School of Public Health

Erin Bouldin

Rural Residence, Dual System Healthcare Use, and Chronic Wound Utilization and Outcomes among Northwest Veterans

As the prevalence of diabetes and peripheral artery disease rise, chronic lower limb wounds are an increasingly important public health issue. These wounds can impair mobility and reduce quality of life. We were interested in how two common Veteran characteristics, rural residence and dual system health care use, influenced wound care treatment and outcomes. Veterans living in rural areas typically have poorer health and lower health care utilization than urban Veterans and we hypothesized that wound healing would be lower among rural Veterans. Veterans who use the Veterans Health Administration (VHA) for health care also may be eligible for Medicare and may receive care outside of VHA. We hypothesized that dual system (VHA and Medicare) wound care use would result in fragmented care and therefore poorer wound healing than VHA-exclusive use. To test our hypotheses, we assembled a cohort of 160 rural and 160 urban VHA users in the Pacific Northwest with incident chronic (¡Ý30 days) lower limb wounds between October 1, 2006 and September 30, 2007 and followed them for one year. We used Poisson models with robust standard errors to compare outpatient and inpatient wound care utilization. We used proportional hazards models to estimate the hazard ratio (HR) of wound healing, accounting for the competing risks of amputation and death, and adjusting for confounding by various factors based on the literature. Rural Veterans had lower outpatient wound care utilization (mean 6.8 versus 9.9 visits) and a similar hazard of wound healing (HR=1.11, 95% CI: 0.84-1.47, p=0.45) compared to urban Veterans. 71% of the cohort was enrolled in Medicare but only 13% of cohort members were dual system wound care users. Dual users had significantly higher observed utilization (mean 11.6 outpatient visits and 1.7 inpatient stays compared to 7.5 and 0.7, respectively) and a lower hazard rate of wound healing compared to VHA-exclusive users (HR=0.38, 95%CI: 0.25-0.56, p<0.001). Additional research is needed to replicate our findings and to understand the mechanisms underlying the differences in utilization and outcomes and to identify interventions to further improve wound healing among Veterans, particularly dual users.