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IIR 12-331 – HSR&D Study

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IIR 12-331
Understanding Dual Use and Other Potential Determinants of Heart Failure Outcomes
Robert Neal Axon MD MS BS
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: December 2013 - November 2017

BACKGROUND/RATIONALE:
Heart failure (HF) is a serious health condition currently affecting 5.8 million Americans and is associated with high mortality. Among Veterans, it is the most frequent cause for hospital admission and one of the most frequent causes of unplanned hospital readmission. Dual use occurs frequently in Veterans when those enrolled for VA care also receive care from non-VA providers or facilities. Evidence suggests that dual use is associated with increased healthcare utilization, costs, and worse health outcomes, including increased risk of death. Veterans receiving care at non-VA facilities risk potentially inefficient information exchange, duplicated medical tests and procedures, delays in care, and barriers to follow up. However, very little is known regarding reasons for dual use, predictors of dual use, and impact of dual use on important clinical endpoints in Veterans with HF.

OBJECTIVE(S):
Study objectives are to:
1) Understand why Veterans with HF use non-VA facilities for care.
Specific Aim 1: To characterize perceptions regarding access to VA and non-VA care, dual use, and HF care quality among Veterans with HF and VA/non-VA healthcare providers.
2) Quantify patient, provider and systems level predictors of dual use in Veterans with HF.
Specific Aim 2: Determine patient-level and provider/systems-level factors associated with differential health-services utilization and outcomes among Veterans treated for HF.
3) Design and evaluate potential interventions focused on addressing dual use and improving HF outcomes.
Specific Aim 3: To integrate data from secondary data analyses and key stakeholder interviews to facilitate the design and formative evaluation of interventions focused on reducing unplanned and potentially preventable HF hospitalizations.

METHODS:
For Aim 1, we will conduct semi-structured interviews using grounded theory to explore perceptions of access to care, dual use, and HF care quality. For Aim 2, we will merge VA/Medicare data for Veterans with HF in SC with comprehensive ED/hospitalization data from the SC Office Revenue and Fiscal Affairs as well as hospital data from American Hospital Association and quality data from CMS. For Aim 3, data from Aims 1 and 2 will be synthesized and used to design novel programs to reduce avoidable HF hospitalizations and readmissions. Finally, in response to calls for formative evaluation in intervention planning, we will conduct focus group sessions with patients and providers to assess the feasibility and acceptability of planned interventions to improve care for Veteran dual users.

FINDINGS/RESULTS:
This mixed methods study included both quantitative and qualitative analyses. Compared to VA-only users, dual users of acute heart failure care had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio (ARR) 1.15, 95% CI 1.04-1.27), hospitalization for HF (ARR 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all-cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). Veteran dual users of acute heart failure care also had higher hazard for mortality from their date of entry into the cohort (HR 1.21, 95% CI 1.11, 1.32, p<0.0001) and from the date of their last hospitalization (HR 1.40, 95% CI 1.28-1.53, p<0.0001) as compared to VA-only users. Non-VA only users did not have significantly different hazard for mortality compared to VA-only users. Additional models in a subset of patients which also included laboratory data for brain-type natriuretic peptide, blood urea nitrogen, and serum sodium yielded similar results. In separate analyses, higher rates of hospital readmission were observed in a cohort of COPD patients and in a cohort of Veteran dual users hospitalized for 15 of 18 Major Diagnostic Categories (MDC) examined.
In a qualitative study using constructivist grounded theory and content analysis to examine decision making among Veterans with HF, all-VA users generally praised specific VA providers, called services helpful, and expressed positive capacity for managing HF. Additionally, several Veterans who described inadvertent one-time non-VA healthcare utilization in emergent situations more closely mirrored all-VA users. By contrast, committed dual users more often reported unmet needs, non-response to VA requests, and faster services in non-VA facilities. In interviews with both VA- and non-VA healthcare providers, both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms of heart failure. Both groups described highly limited roles for providers in shaping choices surrounding dual use. However, VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Some non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system.

IMPACT:
By examining the impact of dual use and other factors among Veterans with HF, we now better understand some of the determinants of increased healthcare utilization and poor patient outcomes in this population. Information gained from this project has influenced the design of quality improvement projects for care coordination locally and in VISN 7. Our team also collaborated with the VA Office of Community Care to develop care transitions initiatives for Veterans hospitalized at community hospitals. Finally, this team will begin a 3-year quality improvement project in 2018 funded by the VA National Center for Patient Safety which specifically focuses on improving medication safety for Veterans receiving non-VA acute hospital and specialty care.

PUBLICATIONS:

Journal Articles

  1. Pope CA, Davis BH, Wine L, Nemeth LS, Haddock KS, Hartney T, Axon RN. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illness. 2018 Dec 1; 14(4):283-296.
  2. Chakraborty H, Axon RN, Brittingham J, Lyons GR, Cole L, Turley CB. Differences in Hospital Readmission Risk across All Payer Groups in South Carolina. Health services research. 2017 Jun 1; 52(3):1040-1060.
  3. Axon RN, Gebregziabher M, Dismuke CE, Hunt KJ, Yeager D, Ana EJS, Egede LE. Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. Journal of general internal medicine. 2016 Nov 1; 31(11):1331-1337.
  4. Axon RN, Gebregziabher M, Hunt KJ, Lynch CP, Payne E, Walker RJ, Egede LE. Comorbid depression is differentially associated with longitudinal medication nonadherence by race/ethnicity in patients with type 2 diabetes. Medicine. 2016 Jun 1; 95(25):e3983.
  5. Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure. American heart journal. 2016 Apr 1; 174:157-63.
  6. Axon RN, Coleman EA. What Will It Take to Move the Needle on Hospital Readmissions? American journal of medical quality : the official journal of the American College of Medical Quality. 2014 Jul 1; 29(4):357-9.
  7. Axon RN, Penney FT, Kyle TR, Zapka J, Marsden J, Zhao Y, Mauldin PD, Moran WP. A hospital discharge summary quality improvement program featuring individual and team-based feedback and academic detailing. The American journal of the medical sciences. 2014 Jun 1; 347(6):472-7.
Conference Presentations

  1. Axon RN. The Interaction between Rural/Urban Status and Dual Use Status among Veterans with Heart Failure. Poster session presented at: VA Rural Health State of the Science Conference; 2016 Sep 23; Washington, DC.
  2. Axon RN. Comparing Hospital Readmission and Mortality among Veteran Dual Users and All-VA users of Hospital Care for Multiple Conditions. Poster session presented at: VA Rural Health State of the Science Conference; 2016 Sep 23; Washington, DC.
  3. Axon RN, Gebregziabher MG, Everett CJ, Hunt KJ. Dual Healthcare System Use is Associated with Higher Rates of Hospitalization and Hospital Readmission Among Veterans with Heart Failure. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  4. Pope CA, Axon RN, Wine L, Davis BH. Triggers of dual use for VA and non-VA emergency department (ED) and other services: Veteran perspectives of decision-making with heart failure. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  5. Axon RN. Update in Hospital Care Transitions. Paper presented at: South Carolina American College of Physicians Annual Meeting; 2013 Oct 27; Charleston, SC.


DRA: Aging, Older Veterans' Health and Care, Health Systems, Cardiovascular Disease
DRE: Prevention
Keywords: Cardiovascular Disease, Disparities, Organizational Structure, Outcomes - Patient, Rural, Utilization
MeSH Terms: none