Care provided by the VA Medical System has come under increasing scrutiny in recent years, but a report suggesting that high risk patients may not be receiving specialized care—a situation that may be more likely when the patients are Black—adds another level of concern. This report from June 30 is a worthwhile year-end read.
Of high-risk patients in the Veterans Health Administration (VHA), 88% were more likely to be assigned to primary care than specialized primary care, according to a new study in JAMA Network Open. Further, nearly one-quarter of patients identified as high-risk in the study were Black.
“Patients assigned to general primary care had more mental health and primary care visits than medical specialty visits,” Evelyn Chang, MD, a health policy physician-scientist with Veterans Affairs Greater Los Angeles Healthcare System, and colleagues wrote.
“Achieving the triple aim of improving patient experience of care, improving population health, and reducing per capita health care costs among high-risk patients has proved to be elusive,” the study authors noted. “Our data suggest that a better understanding of existing and optimal roles of different types of primary and specialty care for high-risk patient populations may be critical for achieving the triple aim.”
According to Said Ibrahim, MD, MPH, MBA, a population health researcher with Weill Cornell Medicine in New York, who was not affiliated with the study, the principal findings were particularly telling for specific subsets of the population.
“The authors found that male sex, marital status (not married), older age, and race (African American) were associated with higher likelihood of being identified as a high-risk patient,” Ibrahim wrote in an editorial accompanying the study. “They also found that high-risk patients, compared with low-risk patients had higher likelihood of face-to-face encounters, telephone encounters, and use of secure messaging during the year prior to being identified as high risk.”
A common assumption across the health care community, Chang and colleagues noted, has been that high-risk patients tend to interact with the delivery system predominantly through the emergency department and medical specialists, or can pose communication challenges outside the office setting.
Other assumptions also exist.
“High-risk patients are often assumed to have low levels of health literacy and to be uninterested in electronic communication with their health care practitioners,” Chang and colleagues wrote. “We aimed to inform health care system level planning for high-risk patient care by testing assumptions about whether, where, and how the more than 350,000 highest-risk patients cared for receive outpatient care…We hypothesized that high-risk patients assigned to general primary care, compared with those assigned to specialized primary care, would have both more primary care and more medical specialty care visits.”
In the cross-sectional study, Chang and colleagues assessed 4,309,192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male), with 308,433 [88%] being ultimately characterized as high-risk. High risk was 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.”
The overwhelming majority of the patients assessed were male (93% OR 1.11; 95% CI 1.10-1.13), unmarried (63% OR 2.30; 95% CI 2.32-2.35), and older than 45 years of age (94%; 45-65 years: 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]). Further, 23% of the patients analyzed were Black (23%; OR 1.63; 95% CI 1.61-1.64). Common medical comorbidities contributing to patients’ high-risk status (n=351,012) included 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]).
Patients in general primary care did tend to receive medical specialty care more frequently (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P<.001)—but also received fewer mental health visits (mean [SD], 9.0 [21.6] versus 11.3 [23.9] per year; P<.001) than those who received primary care in a specialized setting. 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).
Of the high-risk veterans, 88% were assigned to general primary care, with the remaining 12% (42,579 of 363,561) assigned to specialized primary care—a finding study authors acknowledged ran counter to their initial expectations.
Another finding highlighted by study authors offered cause for optimism. The highest-risk patients in the study (n=351,012) were 4 times more likely to participate in telephone-based encounters and twice as likely to take part in secure messaging encounters compared to lower-risk patients.
Study limitations identified by the authors included the fact that the study does not address causation and may not be generalizable to other systems. Moving forward, study authors suggested the results could fuel clinical and research decision-making on the best ways to care for the most vulnerable populations.
“Planning for high-risk patient care improvement in integrated health care systems such as the VHA should focus on enabling high-quality complex patient care within primary care and mental health services,” Chang and colleagues wrote. “In this study, many high-risk veterans were avid users of electronic and telephone care, suggesting that opportunities exist to improve care through maximizing the accessibility and effectiveness of non-face-to-face modalities. Overall, our findings provide a foundation for investigation aimed at informing better design of health care programs and resources that can engage patients in their existing locations of care.”
Scott Harris, Contributing Writer, BreakingMED™
No source appearing in this study disclosed any relevant financial relationship with industry.
Cat ID: 192
Topic ID: 86,192,504,791,730,192,925