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Rural Residence, Dual Use, and Chronic Wound Outcomes Among Veterans
Bouldin ED, Littman AJ, Rice K, Reiber GE. Rural Residence, Dual Use, and Chronic Wound Outcomes Among Veterans. Poster session presented at: Wound Healing Society Annual Meeting; 2014 Apr 26; Orlando, FL.
RURAL RESIDENCE, DUAL USE, AND CHRONIC WOUND OUTCOMES AMONG VETERANS
The VA healthcare system serves a large population of older adults, among whom the burden of chronic conditions and the risk for lower limb (LL) wounds is high. 41% of Veterans live in a rural area and half use both VA and Medicare systems (dual use) for outpatient care, resulting in fragmented and potentially poorly coordinated care. The purpose of this study was to assess whether rural residence and dual system use are associated with wound outcomes. This retrospective cohort study was conducted in the VA's Northwest Health Network and included 320 Veterans (160 rural and 160 urban) who had an incident chronic LL wound between October 1, 2006 and September 30, 2007. All wounds were identified through the VA medical record and followed up to one year. Medicare administrative files were searched to identify dual wound care during follow-up. Quality was measured as the percent of VA visits at which a wound was treated according to evidence-based guidelines for debridement, moist wound healing, and infection assessment. We used Cox proportional hazards models to calculate hazard rates for wound healing, treating amputation and death as competing risks, and adjusted for variables based on causal diagrams. 21% of rural and 19% of urban Veterans used dual wound care. Chronic wound healing did not differ by rural residence, and in fact, there was a suggestion of better wound healing among rural compared to urban patients (age- and chronic condition-adjusted HR = 1.26, 95%CI:0.98-1.63, p = 0.075). When we additionally adjusted for dual use, wound severity, and VA care quality, the results were similar (HR = 1.18, 95%CI:0.91-1.53, p = 0.22). Dual system use was associated with a 50% lower hazard rate of healing within one year (HR = 0.51, 95%CI:0.35-0.74, p < 0.001). This association was not explained by variation in the quality of VA wound care; Medicare quality and coordination should be investigated.
Authors and affiliation: Erin Bouldin,1,2 Alyson Littman, 1,2 Kenneth Rice,2 Gayle Reiber1,2
1. VA Puget Sound Health Care System, Seattle, WA; 2. University of Washington, Seattle, WA
Key words: chronic wounds, health care utilization, rural, dual use, veterans
Supported by: VA Health Services Research and Development IBA 09-061