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Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications


BACKGROUND:
Because of the aging Veteran population and range of dementia risk factors among Veterans (e.g., traumatic brain injury, depression, PTSD), the prevalence of dementia in this patient population is expected to double by 2030. However, dementia care is a challenge. For example, the average patient with dementia has four comorbidities and receives care from five different providers. In addition, recent federal policy changes aimed at expanding access to care (i.e., Affordable Care Act) may make it more difficult for VA to improve care coordination. This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of 75,829 Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible [80% VA-only users and 20% dual VA/Medicare users]. Using data from VA and the Centers for Medicare & Medicaid Services, investigators examined three specific indications of potentially unsafe medication exposure (PUM): 1) exposure to any high-risk drug to be avoided by older adults; 2) exposure to prescriptions with a score of >3 on the anticholinergic cognitive burden scale (ACB); and 3) any prescription for an antipsychotic medication. They also calculated number of days of exposure to these medications. Covariates included patient demographics, distance to the nearest VAMC, county-level rurality, VA priority status, and use of VA home-based primary care in 2009.

FINDINGS:

  • The prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to PUM overall –and to any "high-risk medications to avoid in older adults."
  • Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of PUM-ACB exposure were 2 times higher for dual-users compared to VA-only users, and the odds of antipsychotic PUM exposure were 1.5 times greater for dual-users.

IMPLICATIONS:

  • Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans' access to non-VA care – and to protect vulnerable patients from risks associated with dual system use.

LIMITATIONS:

  • Given the lack of information on characteristics of VA and Medicare prescribers, investigators were unable to determine the role of prescriber characteristics in their findings.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 12-379). Drs. Joshua and Carolyn Thorpe and Dr. Gellad are part of HSR&D's Center for Health Equity Research & Promotion (CHERP) in Pittsburgh.


PubMed Logo Thorpe J, Thorpe C, Gellad W, et al. Dual Healthcare System Use and High-Risk Prescribing in Dementia Patients: A National Cohort Study. Annals of Internal Medicine. December 6, 2016;e-pub ahead of print.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.