Continuity of care and health care cost among community-dwelling older adult veterans living with dementia

Abstract

Objectives: To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia.

Data sources: Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015.

Study design: FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.

Data collection: Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).

Principal findings: Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost.

Conclusions: COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

Keywords: VA health care system; aging/elderly/geriatrics; dementia; health care cost; instrumental variables; primary care.