Objective To characterize the rate of guideline‐concordant initiation of oral anticoagulation (OAC) among elderly Veterans with atrial fibrillation (AF) and high stroke risk. Data Sources/Study Setting Veterans Health Administration (VHA) Corporate Data Warehouse (CDW) linked with Medicare claims 2011‐2015. Study Design We identified 6619 elderly, high stroke‐risk patients with a new episode of AF initially diagnosed in the VHA during fiscal years 2012‐2015. We used logistic regression to estimate marginal effects of associations between patient characteristics and OAC initiation within 90 days of the first AF episode. Data Extraction Methods We identified OACs using generic drug names. We calculated comorbidities and risk scores using diagnosis codes from 1 year of baseline data. Principal Findings Overall, 66.5% of Medicare‐eligible Veterans with AF at high risk of stroke initiated an OAC within 90 days. We found lower initiation rates for patients enrolled in Medicare Part D and those ineligible for drug co‐payment subsidies. OAC initiation rates increased during the study among VHA‐reliant patients but not among dual VHA‐Part D enrollees. Conclusions One‐third of elderly Veterans at risk of stroke are not receiving recommended therapy. Increased coordination between Medicare and VHA providers may lead to improvements in anticoagulation quality and stroke prevention.

The Veteran-Directed Care (VDC) program facilitates independent community living among adults with multiple chronic conditions and functional limitations. Family caregivers value the choice and flexibility afforded by VDC, but rigorous evidence to support its impact on health care costs and use is needed. We identified veterans enrolled in VDC in fiscal year 2017 and investigated differences in hospital admissions and costs after initial receipt of VDC services. We compared VDC service recipients to a matched comparison group of veterans receiving homemaker or home health aide, home respite, and adult day health care services and found similar decreases in hospital use and costs from before to after enrollment in the groups. Further investigation into trends of nursing home use, identification of veterans most likely to benefit from VDC, and relative costs of operating VDC versus other purchased care programs is needed, but our results suggest that VDC remains a valuable option for supporting veterans and caregivers.

Background Rural residents face more barriers to healthcare access, including challenges in receiving home‐ and community‐based long‐term services, compared to urban residents. Self‐directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community. Methods We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran‐Directed Care (VDC), a self‐directed Veterans Health Administration (VHA)‐paid care program, and other VHA‐paid home‐ and community‐based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA‐paid home‐ and community‐based long‐term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA‐paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location. Results Both urban and rural VDC recipients were significantly less likely to be admitted to VHA‐paid nursing homes, compared to those receiving other VHA‐paid personal care services (rural: incremental effect = −0.22, [−0.30, −0.14]; urban: incremental effect = −0.14, [−0.20, −0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA‐paid acute care admissions and ED visits, relative to recipients of other VHA‐paid personal care services (acute care, rural: incremental effect = −0.07, 95% CI = [−0.14, −0.01], urban: incremental effect = −0.01, [−0.06, 0.03]; ED, rural: incremental effect = −0.08, [−0.14, −0.02], urban: incremental effect = 0.01, [−0.03, 0.05]). Conclusions VDC recipients had fewer incidents of potentially avoidable VHA‐paid health care use, compared to similar veterans receiving other VHA‐paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.