For High-Risk Veterans, Fragmented Care from Multiple Providers Does Not Increase Risk of Hospitalization and May Lower Hospitalization for Ambulatory Care-Sensitive Conditions

BACKGROUND:
Care fragmentation – dispersion of a patient’s care across clinicians and healthcare settings – is a common challenge for patients, particularly for those with multiple chronic conditions. Substantial literature has documented the potential risks associated with fragmented care, including information loss and duplicative tests. This longitudinal study sought to examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization. Using VA and Medicare data, investigators identified 130,704 VA patients ages 65 and older with a high risk of hospitalization and four or more outpatient visits in FY2014, who were continuously enrolled in Medicare in FY2014-15. They also examined how fragmentation varied by patients’ demographics, history of homelessness, comorbidities, and mental healthcare use. The main outcome was all-cause VA, Community Care, or Medicare hospitalization in FY2015. Secondary analyses examined hospitalizations for ambulatory care-sensitive conditions (ACSCs), such as asthma, angina, congestive heart failure, dehydration, and pneumonia.

FINDINGS:

• Among this cohort of VA patients at high risk for hospitalization, fragmented outpatient care did not increase Veterans’ likelihood of future admission and, in fact, was associated with a lower likelihood of hospitalization for ambulatory care-sensitive conditions.
• Veterans with greater medical complexity and mental healthcare use experienced more outpatient care fragmentation, but the association between this fragmentation and all-cause hospitalization was close to zero after adjusting for clinical and sociodemographic factors.

IMPLICATIONS:

• Findings suggest that dispersed care might not be problematic for patients with high levels of need, especially when they receive care within an integrated healthcare system, such as VA.

LIMITATIONS:

• The period of investigation preceded the Choice and MISSION Acts that expanded access to community care for Veterans, so evaluations of fragmentation in the current climate will be critical.
• The observational design of this study is subject to bias from residual confounding on account of unmeasured covariates.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 15-316). Dr. Zulman and Mss. Greene and Slightam are part of HSR&D’s Center for Innovation to Implementation in Palo Alto, CA.

Zulman D, Greene L, Slightam C, et al. Outpatient Care Fragmentation in Veterans Affairs Patients at High Risk for Hospitalization. Health Services Research. February 18, 2022; online ahead of print.