Fragmented care and IBD: Outcomes in U.S. veterans

The health care system in the United States is marked by substantial fragmentation, which means patients often seek and receive care from multiple providers at different places.

In turn, this can open doors to detrimental issues for patients, including testing duplications and poor chronic disease outcomes.   

While care coordination interventions do exist, they are less focused on patients with complex conditions that require co-management with different specialists, like patients with inflammatory bowel disease, or IBD.

“IBD is a chronic inflammatory condition that affects the GI tract and requires long-term care by a gastroenterologist, primary care physician, and sometimes, a surgeon,” says Shirley Ann Cohen-Mekelburg, M.D., M.S., a gastroenterologist and assistant professor at Michigan Medicine. “However, optimal IBD care is often limited by fragmentation, which can negatively affect disease management and preventative care.”  

This inspired Cohen-Mekelburg and a team of gastrointestinal experts to examine how to care for IBD patients distributed across providers. Their findings were recently published in JAMA Network Open.

“In order to conduct our study, we decided to examine VA data,” says Cohen-Mekelburg. “The Veterans Health Administration has invested a significant amount of resources in care coordination, so we thought this would be an ideal setting in which to observe care continuity.”

The team used the VA Corporate Data Warehouse to identify patients who both had IBD, as well as an outpatient encounter between 2002 and 2014.

“The IBD patients were identified using a previously validated algorithm that was based on a combination of inpatient and outpatient billing codes,” says Cohen-Mekelburg. “Patients with at least one visit with a PCP during the study period were included, and we followed them during the first three years from their initial IBD visit.”

Cohen-Mekelburg notes that the team wanted to determine if there was an association between patient and facility-level characteristics and continuity of care. In addition, they wanted to evaluate the relationship between continuity of care and IBD-related outcomes.

“We paid attention to things like steroid-treated outpatient flares, hospitalizations and IBD-related surgeries,” says Cohen-Mekelburg.

Continuity of care was measured using the Bice-Boxerman continuity of care index, which provides information on the dispersion of care, or the spread of a patient’s care across multiple providers, as well as care density, or the relative share of visits by each provider.

The team included gastroenterologists, PCPs and surgeons as the three major medical providers for IBD-related care. And patients with less than four visit encounters were excluded from the pool, so as to reduce the bias of limited observations on the calculation of the continuity of care index.

“The index is a scale from zero to one, with a score of zero demonstrating complete discontinuity,” says Cohen-Mekelburg. “A score of one is consistent with perfect continuity, when all visits are with the same provider.”

Of the 46,665 patients with IBD identified by the team, a majority had a VA provider.

“Ultimately, we narrowed our populations size down to 20,079 patients with a calculable continuity of care index within the first year of the study period, and this population was used to identify factors that were most strongly associated with low levels of continuity of care,” says Cohen-Mekelburg.

The team found a higher likelihood of IBD flares, hospitalization rates and related surgeries among individuals with low continuity of care.

“Our findings show that continuity of care is highly variable across patients with IBD,” says Cohen-Mekelburg. “The prevalence of low continuity of care in IBD is likely multifactorial, and may relate to factors like a lack of provider accountability, less focus on coordinating specialty care and poor patient access to gastroenterologists.”

And because the continuity of care for patients with IBD is so low, Cohen-Mekelburg and her team acknowledge that barriers to collaborative care need to be better evaluated.

“We need, for example, to provide PCPs and gastroenterologists with better communication and coordination resources when managing IBD patients. This is hugely important.”

Paper cited: “Association of Continuity of Care with Outcomes in US Veterans with Inflammatory Bowel Disease,” JAMA Network Open. DOI: 10.1001/jamanetworkopen.2020.15899