title: Dual-System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans.
abstract: OBJECTIVE
  The concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.
  
  
  METHODS
  VA and MA quality and administrative data from 2008 to 2009.
  
  
  METHODS
  We used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.
  
  
  METHODS
  VA and MA data were merged to identify VA-only users (n = 1,637) and dual-system users (n = 5,006).
  
  
  RESULTS
  We found no significant differences in intermediate outcomes between VA-only and dual-user populations. Differences ranged from a 3.2 percentage point (95 percent CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with CHD to a 2.2 percentage point (95 percent CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.
  
  
  CONCLUSIONS
  For the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care.
authors.affiliation: Department of Vermont Health Access, Williston, VT.
authors.forename: Alicia L
authors.initials: AL
authors.lastname: Cooper
authors.affiliation: Research Enhancement Award Program, Providence VA Medical Center, Providence, RI.
authors.forename: Lan
authors.initials: L
authors.lastname: Jiang
authors.affiliation: Health Economics Resource Center and Center for Innovation to Implementation, Palo Alto VA Medical Center, Palo Alto, CA.
authors.forename: Jean
authors.initials: J
authors.lastname: Yoon
authors.affiliation: Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA.|Department of Epidemiology, University of Iowa, Iowa City, IA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Charlton
authors.affiliation: Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI.
authors.forename: Ira B
authors.initials: IB
authors.lastname: Wilson
authors.affiliation: Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI.|Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.affiliation: Institute for Population Health Improvement, University of California Davis Health System, Sacramento, CA.
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Kizer
authors.affiliation: Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI.|Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI.
authors.forename: Amal N
authors.initials: AN
authors.lastname: Trivedi
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000628:therapy; D002784:Cholesterol / Q000097:blood; D003920:Diabetes Mellitus / Q000628:therapy; D005260:Female; D006442:Glycated Hemoglobin; D006302:Health Services Research; D006801:Humans; D008297:Male; D020398:Medicare Part C / Q000706:statistics & numerical data*; D008875:Middle Aged; D057216:Propensity Score; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D012737:Sex Factors; D012959:Socioeconomic Factors; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*; D014728:Veterans
chemical_list: D002784:Cholesterol; D006442:Glycated Hemoglobin
keywords: Dual-system use; Medicare Advantage; Veterans Affairs; outcomes; quality of care
references.citation: Med Care. 1998 Jan;36(1):8-27
references.pmid: 9431328
references.citation: Health Aff (Millwood). 2012 Dec;31(12):2609-17
references.pmid: 23213144
references.citation: N Engl J Med. 2005 Sep 22;353(12):1302-3
references.pmid: 16177262
references.citation: Med Care. 2006 Aug;44(8):768-73
references.pmid: 16862039
references.citation: BMC Health Serv Res. 2006;6:131
references.pmid: 17029643
references.citation: Stroke. 2007 Feb;38(2):355-60
references.pmid: 17194888
references.citation: Med Care. 2007 Mar;45(3):214-23
references.pmid: 17304078
references.citation: Am J Public Health. 2007 Dec;97(12):2179-85
references.pmid: 17971544
references.citation: Prim Care Diabetes. 2008 Jun;2(2):73-80
references.pmid: 18684426
references.citation: Health Serv Res. 2008 Aug;43(4):1164-83
references.pmid: 18355256
references.citation: Am J Manag Care. 2009 Mar;15(3):e1-8
references.pmid: 19298095
references.citation: Med Care. 2009 Nov;47(11):1180-5
references.pmid: 19786917
references.citation: JAMA. 2012 Jul 4;308(1):67-72
references.pmid: 22735360
references.citation: JAMA. 2012 Feb 22;307(8):789-90
references.pmid: 22357828
references.citation: Health Serv Res. 2013 Oct;48(5):1769-78
references.pmid: 23521600
references.citation: Medicare Medicaid Res Rev. 2012;2(3). pii: mmrr.002.03.a06. doi: 10.5600/mmrr.002.03.a06
references.pmid: 24800148
references.citation: Med Care Res Rev. 2003 Jun;60(2):253-67
references.pmid: 12800686
references.citation: Med Care. 1992 May;30(5):377-91
references.pmid: 1583916
references.citation: Soc Sci Med. 1994 Jul;39(1):95-104
references.pmid: 8066492
references.citation: J Gen Intern Med. 1997 Apr;12(4):247-9
references.pmid: 9127230
references.citation: N Engl J Med. 1997 Oct 2;337(14):1013-4
references.pmid: 9312676
references.citation: Health Serv Res. 2010 Jun;45(3):762-91
references.pmid: 20403056
references.citation: Inquiry. 2011 Summer;48(2):109-22
references.pmid: 21898983
references.citation: Med Care. 2011 Oct;49(10):911-7
references.pmid: 21685810
references.citation: N Engl J Med. 2012 Jan 12;366(2):150-7
references.pmid: 22236225
references.citation: J Gen Intern Med. 1999 May;14(5):274-80
references.pmid: 10337036