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Chronic wound care and outcomes among older Veterans using VA and Medicare

Bouldin E, Littman AJ, Rice K, Reiber GE. Chronic wound care and outcomes among older Veterans using VA and Medicare. Poster session presented at: American Geriatrics Society Annual Meeting; 2014 May 16; Orlando, FL.

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Chronic wound care and outcomes among older veterans using VA and Medicare Erin Bouldin,1,2 Alyson Littman, 1,2 Kenneth Rice,2 Gayle Reiber1,2 1VA Puget Sound Health Care System, Seattle, WA; 2University of Washington, Seattle, WA Background: An estimated 6.5 million US patients experience chronic wounds annually, most commonly on the lower limbs (LL) of adults with multiple chronic conditions. The Veterans Health Administration (VHA) health care system serves a large population of older adults, among whom the burden of chronic conditions is high. Older Veterans may use the VHA exclusively or in conjunction with Medicare. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. The purpose of this study was to assess whether guideline-concordant care and outcomes among older Veterans with chronic LL wounds vary by dual use. Methods: This retrospective cohort study was conducted in the VA's Northwest Health Network, VISN 20, and included 156 Veterans age 65 and older who had incident chronic LL wounds between October 1, 2006 and September 30, 2007. An ulcer was considered chronic if it did not heal (completely re-epithelialize) within 30 days of the first VHA treatment visit. All wounds were identified through VHA medical record visit notes and followed for up to one year. Medicare administrative files were searched to identify dual care during the wound interval. Guideline-concordant care was measured as the percent of VHA visits during which a wound was treated according to evidence-based guidelines for sharp debridement, moist wound healing, and infection assessment. We used competing risks proportional hazards models to calculate hazard rates for wound healing, treating amputation and death as competing risks, and adjusted for variables known to be associated with wound outcomes and dual use. Results: Among the 156 Veterans included in the study, 121 (77%) received exclusive VHA wound care and 35 (23%) were VHA-Medicare dual wound care users. Dual users had marginally higher prevalence of chronic conditions (diabetes, peripheral vascular disease, and heart disease) at baseline but were otherwise similar to VHA-exclusive users. Sharp debridement, moist wound healing, and infection assessment were done at 26%, 51%, and 75% of visits for dual users and 23%, 45%, and 69% of visits for exclusive VHA users. After adjusting for age, rural residence, chronic health conditions, wound severity, and evidence-based guideline concordant care, the hazard ratio (HR) for wound healing within one year among dual users was 0.22 that for VHA-exclusive users (HR = 0.22, 95%CI:0.12-0.39, p < 0.001). Conclusions: VHA-Medicare dual system wound care use was associated with significantly poorer wound healing compared to single system (VHA-exclusive) wound care use. This association was not explained by variation in the quality of VHA wound care across users. The mechanism for the association is unclear and factors including Medicare guideline-concordance, inter-system provider coordination, and patient-level factors including adherence should be investigated. Health care providers need to be aware of dual use across systems and its potentially negative impact on wound outcomes. Supported by: VA Health Services Research and Development IBA 09-061 Contact:; 206-277-4157

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