Author

Lori K. Rizzo

Defense Date

5-6-2014

Graduation Date

2014

Availability

Immediate Access

Submission Type

dissertation

Degree Name

PhD

Department

Nursing

School

School of Nursing

Committee Chair

Alison M. Colbert

Committee Member

Linda M. Goodfellow

Committee Member

Walid F. Gellad

Keywords

Care coordination, Healthcare utilization, Inflammtory bowel disease, Medication adherence, Veterans, Wagner's Chronic Care Model

Abstract

Background

Medication adherence in inflammatory bowel disease (IBD) ranges between 7-72% . Increased healthcare utilization has been associated with non-adherence in IBD. Wagner's Chronic Care Model (CCM) posits that care coordination between primary and gastroenterology (GI) specialty care could improve adherence and healthcare utilization.

Methods

Guided by the CCM, a retrospective analysis was conducted in veterans with IBD to: describe medication adherence rates; describe healthcare utilization measured by ER visits and inpatient admissions; and describe care coordination measured by primary care and GI specialty care use. A secondary study aim was to explore the relationships between those key outcome variables and select demographic/health history characteristics. A local Veteran's Affairs database was used to extract a cohort of individuals with Crohn's disease and ulcerative colitis for fiscal year (FY) 2011. Medical utilization and IBD medication refills were collected. A dichotomized medication possession ratio (MPR .80) was used in logistic regression to identify factors affecting medication adherence. Logistic regression was also used to examine factors affecting ER visits, inpatient utilization, and care coordination.

Results

The cohort consisted of 165 White male veterans 75 with Crohn's disease and 89 with ulcerative colitis. The overall rate of adherence was 50.9% with a median MPR of .82. Regression models did not render any statistically significant predictors of adherence. ER utilization was significantly associated with adherence (OR=.314, 95%CI=.111-.886, p=.029) and care coordination (OR=45.73,95%CI=9.053-231,p=.001) in multivariate analysis. Inpatient admission was associated with: younger age (OR=.108,95%CI:.019-.609,p=.012), adherence (OR=.113,95%CI=.014-.939,p=.044), IBD diagnosis (OR=.117,95%CI=.017-.784,p=.027), and care coordination (OR=11.89,95%CI=1.228-115,p=.033). Logistic regression identified statistically significance associations with care coordinated between primary and GI specialty care and the following factors: taking both a 5-ASA and immunomodulating medication (OR=5.122,95%CI=1.874-14.00, p=.001), younger age (OR=.905,95%CI=.871-.940,p=.001), and having a comorbidity (OR=2.643,95%=1.171-5.965,p=.027).

Conclusions

No predictors of medication adherence emerged. However, the CCM element of care coordination provided additional insight into the healthcare utilization of veterans with IBD as statistically significant associations between care ER visits and hospitalization were identified. Further inquiry into the influences of medication adherence and healthcare utilization in this population is warranted.

Format

PDF

Language

English

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