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2023 HSR&D/QUERI National Conference Abstract

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4025 — Specialty Care Visit Completion Among Veterans with Newly-Diagnosed Liver Disease: A Retrospective Cohort Study in VISN 10

Lead/Presenter: Bradley Youles,  COIN - Ann Arbor
All Authors: Youles BW (Center for Clinical Management Research), Belancourt PX (Center for Clinical Management Research) Kumbier KE (Center for Clinical Management Research) Saini SD (Center for Clinical Management Research) Su GL (Center for Clinical Management Research)

Chronic liver disease (CLD) is highly prevalent and increasingly common condition among Veterans. Previous studies have shown that Veterans with CLD who have a liver specialty care encounter experience improved survival. But access to specialty care is limited by multiple barriers. The goal of this study was to determine how often Veterans with newly diagnosed CLD complete a liver clinic visit and identify factors associated with visit non-completion.

We identified Veterans who had a new CLD related ICD-9 code occurring in a VISN 10 primary care clinic visit during 2009-2014 (“index primary care visit”). Patients were excluded if they had a CLD diagnosis in the two years preceding the index primary care visit. We retrieved administrative, clinical, and laboratory data from CDW related to disease state and access-related factors. We used Poisson regression to identify factors associated with a completed liver specialty care visit within 180 days after the index primary care visit (and new CLD diagnosis). We examined the following independent variables: age, sex, race, CLD severity, modified Elixhauser index, hepatitis C status, and distance to VAMC.

We identified 22,443 patients with a new CLD diagnosis at an index primary care visit between 2009-2014. Of these, 18,235 (81%) did not complete a liver specialty care visit within 180 days after the new CLD diagnosis, and 77% did not complete a visit within 365 days. Of those with compensated and decompensated cirrhosis, 71% and 52% did not complete a visit within 180 days, respectively. In multivariable Poisson regression, factors positively associated with visit non-completion were age (RR = 1.01 per year), male sex (RR = 1.04), distance from VA primary care site (RR = 1.01 per 10 miles). Factors inversely associated with visit non-completion were decompensated liver disease (RR = 0.62), compensated liver disease (RR = 0.84), Elixhauser index (RR = 0.99), Black race (RR = 0.98), and hepatitis C diagnosis (RR = 0.65).

The vast majority of Veterans with a new diagnosis of CLD did not complete a liver specialty care visit in VA. Even among those with more severe liver disease, few completed a visit. Future studies should identify reasons for visit non-completion and develop potential solutions, especially for those with severe disease.

These results highlight a remarkably low visit completion rate for specialty care clinic among Veterans with CLD. Regression results identify distance as one potential barrier, which might be addressable using virtual care modalities. However, further studies to assess why patients do not complete a visit are needed (e.g., consultation not needed by primary care, inappropriate lack of referral, appointment non-attendance by Veteran), particularly those with more severe liver disease where data have shown benefit and specialist engagement is needed to initiate transplant evaluation.