Lower Levels of Continuity of Care Linked to Worse IBD Outcomes for Veterans


Low levels of COC associated with a higher likelihood of outpatient flares that required corticosteroids, hospitalizations, and surgical interventions.

Shirley Cohen-Mekelburg, MD, MS

Health care fragmentation is a problem in the US, with many patients pursuing and receiving care from different clinicians and specialists at a multitude of institutions.

This can be especially a problem for veterans serving in the US Armed Forces with inflammatory bowel disease (IBD).

A team, led by Shirley Cohen-Mekelburg, MD, MS, Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, examined continuity of care (COC) models and selected outcomes in US veterans with inflammatory bowel disease.

While health care fragmentation is commonly linked to inefficiency and negative outcomes, new continuity of care models have been created to address this issue.

In the retrospective cohort study, the investigators examined data from the Veterans Health Administration (VHA) Corporate Data Warehouse to identify 20,079 veterans with IBD who received care in the VHA hospital between 2002-2014.

Included in the final analysis was patients with IBD who had a primary care physician and at least 4 outpatient visits with key physicians—gastroenterologists, primary care physicians, and surgeons—within the first year following an index IBD encounter. The patient population was 92.8% male and the median age was 59 years old.

The researchers measured care continuity with the Bice-Boxerman COC index to define care density and dispersion within year 1 following the initial presentation.

The team also used a Cox proportional hazards regression model to quantify the association between a low level of continuity-of-care 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).

In the first year of follow-up, the investigators found substantial variation in the dispersion of care (median [IQR] COC, 0.24; 95% CI, 0.13-0.46). In the Cox proportional hazards regression model, they found low levels of COC linked to a higher likelihood of outpatient flares that required corticosteroids (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 authors wrote. “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.”

Fragmented care has been associated with poor chronic disease outcomes, higher health care use, duplication in testing, and increased costs of care in the US. However, in the past decade there have been various programs created concentrated on primary care to reduce fragmentation and promote high-value coordinated care, including a primary care medical home model, known as the Patient Aligned Care Team (PACT), was implemented in more than 800 clinics in the VHA health care system.

In the PACT model, a designated primary care physician 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.

The study, “Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease,” was published online in JAMA Network Open.

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