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

2. 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
Durham VA Center of Innovation in Health Services Research CIN

3. 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

4. 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

5. 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

6. 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

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

8. 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%

9. 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

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)

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)

12. 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)

13. 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

14. 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)

15. 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)

16. 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

17. 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

18. 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

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

20. 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

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

22. Thank you! Questions?