Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

Objectives: To evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.

Design: Retrospective cohort study.

Setting: Department of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.

Participants: Medicare-eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007-08 (baseline period) (N = 243,881).

Measurements: Two measures of longitudinal continuity were estimated using merged VA-Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.

Results: The incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02-1.07), intermediate (IRR = 1.04, 95% CI = 1.02-1.07), and low (IRR = 1.06, 95% CI = 1.03-1.09) UPC than in those with very high UPC (0.9-1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01-1.07), intermediate (OR = 1.03, 95% CI = 1.00-1.06), and low (OR = 1.04, 95% CI = 1.01-1.07) UPC were also more likely to be hospitalized during follow-up. Results were similar for MMCI continuity scores.

Conclusion: Even slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.