Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans

Abstract

Importance: Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described.

Objective: To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA).

Design, setting, and participants: This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019.

Exposures: Risk of hospitalization and assignment to general vs specialized primary care.

Main outcome and measures: High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care).

Results: The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall.

Conclusions and relevance: The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.

Figure 1.. Distribution of Where 351 012 High-Risk Veterans Received Primary Care as of September 30, 2015

Figure 2.. Proportions of 4 309 192 High-Risk Patients in Veterans Health Administration General Primary Care and 7 Specialized Primary Care Settings

Data as of September 30, 2015. ^aP < .05 when comparing general primary care with each specialized primary care setting using Tukey-style multiple comparisons of proportions.

Figure 3.. Mean Number of Veterans Health Administration Ambulatory Encounters During 1 Year Among High-Risk Patients by Primary Care Setting

Mean counts of any in-person primary care (general or specialized), any mental health, any medical specialty, or any emergency department (ED) face-to-face visit from October 1, 2015, to September 30, 2016. Other encounters include any outpatient telephone, telehealth, surgical, radiology, rehabilitation, and procedural visits. Quantitative results are also given in eTable 2 in the Supplement. Two-sample t tests were used for each encounter type comparing patients enrolled in general vs specialized primary care. We performed the Tukey multiple comparison procedure to assess differences in means. ^aP < .05. ^bP < .001.