Abstract
Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation. To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD). This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020. Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation. A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention). Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07). Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.
Highlights
Health care in the United States is marked by substantial fragmentation, with patients pursuing and receiving care from multiple clinicians, often at different institutions.[1]
In a Cox proportional hazards regression model, a low level of Continuity of care (COC) was associated with a higher likelihood of outpatient flares that required corticosteroids, hospitalizations, and surgical interventions
The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to better understanding COC and identifying opportunities to improve care fragmentation
Summary
Health care in the United States is marked by substantial fragmentation, with patients pursuing and receiving care from multiple clinicians, often at different institutions.[1]. A primary care medical home model, known as the Patient Aligned Care Team (PACT), was implemented in more than 800 clinics in the Veterans Health Administration (VHA) health care system.[5] In the PACT model, a designated primary care physician (PCP) leads a clinical care team who sees the patient regularly and coordinates care as both the point of first entry to the health system and as the principal source of referrals to specialists and other health care practitioners These efforts are less relevant to patients with complex chronic medical conditions that require comanagement with specialists
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