How does fragmented care affect IBD outcomes?

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Poor continuity of care can lead to worse outcomes among active patients inflammatory bowel disease (MII), according to data from more than 20,000 veterans.

Even in the Veterans Health Administration’s health care system, which “can provide the ideal environment for care coordination,” patients with active IBD exhibited a “substantial variation” in the dispersion of care. , which led to more frequent surgeries, corticosteroid use, and hospitalizations. main author Shirley Cohen-Mekelburg, MD, EM, from the University of Michigan, Ann Arbor, and colleagues.

“Health care in the United States is marked by substantial fragmentation, as patients seek and receive care from various clinicians, often in different institutions,” the researchers wrote in JAMA network open. “Fragmented care has been associated with poor chronic disease outcomes, increased use of health care, duplication of testing, and increased care costs.”

In HAV, these problems led to the creation of the Patient Care Team (PACT), a model of medical home in which primary care physicians coordinate clinical teams of specialists and other health professionals. But coordination can be a challenge with chronic medical conditions such as IBD, according to Cohen-Mekelburg and colleagues.

“High-quality care for IBD includes not only disease-specific treatment of symptoms, but also disease-specific preventive care, such as vaccinations and cancer screening, to prevent adverse outcomes. associates, ”the researchers wrote. “Identifying which physician is responsible for managing every aspect of care requires some degree of coordination and makes patients with IBD vulnerable to healthcare fragmentation.”

Worst results linked to the poor continuity of the first year

To assess care fragmentation within the AVHA, researchers identified 20,079 veterans with IBD who had at least one outpatient encounter with the system between early 2002 and late 2014. Continuity of care (COC) was calculated with the Bice-Boxerman COC Index, which measures the amount of care a patient has with a different doctor. The researchers used the first-year COC as the primary independent variable.

In the first year of care, the mean COC index was 0.24 (interquartile range, 0.13–0.46). The researchers noted that this figure was lower than that reported in previous studies with patients with other chronic diseases, including IBD.

After controlling for covariates and adjusting for facility-related clusters, the researchers found that a lower COC index in the first year was associated with a higher rate of worse outcomes in the next 2 years, including surgical interventions (adjusted risk ratio, 1.72; 95% confidence interval, 1.43-2.07), hospitalizations (RSH, 1.25; 95% CI, 1.06-1.47) and outpatient outbreaks requiring corticosteroids (RSH, 1.11; 95% CI, 1.01–1.22). In contrast, the improvement in the COC index score reduced by 0.1 the risk of outpatient outbreak (RSH, 0.69; 95% CI, 0.58-0.82), hospitalization (RSH, 0 , 57; 95% CI, 0.41–0.79) and surgery (RSH, 0.25; 95% CI, 0.16–0.38).

Further analysis showed that the relationship between lower COC and worse outcomes was carried out in measures such as baseline use of an immunomodulator or biological agent, as well as subgroups such as patients with non-severe IBD and non-surgical patients.

Among those treated by an HAV gastroenterologist, a lower level of COC was associated with a higher rate of surgery, but not hospitalizations or outpatient outbreaks. Physician-specific COC index scores were highest for primary care providers (0.54), followed by gastroenterologists (0.25) and surgeons (0.17). However, physician-specific lower COC scores do not translate into worse IBD outcomes.

“The level of COC among patients with IBD in the current HAV cohort was … lower than the values ​​described in previous studies of HAV system veterans, including a study of dual enrolled HAV-Medicare students who were especially prone to fragmented care because of its ability to seek attention both inside and outside the HAV system, ”the researchers wrote in reference to a 2018 to study. “The difference in COC between patients with IBD vs. patients without IBD is likely multifactorial and may be associated with confusion about physician accountability and lack of focus on coordination in multidisciplinary IBD care. Patients with IBD they require care from primary care providers, gastroenterologists, and surgeons, but the definition of responsibilities by the doctor is often unclear. “

“Better care, not just more care” is needed

“These results cannot be improved just with more robust armament treatment,” he said Jason K. Hou, MD, EM, AGAF, FACG, acting head of gastroenterology and hepatology at Michael E. DeBakey VA Medical Center and associate professor of medicine at Baylor College of Medicine, Houston, who was listed on editorial published simultaneously, who was also the author of David I. Fudman, MD.

“There are examples of improved coordination and outcomes of care through patient-aligned care teams in primary care homes and medical specialties for IBD,” Hou said in an interview. “However, significant barriers to widespread implementation remain.”

Hou offered several possible approaches to overcoming these barriers.

“We need improved methods to identify and track high-risk patients who are more likely to have complications and use health care,” he said. “We need an investment by payers and health care systems in care coordination so that identified high-risk patients can receive timely testing, referrals, and treatment. These changes require an assessment of how the health care system encourages care. to provide better care, not just more care. “

The researchers reported grants from the U.S. Department of Veterans Affairs and the National Institutes of Health and financial relationships with AbbVie, UCB, and Takeda. He has not reported any conflicts of interest.

This article originally appeared on MDedge.com, which is part of the Medscape professional network.





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