Study Reveals Factors Associated with Increased VA Preventable Acute Care Use
Ambulatory care sensitive conditions (ACSCs) are those for which experts predict the greatest reductions in preventable adverse outcomes through the provision of high-quality ambulatory care, e.g., hypertension, diabetes, pulmonary disease, congestive heart failure, and other chronic illnesses. Mental health disorders have been associated with worse access and quality of ambulatory care but have received surprisingly little attention in the context of new primary care models given their known potential impacts on costs and outcomes. This two-year, longitudinal study is part of the Veterans Assessment and Improvement Laboratory for Patient Centered Care — a VA-funded initiative started in 2010 for assisting and studying the implementation of VA's Patient Aligned Care Teams (PACT) comprehensive primary care model. Investigators sought to identify whether mental illness and other characteristics of primary care patients are related to risk for an acute ACSC event. They identified 18,526 Veterans who received VA healthcare at least twice during FY09 at one of five primary care practices in three VAMCs. They then compared rates, risks, and costs of ACSC-related acute events during a follow-up year (FY10) for Veterans with and without mental illness. Variables included diagnoses, severity of illness, non-VA insurance, and demographics.
- Prior mental health diagnoses and medication use were independent risk factors for ACSC-related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved.
- The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses.
- The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses).
- Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups.
- Investigators used ICD-9 diagnoses to identify mental health conditions, which may under-represent Veterans with disorders such as depression.
- This study did not have access to data on non-VA healthcare utilization.
- Investigators were unable to assess causality.
Drs. Yoon and Barnett, and Mr. Chow are part of HSR&D's Health Economics Resource Center, Menlo Park, CA. Drs. Yano, Rubenstein, Cordasco, and Stockdale are part of HSR&D's Center for the Study of Healthcare Provider Behavior, Sepulveda, CA.
Yoon J, Yano E, Altman L, Cordasco K, Stockdale S, Chow A, Barnett P, and Rubenstein L. Reducing Costs of Acute Care Use for Ambulatory Care Sensitive Medical Conditions: The Central Roles of Co-Morbid Mental Illness. Medical Care 2012 Aug;50(8):705-13.