Receiving VA Care is Stronger Predictor of Appropriate Care for Veterans with Diabetes than Continuity of Care
BACKGROUND:
Continuity of care is considered a critical characteristic of high-performing health systems and effective patient-centered medical homes; however, evidence about the outcomes associated with continuity of care has been developed almost entirely from patients seen in a single healthcare system. Medicare-eligible Veterans who obtain all of their care in the VA healthcare system likely have different continuity of care than Veterans who have all of their care financed by the Medicare fee-for-service (FFS) program and may experience different quality of care. This retrospective cohort study examined whether quality of diabetes care was associated with care continuity or Veterans' usual source of primary care. 'Continuity of care' was defined as an ongoing interaction between patient and provider (or care team) that occurs in the same place with the same medical record. Using VA data, investigators identified 1,867 Medicare-eligible Veterans with diabetes that had two or more primary care visits at any of 72 VAMCs and 108 community clinics across the country (except Alaska) from 2001 to 2004. Using VA, Medicare, and 2000 Census data, investigators then examined three diabetes quality measures: HbA1c testing, eye exams, and urine microalbumin testing, which were performance measures tracked in VA and Medicare from 2001 to 2004.
FINDINGS:
- Reliance on VA primary care vs. Medicare FFS primary care was a stronger predictor of guideline-concordant diabetes care than continuity of care.
- When both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for three diabetes quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care. For example, Veterans who relied only on Medicare FFS for primary care were more likely to be under-provided HbA1c testing than Veterans who relied only on VA primary care. However, dual users of VA and Medicare FFS primary care were significantly more likely to be over-provided HbA1c and microalbumin testing than Veterans who used only VA primary care.
- In both VA and Medicare FFS, under-provision of diabetes care was more common than over-provision during this period (from 2001 to 2004).
LIMITATIONS:
- These results may not pertain beyond the 2001-2004 period because the introduction of Medicare Part D in 2006 and PACT (in VA) in 2010 might have changed choices Veterans face in primary care and their preferences about those choices.
- Using claims data, it was not possible to differentiate over-provision from clinically appropriate follow-up, so it's possible that a large proportion of the (low) rates of over-provision were warranted.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 04-292); Dr. Maciejewski also was supported by an HSR&D Career Scientist Award. Drs. Maciejewski and Wang are part of HSR&D's Center for Health Services Research in Primary Care in Durham, NC; and Dr. Burgess is part of HSR&D's Center for Organization, Leadership & Management Research in Boston, MA.
Maciejewski M, Wang V, Burgess Jr. J, et al. The Continuity and Quality of Primary Care. Medical Care Research and Review October 2013;70(5):497-513.
