title: Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure.
abstract: BACKGROUND
  Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes.
  
  
  METHODS
  To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression.
  
  
  RESULTS
  Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users.
  
  
  CONCLUSIONS
  Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.
authors.affiliation: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC; Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC. Electronic address: axon@musc.edu.
authors.forename: R Neal
authors.initials: RN
authors.lastname: Axon
authors.affiliation: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC; Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC.
authors.forename: Mulugeta
authors.initials: M
authors.lastname: Gebregziabher
authors.affiliation: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Everett
authors.affiliation: Division of Cardiology, VA Palo Alto Healthcare System, Stanford University Medical Center, Palo Alto, CA.
authors.forename: Paul
authors.initials: P
authors.lastname: Heidenreich
authors.affiliation: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, SC; Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC.
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Hunt
mesh_terms: D000368:Aged; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D006233:Persons with Disabilities / Q000534:rehabilitation*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000534:rehabilitation*; D017052:Hospital Mortality / Q000639:trends; D006760:Hospitalization / Q000639:trends*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010359:Patient Readmission / Q000639:trends; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000706:statistics & numerical data*