Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services

<p>Abstract</p> <p>Background</p> <p>Older veterans may use both the Veterans Health Administration (VHA) and Medicare, but the association of dual use with health outcomes is unclear. We examined the association of indirect measures of dual use with mortality.</p> <p>Methods</p> <p>Our secondary analysis used survey, claims, and National Death Index data from the Survey on Assets and Health Dynamics among the Oldest Old. The analytic sample included 1,521 men who were Medicare beneficiaries. Veterans were classified as dual users when their self-reported number of hospital episodes or physician visits exceeded that in their Medicare claims. Veterans reporting inpatient or outpatient visits but having no Medicare claims were classified as VHA-only users. Proportional hazards regression was used.</p> <p>Results</p> <p>897 (59%) of the men were veterans, of whom 134 (15%) were dual users. Among dual users, 60 (45%) met the criterion based on inpatient services, 54 (40%) based on outpatient services, and 20 (15%) based on both. 766 men (50%) died. Adjusting for covariates, the independent effect of any dual use was a 38% increased mortality risk (AHR = 1.38; p = .02). Dual use based on outpatient services marginally increased mortality risk by 45% (AHR = 1.45; p = .06), and dual use based on both inpatient and outpatient services increased the risk by 98% (AHR = 1.98; p = .02).</p> <p>Conclusion</p> <p>Indirect measures of dual use were associated with increased mortality risk. New strategies to better coordinate care, such as shared medical records, should be considered.</p

Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes?

BACKGROUND: Millions of veterans are eligible to use the Veterans Health Administration (VHA) and Medicare because of their military service and age. This article examines whether an indirect measure of dual use based on inpatient services is associated with increased mortality risk. METHODS: Data on 1,566 self-responding men (weighted N = 1,522) from the Survey of Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to Medicare claims and the National Death Index. Dual use was indirectly indicated when the self-reported number of hospital episodes in the 12 months prior to baseline was greater than that observed in the Medicare claims. The independent association of dual use with mortality was estimated using proportional hazards regression. RESULTS: 96 (11%) of the veterans were classified as dual users. 766 men (50.3%) had died by December 31, 2002, including 64.9% of the dual users and 49.3% of all others, for an attributable mortality risk of 15.6% (p < .003). Adjusting for demographics, socioeconomics, comorbidity, hospitalization status, and selection bias at baseline, as well as subsequent hospitalization for ambulatory care sensitive conditions, the independent effect of dual use was a 56.1% increased relative risk of mortality (AHR = 1.561; p = .009). CONCLUSION: An indirect measure of veterans' dual use of the VHA and Medicare systems, based on inpatient services, was associated with an increased risk of death. Further examination of dual use, especially in the outpatient setting, is needed, because dual inpatient and dual outpatient use may be different phenomena

Approaches, strenghts, and limitations of avoidable mortality

Publication of recent papers such as the one by Schoenbaum and colleagues entitled 'Mortality Amenable to Health Care in the United States: The Roles of Demographics and Health Systems Performance' has stimulated this commentary. We discuss strengths and limitations of amenable and avoidable mortality in health-care systems' performance and their contribution to health inequalities. To illustrate, we present a case study of avoidable and amenable mortality in Spain over 27 years. We conclude that amenable mortality is not a good indicator of health-care systems' performance, or for determining whether it could give rise to health inequalities. To understand health problems and to assess the impact of interventions affecting health requires good, basic, and routine monitoring of health indicators and of socioeconomic determinants of health