Association of Age with Patient Experience of Care in Medically Complex Veterans Nicki Hastings, M.D., M.H.S.

Acknowledgements Karen M. Stechuchak, MS Cynthia J. Coffman, PhD Courtney Van Houtven, PhD Morris Weinberger, PhD Madeline Weiner, RN Elizabeth P. Mahanna, MPH Cristina Hendrix, DNP Darryl Wieland, PhD Chad Kessler, MD Katina L. Morris, MS Kenneth Schmader, MD Gene Oddone, MD Supported by: VA HSR&D IIR 12-052 Durham VA Center of Innovation in Health Services Research CIN 13-410

Background Increasing emphasis on ‘high need, high cost’ or ‘medically complex’ individuals in health care U.S. 5/50 Electronic health record data, prediction models Potentially complementary to disease-based approach Multiple chronic conditions Social determinants of health

Background Challenges to improve care for ‘high need, high cost’ or ‘medically complex’ individuals Heterogeneity Limited understanding of experience of care “sum of interactions, shaped by culture, that influence of patients perception across the continuum of care” (Wolf et al 2014) Patient evaluation of care; assoc. with patient activation, treatment adherence, and clinical outcomes

Objective Assess how patient characteristics and experience of care differ among medically complex Veterans according to age Quality of chronic illness care Satisfaction with health care

Veterans Heath Administration Largest vertically integrated health care system in the U.S. Electronic health record Primary care organized according to patient- centered medical home model Patient Aligned Care Teams (PACTs) Enhance access, coordinate care, improve safety and quality; improve chronic illness care outcomes and patient experiences

Methods Design: Cross sectional analysis of data from RCT examining nurse care management for medically complex Veterans after an ED visit

Methods Eligibility Treated and released from VA ED Primary care at VA-affiliated clinic Medically complex presence of ≥2 chronic conditions and ≥1 ED visit or hospitalization during previous 6-months N=513 participants Approx 25%

Methods Examined associations of patient characteristics with age categories using Pearson Chi-Squared statistics and ANOVA. Outcomes examined using multivariable logistic regression models. PACIC overall score (range from 1-5) dichotomized at 3.5 CAHPS health care rating (range from 0-10) dichotomized at 10

Baseline Characteristics Results Baseline Characteristics Age < 55 n=156 Age 55-64 n=158 Age ≥ 65 n=199 P-value Gender Male Female 92 (59.0) 64 (41.0) 113 (71.5) 45 (28.5) 194 (97.5) 5 (2.5) <0.001 Race1 White or other Black or African American 66 (43.4) 86 (56.6) 65 (41.7) 91 (58.3) 122 (62.9) 72 (37.1) Education High school graduate or less Education beyond high school 28 (17.9) 128 (82.1) 53 (33.5) 105 (66.5) 61 (30.7) 138 (69.3) 0.004 1Race (missing: n = 11)

Personal Economic Security Results Personal Economic Security Age < 55 n=156 Age 55-64 n=158 Age ≥ 65 n=199 P-value Personal economic security1   0.005 SECURE: I am in good shape. I am able to save and plan for the future. I am okay. I am saving a little and I am able to provide for my needs. 69 (44.8) 79 (52.3) 117 (62.2) INSECURE: I am barely getting by. I have to budget carefully and I am not able to plan for the future. I am falling behind. I have to use savings or go further into debt to pay my bills. I am in serious financial trouble, and can't quite see how I am going to make it. 85 (55.2) 72 (47.7) 71 (37.8) 1(missing: n=20)

Results Physical And Mental Health Age < 55 n=156 Age 55-64 n=158 P-value Self-reported health   0.006 Fair/Poor 99 (63.5) 101 (64.7) 97 (49.7) Excellent/Very Good/Good 57 (36.5) 55 (35.3) 98 (50.3) Number of unhealthy days in past 30 days, mean (SD) 24.0 (9.0) 21.0 (11.0) 16.6 (11.9) <0.001 Frequent mental distress Yes (between 14 and 30 days mental health not good) 90 (59.6) 57 (37.7) 51 (26.7) No 61 (40.4) 94 (62.3) 140 (73.3) Self-reported health (missing:n=6); Unhealthy days (missing:n=21); Mental distress (missing:n=20)

Results Utilization Age < 55 n=156 Age 55-64 n=158 Age ≥ 65 n=199 P-value Receive health care outside the VA health care system   0.508 Yes 37 (23.7) 29 (18.4) 43 (21.6) No 119 (76.3) 129 (81.6) 156 (78.4) “Super-User”1 0.711 42 (26.9) 45 (28.5) 49 (24.6) 114 (73.1) 113 (71.5) 150 (75.4) 1“Super-User” is defined as 3 or more ED visits in the 6 months preceding index ED visit

Results Experience of Care Age < 55 n=156 Age 55-64 n=158 Age ≥ 65 P-value PACIC   Overall score, mean (SD) 3.0 (1.1) 3.2 (1.1) 3.5 (1.0)  0.001 Overall score ≥3.5, n (%) 55 (37.2) 70 (46.4) 100 (52.9) 0.016 Sub-scales, mean (SD) Patient Activation 3.1 (1.2) 3.5 (1.2) 0.004 Delivery System Design/Decision Support 3.8 (1.1) 4.0 (1.0) <0.001 Goal Setting 3.2 (1.2) 3.3 (1.2) 3.6 (1.2) 0.012 Problem-Solving/Contextual Counseling 3.2 (1.3) 3.4 (1.3) 0.010 Follow-up/Coordination 2.4 (1.1) 2.6 (1.2) 2.8 (1.2) 0.003 Activation (missing: n=21); Delivery and Overall (missing: n=25); Goal and Problem-Solving (missing: n=32); Follow-up (missing: n=48)

Results Experience of Care Age < 55 n=156 Age 55-64 n=158 Age ≥ 65 P-value …rate all your health care in the last 12 months? (range: 0-10), mean (SD) 7.0 (2.4) 7.7 (2.1) 8.7 (1.7) <0.001 …rate all your health care in the last 12 months? = 10, n (%) 22 (14.2) 34 (21.5) 86 (43.4) …rate your primary care team (range: 0-10), mean (SD) 7.7 (2.5) 8.3 (2.0) 9.1 (1.6) How well doctors communicate (range: 1-4), mean (SD) 3.3 (0.8) 3.4 (0.8) 3.6 (0.6) Getting care quickly (range: 1-4), mean (SD) 2.7 (0.9) 3.1 (0.8) Health care (missing: n=2); PC team (missing: n=36); Communicate (missing: n=30); Getting care quickly (missing: n=27)

Results Odds Ratio Lower 95% CI Upper 95% CI P-value Outcome: PACIC overall score ≥3.5   0.535 Age < 55 0.75 0.45 1.25 Age 55-64 0.88 0.54 1.42 Age ≥ 65 Ref Outcome: CAHPS health care rating = 10 <0.001 0.22 0.12 0.41 0.36 0.21 0.61 Models adjusted for gender, race, education, self-rated health, frequent mental distress PACIC c-statistic = 0.64; CAHPS c-statistic = 0.70

Main Findings In this medically complex population receiving primary care in VA system fair/poor self-rated health, economic insecurity, high psychological distress were common, especially in the younger and middle age groups older people rated chronic illness care and overall experience higher across all domains than their younger counterparts

Main Findings In adjusted models, overall satisfaction differed by age although assessment of quality of chronic illness care did not. younger age groups had lower odds of high overall satisfaction compared to ≥ 65 odds of reporting high quality chronic illness care were no different across age groups

Limitations No objective measures of care Unmeasured confounders Generalizability Recent ED visit VA patients Enrolled in clinical trial

Implications Improving coordination and delivery of chronic disease care may have more positive impact on patient experience among older adults than their younger counterparts. Need for additional research around: Patient experience among distinct groups Addressing high levels of psychological distress

Cycle Model of Complexity J Gen Intern Med. 2016 Mar;31(3):329-37 Zullig et al 2016 JGIM

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