Policies that expand patient access to multiple health systems may compromise patient safety

1. Higher rates of potentially unsafe medication (PUM) prescribing were associated with veterans with dementia using dual healthcare systems.

2. Dual users were exposed to an additional month of high anticholinergic burden (ACB) and an additional week of antipsychotics.

Evidence Rating Level: 2 (Good)

Study Rundown: Dementia care poses a significant challenge for health care systems. Veterans with dementia currently comprise a large proportion of dementia patients, and the number of veterans with dementia is expected to double by 2030. The U.S. Department of Veterans Affairs (VA) currently cares for this population. However, due to the projected rise of veterans with dementia, recent feral policy changes attempt to expand veterans’ access to providers outside the Department of VA. This change may increase the risk for unsafe prescribing; previous studies have shown that dual health system use is associated with duplication of health care services and worse health outcomes. Therefore, the authors of this study aimed to assess the impact of dual health care system use on PUM prescribing. They observed that dual users had higher odds of exposure to any PUM compared to VA-only users. This study had several limitations. First, regarding sampling, the study is only representative of veterans with dementia who are enrolled in Medicare fee-for-service and use VA outpatient facilities. As well, it was not possible to determine whether prescriber characteristics influenced study results. Overall, the results of this study may aid in guiding national dementia care policies and for improving coordination between these dual health care systems.

Click to read the study in the Annals of Internal Medicine

Relevant Reading: Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure.

In-Depth [retrospective cohort]: Veterans with a diagnosis of Alzheimer’s or related dementia, aged 68 or older, were identified for this study. Following exclusion criteria, 75 829 veterans were included in the final sample. Veterans were assessed with respect to high ACB (PUM-ACB), antipsychotic prescription (PUM-antipsychotic), and any PUM exposure (any-PUM). Compared to VA-only users, dual users had more than double the odds of exposure to any-PUM (OR 2.2; 95%CI 2.2 to 2.3) and PUM-ACB (OR 2.1; CI 2.0 to 2.2). Dual users also had higher odds of exposure to PUM-antipsychotics (OR 1.5; CI 1.4 to 1.6). Finally, dual users had a greater number of additional days of any PUM-exposure (adjusted average of 44.1 additional days, CI 37.2 to 45.0 days).

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