title: Do correlates of dual use by American Indian and Alaska Native Veterans operate uniformly across the Veterans Health Administration and the Indian Health Service?
abstract: OBJECTIVE
  To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use.
  
  
  METHODS
  We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans.
  
  
  RESULTS
  Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only.
  
  
  CONCLUSIONS
  Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.
authors: VA Greater Los Angeles Healthcare System, Geriatric Research Education Clinical Center, 16111 Plummer Street (11E), Sepulveda, CA 91343, USA. Josea.Kramer@va.gov
authors: B Josea
authors: BJ
authors: Kramer
authors: Stella
authors: S
authors: Jouldjian
authors: Mingming
authors: M
authors: Wang
authors: Jeff
authors: J
authors: Dang
authors: Michael N
authors: MN
authors: Mitchell
authors: Bruce
authors: B
authors: Finke
authors: Debra
authors: D
authors: Saliba
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006297:Health Services Accessibility; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007198:Indians, North American / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*; D016549:United States Indian Health Service / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data*; D058014:Veterans Health / Q000592:standards*