title: Home-based primary care and the risk of ambulatory care-sensitive condition hospitalization among older veterans with diabetes mellitus.
abstract: OBJECTIVE
  Primary care services based at home have the potential to reduce the likelihood of hospitalization among older adults with multiple chronic diseases.
  
  
  OBJECTIVE
  To characterize the association between enrollment in Home-Based Primary Care (HBPC), a national home care program operated by the US Department of Veterans Affairs (VA), and hospitalizations owing to an ambulatory care-sensitive condition among older veterans with diabetes mellitus.
  
  
  METHODS
  Retrospective cohort study. Patients admitted to VA and non-VA hospitals were followed up from January 1, 2006, through December 31, 2010.
  
  
  METHODS
  Veterans 67 years or older who were fee-for-service Medicare beneficiaries, were diagnosed as having diabetes mellitus and at least 1 other chronic disease, and had at least 1 admission to a VA or non-VA hospital in 2005 or 2006.
  
  
  METHODS
  Enrollment in HBPC, defined as a minimum of 2 HBPC encounters during the study period.
  
  
  METHODS
  Admission to VA and non-VA hospitals owing to an ambulatory care-sensitive condition, as measured by the Agency for Healthcare Research and Quality's Prevention Quality Indicators in VA medical records and Medicare claims. Outcomes were analyzed using distance from the veteran's residence to a VA facility that provides HBPC as an instrumental variable.
  
  
  RESULTS
  Among 56 608 veterans, 1978 enrolled in HBPC. These patients were older (mean age, 79.1 vs 77.1 years) and had more chronic diseases (eg, 59.2% vs 53.5% had congestive heart failure). Multivariable predictors for HBPC enrollment included paralysis (odds ratio [OR], 2.11; 95% CI, 1.63-2.74), depression (OR, 1.99; 95% CI, 1.70-2.34), congestive heart failure (OR, 1.36; 95% CI, 1.17-1.58), and distance from the nearest HBPC-providing VA facility (OR, 0.59; 95% CI, 0.50-0.70 for >10-30 vs <5 miles). After controlling for selection using an instrumental variable analysis, HBPC was associated with a significant reduction in the probability of experiencing a hospitalization owing to an ambulatory care-sensitive condition (hazard ratio, 0.71; 95% CI, 0.57-0.89), with an absolute reduction in the probability of hospitalization of 5.8% in 1 year.
  
  
  CONCLUSIONS
  Home-Based Primary Care is associated with a decreased probability of ambulatory care-sensitive condition hospitalization among elderly veterans with diabetes mellitus. In accountable care models, HBPC may have an important role in the management of older adults with multiple chronic diseases.
authors.affiliation: Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts2Massachusetts Veterans' Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston3Harvard Medical School, Boston.
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Edwards
authors.affiliation: Healthcare Financing and Economics, Veterans Affairs Boston Healthcare System, Boston, Massachusetts5Boston University School of Medicine and School of Public Health, Boston, Massachusetts.
authors.forename: Julia C
authors.initials: JC
authors.lastname: Prentice
authors.affiliation: Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts6Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Simon
authors.affiliation: Healthcare Financing and Economics, Veterans Affairs Boston Healthcare System, Boston, Massachusetts7Northeastern University, Boston, Massachusetts.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Pizer
mesh_terms: D000368:Aged; D048909:Diabetes Complications; D005260:Female; D006699:Home Care Services / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment; D014728:Veterans / Q000706:statistics & numerical data