Patients' Experience of Specialty Care Coordination: Survey Development and Validation.

Purpose: Specialty care coordination relies on information flowing bidirectionally between all three participants in the "specialty care triad" - patients, primary care providers (PCPs), and specialists. Measures of coordination should strive to account for the perspectives of each. As we previously developed two surveys to measure coordination of specialty care as experienced by PCPs and specialists, this study aimed to develop and evaluate the psychometric properties of a related survey of specialty care coordination as experienced by the patient, thereby completing the suite of surveys among the triad. Methods: We developed a draft survey based on literature review, patient interviews, adaptation of existing measures, and development of new items. Survey responses were collected via mail and online in two waves, August 2019-November 2019 and September 2020-May 2021, among patients (N=939) receiving medical specialty care and primary care in the Veterans Affairs health system. Exploratory and confirmatory factor analysis were used to assess scale structure. Multiple linear regression was used to examine the relationship of the final coordination scales to patients' overall experience of specialty care coordination. Results: A 38-item measure representing 10 factors that assess the patient's experience of coordination in specialty care among the patient, PCP, and specialist was finalized. Scales demonstrated good internal consistency reliability and, together, explained 59% of the variance in overall coordination. Analyses revealed an unexpected construct describing organization of care between patient and specialist that accounted for patient goals and preferences; this 10-item scale was named Patient-Centered Care Coordination. Conclusions: The final survey, Coordination of Specialty Care - Patient, or CSC-Patient for short, is a reliable instrument that can be used alone or with its companions (CSC-PCP, CSC-Specialist) to provide a detailed assessment of specialty care coordination and identify targets for coordination improvement.

Adaptations for remote research work: a modified web-push strategy compared to a mail-only strategy for administering a survey of healthcare experiences.

BACKGROUND: The COVID-19 pandemic required that our research team change our mail-only (MO) strategy for a research survey to a strategy more manageable by staff working remotely. We used a modified web-push approach (MWP), in which patients were mailed a request to respond online and invited to call if they preferred the questionnaire by mail or phone. We also changed from a pre-completion gift to a post-completion gift card incentive. Our objective is to compare response patterns between modes for a survey that used an MO strategy pre-pandemic followed by an MWP strategy peri-pandemic for data collection. METHODS: Observational study using data from a national multi-scale survey about patients' experience of specialty care coordination administered via MO in 2019 and MWP from 2020 to 2021 to Veterans receiving primary care and specialty care within the Veterans Health Administration (VA). We compared response rates, respondent characteristics and responses about care coordination between MO and MWP, applying propensity weights to account for differences in the underlying samples. RESULTS: The response rate was lower for MWP vs. MO (13.4% vs. 36.6%), OR = 0.27, 95% CI = 0.25-0.30, P < .001). Respondent characteristics were similar across MO and MWP. Coordination scale scores tended to be slightly higher for MWP, but the effect sizes for these differences between modes were small for 9 out of 10 scales. CONCLUSIONS: While the logistics of MWP survey data collection are well-suited to the remote research work environment, response rates were lower than those for the MO method. Future studies should examine addition of multi-mode contacts and/or pre-completion incentives to increase response rates for MWP.

Variation in telehealth use for endocrine care: Patterns and predictors under the "new normal".

INTRODUCTION: Use of telehealth for outpatient endocrine care remains common since onset of the COVID-19 pandemic, though the context for its use has matured. We aimed to describe the variation in telehealth use for outpatient endocrine visits under these "new normal" conditions and examine the patient, clinician-, and organization-level factors predicting use. METHODS: Retrospective cross-sectional study using data from the U.S. Department of Veterans Affairs (VA) Corporate Data Warehouse on 167,017 endocrine visits conducted between 3/9/21 and 3/8/22. We used mixed effects logistic regression models to examine 1) use of telehealth vs. in-person care among all visits and 2) use of telephone vs. video among the subsample of telehealth visits. RESULTS: Visits were in person (58%), by telephone (29%), or by video (13%). Unique variability in telehealth use at each level of the analysis was 56% patient visit, 24% clinician, 18% facility. The strongest predictors were visit type (first vs. follow up) and clinician and facility characteristics. Among telehealth visits, unique variability in telephone (vs. video) use at each level was 44% patient visit, 24% clinician, 26% facility. The strongest predictors of telephone vs. video were visit type, patient age, and percent of the facility's population that was rural. CONCLUSIONS: We found wide variation in use of telehealth for endocrinology under the "new normal". Future research should examine clinician and facility factors driving variation, as many may be amenable to influence by clinical leaders and leveraged to enhance the availability of telehealth for all clinically appropriate patients.

Comparison of Endocrinologists' Physical Examination Documentation for In-person vs Video Telehealth Diabetes Visits.

Objective: Outpatient diabetes mellitus (DM) care over video telehealth (TH) requires modifications to how endocrinologists complete physical examinations (PEs). But there is little guidance on what PE components to include, which may incur wide variation in practice. We compared endocrinologists' documentation of DM PE components for in-person (IP) vs TH visits. Methods: Retrospective chart review of 200 notes for new patients with DM from 10 endocrinologists (10 IP and 10 TH visits each) in the Veterans Health Administration between April 1, 2020, and April 1, 2022. Notes were scored from 0 to 10 based on documentation of 10 standard PE components. We compared mean PE scores for IP vs TH across all clinicians using mixed effects models. Independent samples t-tests were used to compare both mean PE scores within clinician and mean scores for each PE component across clinicians for IP vs TH. We described virtual care-specific and foot assessment techniques. Results: The overall mean (SE) PE score was higher for IP vs TH (8.3 [0.5] vs 2.2 [0.5]; P < .001). Every endocrinologist had higher PE scores for IP vs TH. Every PE component was more commonly documented for IP vs TH. Virtual care-specific techniques and foot assessment were rare. Conclusions: Our study quantifies the degree to which Pes for TH were attenuated among a sample of endocrinologists, raising a flag that process improvements and research are needed for virtual Pes. Organizational support and training could help increase PE completion via TH. Research should examine reliability and accuracy of virtual PE, its value to clinical decision-making, and its impact on clinical outcomes.

Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C.

BACKGROUND: Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations. OBJECTIVE: This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care. DESIGN: Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients. PARTICIPANTS: Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5). KEY RESULTS: All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care. CONCLUSIONS: Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

Is the Availability of Direct-Acting Antivirals Associated with Increased Access to Hepatitis C Treatment for Homeless and Unstably Housed Veterans?

OBJECTIVE: Hepatitis C virus (HCV) treatment has experienced a rapid transformation in the USA. New direct-acting antiviral (DAA) medications make treatment easier, less toxic, and more successful (90% or greater viral cure) than prior, interferon-based HCV medications. We sought to determine whether DAAs may have improved access to HCV treatment for hard-to-reach populations such as the homeless. METHODS: In a retrospective study of VA electronic medical record data, a cohort was created of 63,586 veterans with a positive HCV RNA or genotype test taken at any point from January 1, 2012, through December 31, 2016. Patient data were examined for up to 5 years using a discrete time survival model to assess the relationship between their housing status and receipt of HCV medications in 6-month time periods in both the interferon and DAA eras. RESULTS: In the interferon era, the probability of HCV treatment in a given 6-month window among housed veterans, at 6.2% (95% CI: 5.3-7.1%) was significantly higher than among veterans who were homeless or unstably housed; for example, among currently homeless veterans, the probability of treatment initiation, in a given 6-month window, was 2.6% (95% CI: 1.9-3.3%). With the arrival of DAAs, each housing category had an increased probability of treatment initiation. For housed veterans, the probability was 8.6% (95% CI: 8.3-8.9%) while for currently homeless veterans, it was 6.3% (95% CI: 5.7-6.9%). CONCLUSIONS: We found a clear indication that the likelihood of treatment initiation was greater for all veterans in the DAA era as compared to the interferon era. However, disparities in treatment initiation rates between housed and homeless veterans that were observed in the interferon era persisted in the DAA era.

The Effect of Clinicians' Personal Acquaintance on Specialty Care Coordination as the Sharing of an EHR Increases.

We used an online survey to measure how personal acquaintance with referring primary care providers (PCPs) affects specialists' experience of care coordination as use of a shared electronic health record (EHR) increases. Only 9% of specialists rated Overall Coordination as 9 or 10 out of 10. Personal acquaintance positively impacted Overall Coordination and all measured coordination subdomains. This effect was attenuated, but persisted, even at higher levels of EHR sharing. The impact of a shared EHR alone was limited to Overall Coordination and the Data Transfer subdomains. Health systems can improve coordination through investment in clinician relationships, while research should address the gaps in coordination even with widespread personal acquaintance and shared EHRs.

Concerns of Primary Care Clinicians Practicing in an Integrated Health System: a Qualitative Study.

BACKGROUND: Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration. OBJECTIVE: To improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system. DESIGN: We analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA. PARTICIPANTS: A total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not. APPROACH: The data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme. KEY RESULTS: VHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals. CONCLUSION: PCCs in integrated health systems feel many of the same pressures as their counterparts in non-integrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

Electronic consultations (E-consults) and their outcomes: a systematic review.

OBJECTIVE: Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes. MATERIALS AND METHODS: We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome. RESULTS: We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias. CONCLUSION: Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders.

BACKGROUND: Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs. METHODS: We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS). RESULTS: Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs. CONCLUSIONS: Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.

Tools to improve referrals from primary care to specialty care.

OBJECTIVES: Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness of referrals are common. We examined (1) whether 3 tools to coordinate specialty care are associated with better referral characteristics and (2) whether greater perceived helpfulness of these tools is associated with better referral characteristics among specialists who use all 3 of them. STUDY DESIGN: National online survey about care coordination among medical specialists receiving referrals in the Veterans Health Administration. METHODS: Adjusted odds ratios (ORs) for associations between use and helpfulness of 3 coordination tools (service agreements, referral templates, and e-consults) and perceived frequency of 3 referral characteristics (appropriateness, clarity, and completeness). RESULTS: Among specialists (N = 497), use of referral templates was associated with perceptions that referrals were more frequently appropriate (adjusted OR, 1.5; 95% CI, 1.0-2.4), clear (adjusted OR, 1.6; 95% CI, 1.0-2.5), and complete (adjusted OR, 1.9; 95% CI, 1.1-3.2). Use of e-consults was associated with more frequent referral clarity (adjusted OR, 1.7; 95% CI, 1.0-3.0). Among specialists using all 3 tools, those reporting that templates were very helpful also perceived more frequent referral clarity (adjusted OR, 3.1; 95% CI, 1.1-8.5) and completeness (adjusted OR, 3.6; 95% CI, 1.5-8.7). Service agreements were not associated with any referral characteristic. CONCLUSIONS: Well-designed referral templates may help improve the clarity and completeness of primary care-specialty care referrals. Existing templates may provide models that can be adapted in collaboration with primary care and broadly applied to improve referrals. Work is needed to improve the impact of service agreements and e-consults on referrals.

A novel application of process mapping in a criminal justice setting to examine implementation of peer support for veterans leaving incarceration.

BACKGROUND: Between 12,000 and 16,000 veterans leave incarceration every year, yet resources are limited for reentry support that helps veterans remain connected to VA and community health care and services after leaving incarceration. Homelessness and criminal justice recidivism may result when such follow-up and support are lacking. In order to determine where gaps exist in current reentry support efforts, we developed a novel methodological adaptation of process mapping (a visualization technique being increasingly used in health care to identify gaps in services and linkages) in the context of a larger implementation study of a peer-support intervention to link veterans to health-related services after incarceration ( https://clinicaltrials.gov/ , NCT02964897, registered November 4, 2016) to support their reentry into the community. METHODS: We employed process mapping to analyze qualitative interviews with staff from organizations providing reentry support. Interview data were used to generate process maps specifying the sequence of events and the multiple parties that connect veterans to post-incarceration services. Process maps were then analyzed for uncertainties, gaps, and bottlenecks. RESULTS: We found that reentry programs lack systematic means of identifying soon-to-be released veterans who may become their clients; veterans in prisons/jails, and recently released, lack information about reentry supports and how to access them; and veterans' whereabouts between their release and their health care appointments are often unknown to reentry and health care teams. These system-level shortcomings informed our intervention development and implementation planning of peer-support services for veterans' reentry. CONCLUSIONS: Systematic information sharing that is inherent to process mapping makes more transparent the research needed, helping to engage participants and operational partners who are critical for successful implementation of interventions to improve reentry support for veterans leaving incarceration. Even beyond our immediate study, process mapping based on qualitative interview data enables visualization of data that is useful for 1) verifying the research team's interpretation of interviewee's accounts, 2) specifying the events that occur within processes that the implementation is targeting (identifying knowledge gaps and inefficiencies), and 3) articulating and tracking the pre- to post-implementation changes clearly to support dissemination of evidence-based health care practices for justice-involved populations.

A Novel Measure to Assess Variation in Hepatitis C Prevalence Among Homeless and Unstably Housed Veterans, 2011-2016.

We constructed a novel measure of homelessness to examine differences in hepatitis C virus (HCV) prevalence across 3 categories of unstably housed and homeless veterans and across US Department of Veterans Affairs Medical Center facilities. We used Veterans Affairs administrative data to classify a cohort of 434 240 veterans as at risk of homelessness, currently homeless, or formerly homeless, and we examined variation in HCV prevalence by using descriptive measures and mixed-effect logistic regression models. HCV prevalence was highest among veterans who were formerly homeless (16.7%; 32 490 of 195 000), followed by currently homeless (12.4%; 22 050 of 178 056) and at risk of homelessness (8.2%; 5015 of 61 184). Veterans Affairs Medical Center-level prevalence ranged from 5.4% to 21.5%. Differences in HCV prevalence were significant by sex, race/ethnicity, and age. Targeting specific populations of homeless veterans for tailored HCV interventions and allocating additional resources to certain Veterans Affairs Medical Centers may be warranted.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System.

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

Cardiovascular disease risk factors among women veterans at VA medical facilities.

BACKGROUND: Hypertension, hyperlipidemia, diabetes, and obesity in middle adulthood each elevate the long-term risk of cardiovascular disease (CVD). The prevalence of these conditions among women veterans is incompletely described. OBJECTIVE: To describe the prevalence of CVD risk factors among women veterans in middle adulthood. DESIGN: Serial cross-sectional studies of data from the Diabetes Epidemiologic Cohorts (DEpiC), a national, longitudinal data set including information on all patients in the Veterans Health Administration (VA). PARTICIPANTS: Women veterans (n = 255,891) and men veterans (n = 2,271,605) aged 35-64 receiving VA care in fiscal year (FY) 2010. MAIN MEASURES: Prevalence of CVD risk factors in FY2010 by age and, for those aged 45-54 years, by race, region, period of military service, priority status, and mental illness or substance abuse; prevalence by year from 2000 to 2010 in women veterans receiving VA care in both 2000 and 2010 who were free of the factor in 2000. KEY RESULTS: Hypertension, hyperlipidemia, and diabetes were common among women and men, although more so among men. Hypertension was present in 13 % of women aged 35-44 years, 28 % of women aged 45-54, and 42 % of women aged 55-64. Hyperlipidemia prevalence was similar. Diabetes affected 4 % of women aged 35-44, and increased more than four-fold in prevalence to 18 % by age 55-64. The prevalence of obesity increased from 14 % to 18 % with age among women and was similarly prevalent in men. The relative rate of having two or more CVD risk factors in women compared to men increased progressively with age, from 0.55 (35-44 years) to 0.71 (45-54) to 0.73 (55-64). Most of the women with a factor present in 2010 were first diagnosed with the condition in the 10 years between 2000 and 2010. CONCLUSIONS: CVD risk factors are common among women veterans aged 35-64. Future research should investigate which interventions would most effectively reduce risk in this population.

Does diabetes care differ by type of chronic comorbidity?: An evaluation of the Piette and Kerr framework.

OBJECTIVE: To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes. RESEARCH DESIGN AND METHODS: Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA(1c) and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency. RESULTS: Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA(1c) <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83-1.11]) and lower in the discordant (0.90 [0.81-0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category. CONCLUSIONS: Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.

Primary care and health outcomes among older patients with diabetes.

OBJECTIVE: The aim of this study was to measure the relationship between days spent waiting for primary care and health outcomes among patients diagnosed with diabetes, especially among the elderly population. DATA SOURCE: Secondary data from VA administrative databases and Medicare claims. STUDY DESIGN: This is a retrospective observational study. Outcome variables include primary care utilization, mortality, heart attack, stroke, and ambulatory-care sensitive condition (ACSC) hospitalization. The main explanatory variable of interest is VA primary care wait time. Negative binomial models predict utilization and stacked logistic regression models predict the probability of experiencing each health outcome. Models are stratified by the presence of a selected health condition and age. PRINCIPAL FINDINGS: Longer wait times were predicted to decrease utilization between 2 and 4 percent. There was no significant relationship between wait times and health outcomes for the overall sample. In stratified analyses, longer waits were associated with undesirable outcomes for those over age 70 with one of the selected health conditions or in certain narrower 5-year age groups, but the overall pattern of results does not indicate a systematic and significant effect. CONCLUSIONS: There was a modest effect of long wait times on primary care utilization but no robust effect of longer wait times on health outcomes. Waiting for care did not significantly compromise long-term health outcomes for veterans with diabetes.

Gender disparities in lipid-lowering therapy among veterans with diabetes.

PURPOSE: We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia. METHODS: We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of patients with any prescription for lipid-lowering therapy in the year and, among those with elevated low-density lipoprotein cholesterol (LDL >100 mg/dL) and no prior treatment, we compared initiation of lipid-lowering therapy. We used multiple logistic regression to estimate odds ratios (AOR) and 95% confidence intervals (CI), adjusting for race, VA eligibility, health care utilization, cardiovascular diseases, mental health conditions, and a comprehensive list of other comorbidities. We also performed the analysis stratified by age. FINDINGS: Women had higher LDL levels than men (110 ± 38 vs. 101 ± 36 mg/dL) and were less likely to be receiving lipid-lowering therapy (80% vs. 84%; AOR, 0.79; 95% CI, 0.76-0.82) or to be initiated on such therapy (37% vs. 42%; AOR, 0.82; 95% CI, 0.74-0.90). Differences were greatest in the youngest women (<45 years old) for both any lipid-lowering therapy (61% vs. 75%; AOR, 0.50; 95% CI, 0.45-0.56) and initiation of therapy (26% vs. 38%; AOR, 0.55; 95% CI, 0.42-0.73). Adjustment for potential confounders did not change the risk estimates. CONCLUSION: Women veterans with diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men, especially among younger age groups. This disparity is of concern, because early intervention to control hyperlipidemia can reduce the later burden of cardiovascular disease among diabetic women.

Outpatient wait time and diabetes care quality improvement.

OBJECTIVE: To examine the relationship between glycated hemoglobin (A1C) levels and the number of days spent waiting for primary care appointments. STUDY DESIGN: Retrospective observational study that relied on Department of Veterans Affairs (VA) utilization data and Medicare claims data from 2001 to 2003. The outcome was A1C levels. The main explanatory variable of interest was facility-level primary care wait times measured in days. METHODS: Heckman selection models simultaneously predicted the presence of an A1C value and its level. Models were risk adjusted for prior individual health status. Separate models were estimated on the entire sample and on subsamples stratified by baseline A1C levels. RESULTS: Veterans who visited VA facilities with wait times of longer than 32.5 days had small significant increases in A1C levels of 0.14 percentage point for the whole sample, 0.07 percentage point for patients with baseline A1C levels less than 7%, 0.11 percentage point for patients with baseline A1C levels between 7% and 8%, and 0.18 percentage point for patients with baseline A1C levels greater than 8%. CONCLUSIONS: Decreasing wait times has the potential to reduce A1C levels by 0.18 percentage point for patients with baseline A1C levels exceeding 8%. This effect is roughly one-third of what is achieved with the most successful existing quality improvement strategies. Ensuring timely access to outpatient care could be an important addition to future diabetes care quality improvement programs.