Home-Based Primary Care and Emergency Department Use Among Veterans With Dementia: An Instrumental Variable Analysis.

Abstract

Background: As the veteran population ages, the Veterans Health Administration (VHA) faces challenges in how to meet the care needs of patients with dementia. Providing high-quality, integrated care models in the home, such as home-based primary care (HBPC), can offer care aligned with veteran goals and present potential cost-savings to the VHA.

Objective: Examine the effect of VHA HBPC on the probability of emergency department/urgent care (ED) use.

Research design: Cohort analysis using an instrumental variable approach.

Subjects: Veterans aged 65+ with dementia (2021-2023).

Measures: We define HBPC as beginning the first month veterans have 2+ HBPC claims within 91 days. ED use is the key outcome.

Results: Among 133,846 veterans with dementia, 17.36% (n=23,240) received HPBC during the evaluation period. Compared with non-HBPC veterans, veterans in HBPC were older and more likely to be female, reside in a metropolitan area, be Hispanic, be Black/African American, have post-traumatic stress disorder, a traumatic brain injury, have more Elixhauser conditions, and have higher ED use (7.1% vs. 5.9%). When using the instrumental variable of lagged HBPC penetration to address selection into HBPC (F-stat>100), we find that HBPC enrollees were 3.60 percentage points less likely to have ED use than non-HBPC enrollees (P<0.001).

Conclusions: Reducing ED visits among people with dementia may signal improved care and offer potential cost-savings to health care systems. Our findings can help inform VHA efforts to invest in the optimal allocation of resources to best support veterans with dementia while containing costs by avoiding potentially avoidable, high-cost care.