Adverse Outcomes of Dual Use of Health Systems Among Older Male Veterans

老年男性退伍军人双重使用卫生系统的不良后果

• 批准号: 7064680
• 负责人: Fredric D Wolinsky
• 金额: $ 6.64万
• 依托单位: UNIVERSITY OF IOWA
• 依托单位国家: 美国
• 财政年份: 2006
• 资助国家: 美国
• 起止时间: 2006-04-15 至 2008-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7064680
• 关键词: behavioral /social science research tag; health care quality; health care service utilization; health services research tag; hospital utilization; human data; human mortality; human old age (65+); human very old age (85+); male; patient oriented research; veterans

DESCRIPTION (provided by applicant): Veterans aged 65 years old or older are eligible to use both the Veterans Health Administration (VHA) system, and the private health care delivery system via Medicare. Such "dual" system use can have both positive and negative effects. We hypothesize that dual use among older male veterans increases their risk of being hospitalized for ambulatory care sensitive conditions (ACSCs), and increases their risk of mortality. We examine this hypothesis among older male veterans in the Survey of Assets and Health Dynamics Among the Oldest Old (AHEAD), which included 2,911 men aged 70 years old or older at baseline (1993). 1,574 (54%) of the AHEAD men are veterans, and 281 (17.9%) reported having a service-related disability. We will link the AHEAD survey data to Medicare claims and the National Death Index, and we will geocode data on health care market structure. Because VHA claims data are not available, we will indirectly measure dual use based on the discrepancy between self-report and Medicare claims through a 3-step process: (1) identify discordance between self-reported use and Medicare claims by generating binary inpatient and outpatient reporting discrepancy markers; (2) create propensity scores for the likelihood of discordance on each of the markers in Step 1 using multiple logistic regression and all appropriate baseline covariates including the veterans' status marker; and, (3) use the propensity scores obtained in Step 2 and the veterans' status marker to (a) first additively model the risk of ACSCs and mortality after baseline, then (b) add a marker for the multiplicative interaction between the veterans' status marker and the propensity scores to tap their synergistic effect, and finally (c) adjust for potential confounders in an attempt to decompose the effect observed in Step 3b. We will use proportional hazards models and our focus is on the multiplicative interaction between the veterans' status marker and the propensity score. Because non-veterans are coded zero on the veterans' status marker, significant and positive parameter estimates for this multiplicative interaction term will be prima facie evidence supporting our hypothesis. At that point we will petition AHEAD, VHA, and CMS for permission to link VHA claims to the existing AHEAD comprehensive data files, and then propose a follow-on NIH R01 study to provide a more definitive and direct examination of our hypothesis about the adverse effect of dual use on health care outcomes using both Medicare and VHA claims data.

描述（由申请人提供）：65岁或以上的退伍军人有资格使用退伍军人健康管理局（VHA）系统和通过医疗保险的私人医疗保健提供系统。这种“双重”制度的使用既有积极的影响，也有消极的影响。我们假设老年男性退伍军人的双重使用增加了他们因门诊护理敏感性疾病（ACSC）住院的风险，并增加了他们的死亡风险。我们在老年男性退伍军人资产和健康动态调查（AHEAD）中检验了这一假设，其中包括2，911名基线年龄为70岁或以上的男性（1993年）。1，574名（54%）AHEAD男性是退伍军人，281名（17.9%）报告有与服务相关的残疾。我们将把AHEAD调查数据与医疗保险索赔和国家死亡指数联系起来，我们将对医疗保健市场结构的数据进行地理编码。由于VHA索赔数据不可用，我们将通过3步过程，根据自我报告和医疗保险索赔之间的差异间接衡量双重使用：（1）通过生成二元住院和门诊报告差异标记，识别自我报告使用和医疗保险索赔之间的不一致;（2）使用多元逻辑回归和所有适当的基线协变量（包括退伍军人的状态标记），为步骤1中的每个标记的不一致可能性创建倾向分数;以及（3）使用步骤2中获得的倾向分数和退伍军人的状态标记来（a）首先对基线后的ACSC和死亡率的风险进行加性建模，然后（B）添加退伍军人的状态标记和倾向分数之间的乘法相互作用的标记以挖掘它们的协同效应，最后（c）调整潜在的混杂因素，试图分解步骤3b中观察到的影响。我们将使用比例风险模型，我们的重点是退伍军人的状态标记和倾向得分之间的乘法相互作用。因为非退伍军人在退伍军人的状态标记上被编码为零，所以这个乘法相互作用项的显著和正的参数估计将是支持我们假设的初步证据。届时，我们将向AHEAD、VHA和CMS申请将VHA声明与现有的AHEAD综合数据文件联系起来，然后提出一项后续NIH R 01研究，以使用Medicare和VHA声明数据对我们关于双重使用对医疗保健结果的不良影响的假设进行更明确和直接的检查。