Abstract

BACKGROUND: Heart failure is associated with high mortality, and health system-related factors contribute to this risk. Dual health system use occurs when patients receive care from multiple facilities over time, and such fractured care has been associated with higher healthcare utilization and higher mortality in selected conditions.

METHODS: We analyzed a cohort of 13,948 U.S. Veterans receiving emergency department (ED) or hospital care for heart failure between 2007-2011 using information from the VA, Medicare, and an all-payor state-level claims database. Cox proportional hazards regression was used to model the association between all-cause mortality and dual use comparing dual users to those receiving VA-only care or non-VA only care.

RESULTS: In fully adjusted models accounting for age, gender, race/ethnicity, marital status, disability, and comorbidities, dual use Veterans with heart failure had higher hazard for mortality from their date of entry into the cohort (HR 1.21, 95% CI 1.11, 1.32, p<0.0001) and from the date of their last hospitalization (HR 1.40, 95% CI 1.28-1.53, p<0.0001) as compared to VA-only users. Non-VA only users did not have significantly different hazard for mortality compared to VA-only users. Additional models in a subset of patients which also included laboratory data for brain-type natriuretic peptide, blood urea nitrogen, and serum sodium yielded similar results.

CONCLUSIONS: Dual use appears to be associated with higher risk for mortality among Veterans with heart failure. While cross-system care is necessary and even desirable in many situations, strategies to identify high-risk patients and to mitigate risks of fractured care are warranted.

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