department of Veterans Affairs Medical Center]

Objectives:
Patients with more than one chronic condition often receive care from several providers and facilities, which can lead to fragmentation of care. Poor care coordination in dual healthcare system use has been associated with increased emergency department visits, hospitalizations and costs. Dual healthcare system use is increasing among Veterans, and we sought to evaluate the impact of poor care coordination on lipid management in Veterans with type 2 diabetes utilizing varying degrees of Centers for Medicare and Medicaid Services (CMS) services.

Methods:
Retrospective longitudinal study of national clinical and administrative data of 729,822 Veterans with type 2 diabetes who were 65 or older on 1/1/2006. Patients were followed until 12/31/2016. Administrative and clinical data from the VA Corporate Data Warehouse were merged with CMS inpatient, outpatient and pharmacy data. Marginal general estimating equation models for the clustered data were run to predict low-density lipoprotein cholesterol (LDL) control, defined as either LDL-C > 100 or > 70 mg/dL. Models were adjusted by age, gender, marital status, race-ethnicity, dual use status ( > 80%, 50-80% or < 50% VA utilization), use of statins, occurrence of atherosclerotic cardiovascular disease (ASCVD), smoking status, number of annual primary-care visits, and service-related disability status.

Results:
Patients with lowest VA utilization were slightly older (mean age 75.4 versus 74.2 years), and significantly more likely to have experienced acute coronary syndrome (29.3% vs. 23.8% overall) or atherosclerotic cerebrovascular disease (25.7% vs. 20.8% overall). Patients with lowest VA utilization were less likely to be taking a statin (91.5% vs. 94.6% overall), but were also more likely to have controlled LDL; for LDL < 100 mg/dL: odds ratio (OR) and 95% confidence interval (CI) = 1.12 (1,11, 1.13) when compared to those with highest VA utilization; similarly, for LDL < 70 mg/dL: 1.22 (1.20, 1.23).

Implications:
Dual healthcare system utilization for Veterans with diabetes was associated with a higher prevalence of ASCVD events, lower use of statins, but also slightly better odds of achieving LDL control.

Impacts:
Involving 11 years of follow time, this study boosts our understanding of the impact of dual healthcare utilization on Veterans with multiple chronic diseases.