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IIR 03-151 – HSR&D Study

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IIR 03-151
VA and non-VA Rehabilitation Utilization by Veterans with Acute Stroke
Huanguang Jia PhD MPH BA
North Florida/South Georgia Veterans Health System, Gainesville, FL
Gainesville, FL
Funding Period: July 2004 - June 2006

BACKGROUND/RATIONALE:
No research has been done on the dual utilization of VA and Medicare or VA and Medicaid by veteran stroke patients. Little is known about which veteran stroke patients have used rehabilitation services within the VA system only, and who have used VA and Medicare and/or VA and Medicaid-funded services. Likewise, little is known about the differences in rehabilitation related outcomes between these user groups.

OBJECTIVE(S):
This purpose of this retrospective observational cohort study is to understand the utilization and outcomes of stroke rehabilitation services by veterans living in the state of Florida who used a single source of care (VA only) versus those patients who received care from multiple sources (VA and Medicare, VA and Medicaid, and VA, Medicare and Medicaid), in calendar years (CY) 2000 and 2001.

METHODS:
This retrospective observational cohort study used secondary data gathered from three major sources: Austin Automation Center for VHA data, VA Information Resource Center for Medicare data, and Florida Agency for Health Care Administration for Medicaid data. From the inpatient datasets, we identified 1,953 study patients who lived in Florida; had a primary inpatient diagnosis matching Reker’s high sensitivity stroke ICD-9 codes; and were confirmed veterans between calendar year 2000 and 2001. Patient demographic and clinical characteristics were examined using descriptive statistics. After adjusting for risk factors, a multinomial logit model was constructed to predict out-of-system utilization, and a multivariable logistic regression model was fitted for the study of each outcome measure (12-month rehospitalization and mortality as well as discharge to home at index).

FINDINGS/RESULTS:
Of the 1,953 study patients, 30% used VHA-only care within the first 12 months post-stroke and 70% relied on VHA and other health care programs as well. The user groups were demographically and clinically distinctive. Patients who had their initial inpatient stroke care under VHA received less rehabilitation services during their inpatient and 12-month follow-up outpatient care than Medicare-initial inpatients. Many multiple systems users obtained their post-acute rehabilitation services from VHA outpatient clinics. We predicted that the older and frequent acute care VHA stroke patients were more likely to be either VHA-Medicare or triple users, whereas younger and long-term care users were more likely to be VHA-Medicaid or VHA-only users. The Medicare- and Medicaid-initial inpatients were less likely to be discharged home from their index admission when compared to the VHA-initial inpatients. Further, the multiple-source users were more likely to be rehospitalized for any cause and for recurrent stroke within the first 12 months post index as compared to the VHA-only users. Mortality outcomes depended on when the outcome was measured: If measured from the index admission date, no significant difference across the user groups occurred; if measured from the index discharge date, the VHA-only users were less likely to die within the first 12 months than users of the two dual groups.

IMPACT:
As the first study to examine the utilization and related outcomes of VHA stroke patients who used multiple sources of care, our findings suggest that using multiple sources for post-acute care was common among VHA stroke patients in Florida. In addition, while VHA-initial inpatients received less rehabilitation services than the Medicare patients, VHA provided a safety net for multiple-system enrollee users who need rehabilitation care post-stroke; older and acute-care patients were more likely to be VHA-Medicare dual or triple-system users whereas younger and long-term care patients were more likely to be VHA-Medicaid or VHA-only users; VHA inpatients were more likely to be discharged home than Medicare and Medicaid inpatients; multiple-system users were more likely to be rehospitalized; and the mortality outcomes were dependent on when the outcome was measured. These findings are limited to VHA enrollee stroke patients who lived in Florida between 2000 and 2001. Future research is necessary, particularly at the national level, to compare the outcomes of different user groups and understand factors such as accessibility, scope of services of each system, benefits under each plan, and patient satisfaction due to possible impacts on patient preference and choice of care across different systems. These findings may help improve VA clinicians’ understanding of their patients’ characteristics, continuum of care post-stroke, and the importance of considering dual or triple system usage when conducting program evaluations for healthcare systems with a high proportion of dual or triple enrollees.

PUBLICATIONS:

Journal Articles

  1. Jia H, Zheng Y, Reker DM, Cowper DC, Wu SS, Vogel WB, Young GC, Duncan PW. Multiple system utilization and mortality for veterans with stroke. Stroke; A Journal of Cerebral Circulation. 2007 Feb 1; 38(2):355-60.
  2. Jia H, Zheng YE, Cowper DC, Stansbury JP, Wu SS, Vogel WB, Duncan PW. Race/Ethnicity: who is counting what? Journal of rehabilitation R&D / Veterans Administration, Department of Medicine and Surgery, Rehabilitation R&D Service. 2006 Sep 30; 43(4):475-484.
  3. Jia H, Zheng E, Cowper DC, Wu SS, Vogel WB, Duncan PW, Reker DM. How Veterans Use Stroke Services in the VA and Beyond. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2006 Jun 1; 23(6):21-24.
Journal Other

  1. Jia J, Cowper Ripley DC, Reker DM, Vogel WB, Marshall C, Bidelspach D. How Does Access to Inpatient Rehabilitation Services Affect Veterans' Outcomes? Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2006 Sep 1; 23(9):8; 11.
Conference Presentations

  1. Chuang HC, Jia H, Cowper Ripley DC, Vogel WB, Wu SS, Chen JG, Litt E, Reker DM. Factors Related to Preventable Hospitalization among VHA Stroke Patients. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD.
  2. Cowper DC, Jia H, Qin H, Reker DM. Veterans, Multiple System Use, and Stroke Rehabilitation: Who Gets What from Where? Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  3. Jia H, Cowper DC, Wu SS, Vogel WB, Zheng Y, Reker DM. Workshop Presentation: Combining veterans' healthcare data from VHA and Medicare: methodological issues and research examples. Paper presented at: VA HSR&D National Meeting; 2007 Feb 16; Arlington, VA.
  4. Hynes DM, Mallin K, Koelling K, Stroupe K, Kwon S, Jia H. Combining Veterans' Health Care Data from VHA and Medicare: Methodological Issues and Research Examples. Presented at: VA HSR&D National Meeting; 2007 Feb 15; Arlington, VA.
  5. Zheng Y, Jia H, Reker DM, Cowper DC, Wu SS, Vogel WB. VHA and non-VHA Post-stroke Rehospitalization of Veterans with Acute Stroke. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.


DRA: Health Systems
DRE: none
Keywords: Managed care, Stroke, VA/non-VA comparisons
MeSH Terms: Utilization, Rehabilitation, Cerebrovascular Accident

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