Cost Effectiveness of a Primary Care Intervention: Results from a VA Cooperative Study

Hynes DM, Oddone E, Weinberger M. Cost Effectiveness of a Primary Care Intervention: Results from a VA Cooperative Study. Paper presented at: VA HSR&D National Meeting; 1999 Feb 26; Washington, DC.

Ojectives: We examined the cost effectiveness of a primary care intervention in VA hospitals in a multi-site randomized clinical trial. We focused specifically on marginal costs relative to a key patient centered outcome: improvement in patient satisfaction. Methods: This multi-site RCT was conducted at nine geographically and academically diverse VA medical Centers to ascertain whether enhanced access to primary care intervention reduced hospital use of chronically ill veterans over a six month period. Eligible patients with a diagnosis of deabetes mellitus, chronic obstructive pulmonary disease, or congestive heart failure at or before the time of their index admission were enrolled during an admission to the General Medicine Service. Following enrollment, 1,396 eligible patients were randomized to receive their usual care physicians, contained an inpatient and outpatient component. Teh inpatient component included discharge planning with the nurse and physician, disease education, and scheduling of a follow-up visit within 7 days to that primary care physician and nurse. The outpatient appointment within a week after discharge and a monitoring of the treatment plan by the nurse and physician. Patients were followed for six months and utilization data were tracked for one year after randomization. Costs were measured using information from VA (Patient Treatment File, Outpatient File and Cost Distribution Report) and non-VA sources (Medicare claims data and validated patient self-report) about the use and costs of inpatient and outpatient care for the intervention and usual care group. Patient satisfaction was measured using the Patient Satisfaction Questionnaire (PSQ) at baseline and at the completion of the intervention for the intervention and the usual care group. Results: VA hospital and outpatient visit costs were significantly greater in the intervention group (Mean hospital: $5,438_12,356 versus $4,079_9,108; p = 0.02; Mean outpatient: $1,036_832 versus $927_1,269). While use of non-VA inpatient and outpatient care accounted for less than 10% of health care use, non-VA outpatient costs for the usual care group were significantly greater than for the interention group. Mean level of patient satisfaction for the intervention group increased by 6% from baseline compared to no change in the usual care group (p = 0.0001). Marginal cost effectiveness ratios will be forthcoming. Conclusions: With increasing emphasis on managed care priciples in VHA, the impact of patient care interventions must be examined relative to patient centered outcomes.