Original Research

The VHA assigns all enrolled veterans to a primary care provider (PCP). However, almost 80% of veterans enrolled in VHA have another form of health care coverage, including Medicare, Medicaid, private insurance, and TRICARE for Life program.¹ Consequently, veterans may choose to use more than 1 health care system to manage their health care needs.

Studies based on merged VHA and Medicare claims data have demonstrated substantial dual use by VHA enrollees with Medicare. Petersen and colleagues reported that about 80% of VHA enrollees with Medicare chose to use services in both systems and that greater distance to VHA facilities and lower priority level for VHA care predicted lower VHA reliance.² Among those aged < 65 years who had Medicare due to disability, 58% weredual users. These dual users relied more on private sector care for many health conditions, with the notable exception of substance abuse and mental health disorders, for which reliance on VHA care was greater.² Another study found that over half of VHA enrollees assigned to a PCP at a community-based outpatient clinic (CBOC) received some or all of their care outside VHA and that reliance on VHA outpatient care declined over the 4-year study period.³

Related: Mutual Alignment Trumps Merger for Joint VA/DoD Health Care Programs

This use of multiple health care providers (HCPs), facilities, and modalities is often described as dual use or comanagement. Dual use in the case of veterans refers to use of both VHA and non-VHA health care, whereas comanagement implies an expectation of shared decision making and open communication between VHA and non-VHA providers. In addition to VHA PCPs, rural veterans frequently receive care from local, non-VHA HCPs in the community where they live. As health care in the U.S. evolves and patients have increasing choices through the Affordable Care Act (ACA), the challenge of comanagement for patients receiving care in multiple systems is likely to increase both within and outside VHA.

This study was part of a qualitative rural health needs assessment designed to ascertain the issues facing rural veterans and their providers in the upper Midwest.⁴ The objective was to examine VHA primary care clinic staff perspectives on dual users, perceived barriers that inhibit comanagement, and factors that contribute to the need for dual use in rural areas.

Methods

A qualitative study design with in-person interviews was used to elicit the perspective of VHA clinic staff on the current and ideal states of comanagement. Clinics were selected using a stratified purposeful sample of 15 urban and rural primary care clinics at VHA CBOCs and VAMCs in 8 Midwestern states (Illinois, Iowa, Minnesota, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming). The stratification criteria included (1) urban and rural; (2) geographic coverage of VISN 23; and (3) VHA-managed and contract clinics, resulting in a purposeful sample of 2 urban VAMC clinics, 3 urban CBOCs, 7 rural VHA-managed CBOCs, and 3 rural contract CBOCs. The distance from the CBOC to the closest VAMC ranged from 32 to 242 miles.

Related: VA Relaxes Rules for Choice Program

Interview guides were developed and tested by the research team for comprehension, length, and timing prior to data collection and iteratively revised as analysis evolved and new topics emerged. Clinic staff were asked about their perceptions of rural veteran use of VHA care; barriers and facilitators to accessing care; and their personal experience working within VHA. Several questions focused on dual use and why rural veterans use multiple health care systems, their perspectives of dual use, their expectations of patients’ role(s) in health care coordination, and the perceived barriers that inhibit comanagement. Interviewers used comanagement and dual use interchangeably to discuss patients with multiple care providers, allowing interviewees to use their preferred terminology; assigned meanings were probed for clarification but not corrected by interviewers.

Between June and October 2009, teams of 2 to 3 researchers visited 15 clinics for 1 to 2 business days each. Researchers conducted interviews with a convenience sample of clinical staff. Consent forms and an explanation of the study were distributed, and those electing to participate voluntarily came to a designated room to complete an interview. All interviews were audio recorded for accuracy.

Interview recordings were transcribed verbatim and reviewed for accuracy. Prior to coding, transcripts were imported into a qualitative data management software program. A codebook, including a priori research hypotheses and de novo themes, was developed based on a systematic review of a randomly selected subset of interview transcripts.⁵ Four coders were responsible for coding all transcripts and validating coding through tests of agreement at predetermined intervals.

Regular meetings were conducted with coders and the lead qualitative investigator to discuss disagreements, clarify code definitions, or add new codes as needed. As codes were added, previous transcripts were coded/recoded for content related to the new codes. An audit trail was maintained, and iterative mediation of codes continued throughout the process. The final codebook contained 42 thematic codes, which reached saturation or data redundancy.⁶ Detailed analysis of the codes dual use, distance, and care coordination were used to inform this study.

Results

Among the 15 sites, 64 in-depth individual interviews were conducted, ranging from 5 to 53 minutes (average 26 minutes). Clinic staff demographic characteristics are depicted in the Table. Analysis of data captured in the codes dual use, distance, and care coordination resulted in notable concentration in 4 thematic areas: (1) clinic staff perceptions of the influence of access, convenience, and distance on dual use for rural patients; (2) communication and patient’s role in comanagement; (3) rules and regulations related to comanagement from the VHA perspective; and (4) barriers to comanagement and recommendations for education.

Influence of Access, Convenience, and Distance

Access to health care was central to the discussion of dual use and comanagement by clinic staff. Convenience was identified as the primary reason for rural patients’ use of non-VHA services, as many rural patients must travel outside their local community to access VHA care. Thus, dual use was most often noted for services typically available in patients’ local communities, especially management of chronic conditions.

The CBOCs provide important services for primary care and management of chronic conditions but are not available in all communities and may have limited hours/days that do not fit with patients’ schedules. The CBOCs are often unable to provide needed services, including but not limited to emergency care, diagnostic tests, physical and occupational therapy, and other specialty care services. As one VHA provider put it, “The biggest factor for [dual use] is availability, access, convenience.… It’s a lot more convenient to go to the hospital down the street than it is to go 120 miles to [the VAMC], or for some guys who live 30, 40 minutes the other side of here it becomes 150, 160-mile one-way trip.”

Related to access, distance and transportation barriers were identified by clinic staff as obstacles to care for rural patients. Despite efforts to offset the expense of travel through reimbursement to qualified veterans and coordinated van transport with Veterans Service Organizations, travel costs—both time and money—were seen as significant barriers to accessing VHA care, as was an inability to travel for those who are ill or frail and elderly. “We send people … in the van and for the most part that works, but eventually it gets expensive, or you’ve got somebody with chronic pain that can’t tolerate the van ride for 2 hours,” one interviewee
reported.

According to clinic staff, dual-use patients also rely on non-VHA providers in particular for urgent or emergency care, while relying on VHA primary care for reduced-cost medications, diagnostic testing, chronic disease management, or annual exams. When asked why rural patients may choose to see more than 1 provider, VHA providers responded. “[It’s] more convenient to have a local doctor just in case something went wrong and they need to see a doctor right away. So distance to this clinic would be the number one reason.” Another reported, “If it’s once or twice a year routine appointments they’ll come here, but… they’d rather go to a walk-in clinic nearby than spend so much [money] on gas.”

Communication and Patients’ Role

Communication between VHA and non-VHA providers is a necessary element of comanagement. Although phone calls or faxing patient medical records are available options, clinic staff reported it was more common to encounter patients hand carrying their records between providers. For dual-use patients, clinic staff indicated it was often unclear who was responsible for relaying information between providers. There is often ambiguity about who will (and should) fulfill this role and not enough time to adequately address or clarify how this is done. Some clinic staff believed that acting as the main conduits of information placed an undue burden on the patients, particularly asking them to be able to accurately relay medical information about tests or prescriptions that they may not fully understand. Others said that it was primarily the patients’ responsibility to give relevant information about their care to all their providers, because of VHA regulations and patient privacy laws. “[The] patient should tell the primary doctor to send them [medical records] because we can’t get the medical records without the patient’s permission,” said one provider.

Another provider utilized the nursing staff to call patients after their appointments to remind them to give their medical records to their non-VHA provider. The data suggest that responsibility for maintaining communication between providers ultimately falls on the patient. From the perspective of a nurse practitioner, “We just keep trying to educate the community…. I’ve been told that if the patient wants that privilege of using the VA for a pharmacy for an outside provider that we’re glad to do that. But it is their responsibility to communicate with their [non-VHA] physician. I think we just need to keep educating the patients.”

Rules and Regulations

VHA policies governing prescriptions, hospitalizations at outside facilities, and release of patient information regulate, and in some cases hinder, information flow between VHA and non-VHA providers. Many patients use VHA to obtain medications for lower out-of-pocket costs. This contributes to the number of dual-use patients in VHA and results in several challenges for VHA providers trying to manage patients’ prescriptions. For example, patients will ask to fill a prescription at a VHA pharmacy from their non-VHA providers; however, VHA pharmacies can only fill prescriptions from VHA providers.

Many VHA providers are willing to rewrite these prescriptions, but they may need to see the patient before adding or changing the prescription and require documentation to address contraindications, adverse reactions and/or therapeutic failure, and associated risks before making the authorization. VHA providers noted that because the VHA formulary does not contain all medications, non-VHA providers are often unfamiliar with the VHA National Formulary specifics and will write prescriptions for nonformulary medications, which require a nonformulary request from a VHA provider.

Clinic staff also mentioned difficulty in obtaining records from non-VHA providers. This can be particularly problematic if the patient lives a distance away from a VHA facility and does not have the necessary authorization to share records on file.

Barriers and Education Recommendations

Clinic staff identified coordination of care for dual-use patients as a barrier to providing care. Specifically, providers identified coordination as complicated by communication difficulties, inefficient medical record exchange, short staffing in VHA clinics, duplication of diagnostic services, and non-VHA providers’ lack of understanding regarding the services that VHA provides. Specific to rural clinics, comanagement was reportedly hindered by limitations in technology (eg, consistent Internet access), access to routine diagnostic services, and lack of relationships with non-VHA providers. Providers most frequently reported that the critical piece missing in comanagement is a relationship—and implied communication—between VHA clinics and non-VHA community clinics. The concept of a relationship between providers is evoked as a critical element to comanaging dual-use patients; however, clinic staff had a difficult time articulating what that relationship would actually look like if put into practice.

Related: Patients Benefit From ICU Telemedicine

In spite of the numerous barriers identified by clinic staff, the recommendation for education to improve comanagement was consistent across study sites and clinic staff roles. Education was proposed for patients and non-VHA providers as the best intervention. In response to a question about ideas and recommendations to improve comanagement, clinic staff drew on varied experiences. To illustrate this theme, a provider gave this example of dual-use patients seeking prescription medication from VHA and its impact on comanagement: “I would [recommend] an outreach program to community resources and [non-VHA] providers. To let them know more about how the VA works and the resources that are available, and how specifically to coordinate care through the VA, would be a significant benefit.… If the [non-VHA] providers knew how to—who to—talk to, what information the VA needs, for example, for medication changes, it would help the patients make it work…without having to overburden the patients with having to physically hand carry their blood test results, or their notes, discharge summaries, procedure notes.”

Along with providing outreach and education on working with the VHA, clinic staff addressed the need to educate patients more effectively, because they are seen as central to the information exchange. There is motivation on the part of patients to learn the system. “Just making sure that the patients realize that they need to tell their local providers to send us the records and make sure that there is an exchange going on consistently,” explained a case manager. “If the patient wants to get those medications that are costly, then they figure out pretty quick what they have to have, what they need to send to us.” The need for education is an ongoing process; who is responsible for this continues to be a point of debate.

Discussion

In order to better understand comanagement of dual-use patients, this study focused on the experiences and perceptions of staff at VHA primary care clinics in the upper Midwest. The data indicated that:

Distance to health care and perceived convenience were clearly seen by clinic staff as the driving factors behind their patients’ dual use. In the authors’ prior work, interviews with veterans and their VA providers supported this assertion as well; however, it was also found that distance must not be understood in isolation of other contingencies, such as urgency of need.⁴

Clinic staff identified institutional and individual barriers that lead to miscommunication and confusion on the part of patients and reported misunderstandings with non-VHA providers, including 3 potential barriers to comanagement. These included (1) inconsistent communication and flow of information between VHA and non-VHA providers; (2) uncertainty about who will (and should) be responsible for information flow between providers; and (3) VHA and federal regulations over patient privacy. Throughout the interviews, access to less expensive prescription medications in VHA was considered an additional driver of dual use. According to clinic staff interviewed, education of patients and non-VHA providers could facilitate efficient and safe comanagement for dual-use patients.⁷

This study suggests both advantages and disadvantages for patients choosing to use multiple health care systems from the perspective of the clinic staff. The primary advantage is better overall health care access, especially for rural patients and those with longer travel times to VHA facilities. The primary disadvantage of dual use is discontinuity of care between multiple care sites. Specifically, this study identified concerns regarding poor communication between providers and transfer of patient medical records. An underlying theme was a concern for quality of care and patient safety, which are recognized by others in the literature as potential consequences of inadequate comanagement.^8-12

If there is one aspect of co-management for dual-use patients to target, this study’s findings point to developing strategies to improve communication between providers caring for dual-use patients and, more specifically, cultivating relationships that are currently underdeveloped. This will necessitate a clearer articulation of what constitutes a relationship between comanaging providers and is a direction for further research that would have applicability beyond VHA to any comanagement of patients using multiple health care systems.

There are 3 simultaneous, yet unrelated, factors that may contribute to increasing dual use. First is the rise in VHA eligible veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.^13,14 All returning veterans who meet minimal requirements are eligible for 5 years of VHA health care. A large proportion of these individuals are in the Reserve and National Guard, most of whom have nonmilitary jobs that may provide employer-based health insurance. Thus, these veterans have a greater opportunity for dual use. Second, with the aging cohort of Vietnam-era veterans, a greater proportion is becoming Medicare eligible. Third, with the recent passing of the ACA, more patients, including veterans, may choose to purchase insurance through ACA health exchanges. Taken individually or collectively, these factors will likely have effects reaching beyond VHA, especially when veterans receiving care in non-VHA health care systems engage in dual use.^3,13,15,16

Limitations

This study has a number of limitations. First, it was limited to VHA facilities located in the upper Midwest, which may limit generalizability to other parts of the country. The convenience sample of clinic staff at VHA clinics may not represent the full range of perspectives among HCPs generally. This study did not interview clinic staff in non-VHA clinics, although this has been the focus of other studies.^17,18 Although dual use also applies to specialty care and related access issues in rural areas, this was not a focus of this study. Last, the data were collected in 2009, prior to the implementation of the patient-aligned care team (PACT) model and prior to the recently revealed issues regarding patient wait times for VHA care. Thus, perceptions may have changed, and additional study is needed.

Conclusions

The results of this study support prior assumptions of barriers to care, but also introduce previously unreported challenges. Dual use is perceived to have both positive and negative impacts, but for the positives to outweigh the negatives, thoughtful comanagement is critical. This may be particularly so in rural areas where dual use is encouraged as a way to overcome distance and increase convenience in accessing care.

As demonstrated by recent events, there are still VHA health care access issues for veterans. Recently, VA leadership and the U.S. Congress proposed that veterans have greater access to community providers as well as VHA in order to overcome delays in care.¹⁹ As this option is explored and put into practice, it is more important than ever to consider the need for care coordination and management of dual-use patients, to ensure good communication and care that is timely, safe, and high quality.

Few models exist in which 2 PCPs coordinate across health care systems, and greater understanding of this dual use is needed. This information is important in designing interventions to improve care coordination across systems to ensure continuity of care, patient safety, and patient satisfaction. Although some work has been done to examine the perspectives of non-VA PCPs, little is known about VHA provider perspectives on rural veteran dual use.^17,18 This study explores VHA provider perspectives and identifies areas where interventions to improve care coordination across systems might be targeted.

Next steps for intervention studies would be to improve communication and develop educational tools to aid in the coordination of care between VHA and non-VHA providers. A recent example of this is the Co-Management Toolkit developed by the Veterans Rural Health Resource Center-Central Region, which provides information on VHA policies and targets non-VHA providers.²⁰ Although VHA perceptions of comanageing dual-use patients were the target, a similar study of non-VHA providers is important to understand this complex and multifaceted dynamic. Additional work is needed to measure the impact of dual use on clinical outcomes, patient safety and quality, and efficient use of resources, as these are understudied. As dual use continues and potentially increases with the ACA and changing health care in the U.S., it is important to understand the management of patients using multiple health care systems. This is salient as primary care adopts the PACT model and to inform interventions to improve quality and safety while eliminating duplicative health care and costs.

Acknowledgements
The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Central Region (VRHRC-CR) and the VA Health Services Research and Development (HSR&D) Service, the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, and Center to Improve Veteran Involvement in Care (CIVIC) at VA Portland Health Care System. Dr. Reisinger was supported by a Research Career Development Award from the Health Services Research and Development Service, Department of Veterans Affairs (CD1 08-013-1).

We would like to thank all health care providers who graciously agreed to participate in this study and VRHRC-CR staff, in particular Monica Paez for assistance on this manuscript.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

The VHA assigns all enrolled veterans to a primary care provider (PCP). However, almost 80% of veterans enrolled in VHA have another form of health care coverage, including Medicare, Medicaid, private insurance, and TRICARE for Life program.¹ Consequently, veterans may choose to use more than 1 health care system to manage their health care needs.

Studies based on merged VHA and Medicare claims data have demonstrated substantial dual use by VHA enrollees with Medicare. Petersen and colleagues reported that about 80% of VHA enrollees with Medicare chose to use services in both systems and that greater distance to VHA facilities and lower priority level for VHA care predicted lower VHA reliance.² Among those aged < 65 years who had Medicare due to disability, 58% weredual users. These dual users relied more on private sector care for many health conditions, with the notable exception of substance abuse and mental health disorders, for which reliance on VHA care was greater.² Another study found that over half of VHA enrollees assigned to a PCP at a community-based outpatient clinic (CBOC) received some or all of their care outside VHA and that reliance on VHA outpatient care declined over the 4-year study period.³

Related: Mutual Alignment Trumps Merger for Joint VA/DoD Health Care Programs

This use of multiple health care providers (HCPs), facilities, and modalities is often described as dual use or comanagement. Dual use in the case of veterans refers to use of both VHA and non-VHA health care, whereas comanagement implies an expectation of shared decision making and open communication between VHA and non-VHA providers. In addition to VHA PCPs, rural veterans frequently receive care from local, non-VHA HCPs in the community where they live. As health care in the U.S. evolves and patients have increasing choices through the Affordable Care Act (ACA), the challenge of comanagement for patients receiving care in multiple systems is likely to increase both within and outside VHA.

This study was part of a qualitative rural health needs assessment designed to ascertain the issues facing rural veterans and their providers in the upper Midwest.⁴ The objective was to examine VHA primary care clinic staff perspectives on dual users, perceived barriers that inhibit comanagement, and factors that contribute to the need for dual use in rural areas.

Methods

A qualitative study design with in-person interviews was used to elicit the perspective of VHA clinic staff on the current and ideal states of comanagement. Clinics were selected using a stratified purposeful sample of 15 urban and rural primary care clinics at VHA CBOCs and VAMCs in 8 Midwestern states (Illinois, Iowa, Minnesota, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming). The stratification criteria included (1) urban and rural; (2) geographic coverage of VISN 23; and (3) VHA-managed and contract clinics, resulting in a purposeful sample of 2 urban VAMC clinics, 3 urban CBOCs, 7 rural VHA-managed CBOCs, and 3 rural contract CBOCs. The distance from the CBOC to the closest VAMC ranged from 32 to 242 miles.

Related: VA Relaxes Rules for Choice Program

Interview guides were developed and tested by the research team for comprehension, length, and timing prior to data collection and iteratively revised as analysis evolved and new topics emerged. Clinic staff were asked about their perceptions of rural veteran use of VHA care; barriers and facilitators to accessing care; and their personal experience working within VHA. Several questions focused on dual use and why rural veterans use multiple health care systems, their perspectives of dual use, their expectations of patients’ role(s) in health care coordination, and the perceived barriers that inhibit comanagement. Interviewers used comanagement and dual use interchangeably to discuss patients with multiple care providers, allowing interviewees to use their preferred terminology; assigned meanings were probed for clarification but not corrected by interviewers.

Between June and October 2009, teams of 2 to 3 researchers visited 15 clinics for 1 to 2 business days each. Researchers conducted interviews with a convenience sample of clinical staff. Consent forms and an explanation of the study were distributed, and those electing to participate voluntarily came to a designated room to complete an interview. All interviews were audio recorded for accuracy.

Interview recordings were transcribed verbatim and reviewed for accuracy. Prior to coding, transcripts were imported into a qualitative data management software program. A codebook, including a priori research hypotheses and de novo themes, was developed based on a systematic review of a randomly selected subset of interview transcripts.⁵ Four coders were responsible for coding all transcripts and validating coding through tests of agreement at predetermined intervals.

Regular meetings were conducted with coders and the lead qualitative investigator to discuss disagreements, clarify code definitions, or add new codes as needed. As codes were added, previous transcripts were coded/recoded for content related to the new codes. An audit trail was maintained, and iterative mediation of codes continued throughout the process. The final codebook contained 42 thematic codes, which reached saturation or data redundancy.⁶ Detailed analysis of the codes dual use, distance, and care coordination were used to inform this study.

Results

Among the 15 sites, 64 in-depth individual interviews were conducted, ranging from 5 to 53 minutes (average 26 minutes). Clinic staff demographic characteristics are depicted in the Table. Analysis of data captured in the codes dual use, distance, and care coordination resulted in notable concentration in 4 thematic areas: (1) clinic staff perceptions of the influence of access, convenience, and distance on dual use for rural patients; (2) communication and patient’s role in comanagement; (3) rules and regulations related to comanagement from the VHA perspective; and (4) barriers to comanagement and recommendations for education.

Influence of Access, Convenience, and Distance

Access to health care was central to the discussion of dual use and comanagement by clinic staff. Convenience was identified as the primary reason for rural patients’ use of non-VHA services, as many rural patients must travel outside their local community to access VHA care. Thus, dual use was most often noted for services typically available in patients’ local communities, especially management of chronic conditions.

The CBOCs provide important services for primary care and management of chronic conditions but are not available in all communities and may have limited hours/days that do not fit with patients’ schedules. The CBOCs are often unable to provide needed services, including but not limited to emergency care, diagnostic tests, physical and occupational therapy, and other specialty care services. As one VHA provider put it, “The biggest factor for [dual use] is availability, access, convenience.… It’s a lot more convenient to go to the hospital down the street than it is to go 120 miles to [the VAMC], or for some guys who live 30, 40 minutes the other side of here it becomes 150, 160-mile one-way trip.”

Related to access, distance and transportation barriers were identified by clinic staff as obstacles to care for rural patients. Despite efforts to offset the expense of travel through reimbursement to qualified veterans and coordinated van transport with Veterans Service Organizations, travel costs—both time and money—were seen as significant barriers to accessing VHA care, as was an inability to travel for those who are ill or frail and elderly. “We send people … in the van and for the most part that works, but eventually it gets expensive, or you’ve got somebody with chronic pain that can’t tolerate the van ride for 2 hours,” one interviewee
reported.

According to clinic staff, dual-use patients also rely on non-VHA providers in particular for urgent or emergency care, while relying on VHA primary care for reduced-cost medications, diagnostic testing, chronic disease management, or annual exams. When asked why rural patients may choose to see more than 1 provider, VHA providers responded. “[It’s] more convenient to have a local doctor just in case something went wrong and they need to see a doctor right away. So distance to this clinic would be the number one reason.” Another reported, “If it’s once or twice a year routine appointments they’ll come here, but… they’d rather go to a walk-in clinic nearby than spend so much [money] on gas.”

Communication and Patients’ Role

Communication between VHA and non-VHA providers is a necessary element of comanagement. Although phone calls or faxing patient medical records are available options, clinic staff reported it was more common to encounter patients hand carrying their records between providers. For dual-use patients, clinic staff indicated it was often unclear who was responsible for relaying information between providers. There is often ambiguity about who will (and should) fulfill this role and not enough time to adequately address or clarify how this is done. Some clinic staff believed that acting as the main conduits of information placed an undue burden on the patients, particularly asking them to be able to accurately relay medical information about tests or prescriptions that they may not fully understand. Others said that it was primarily the patients’ responsibility to give relevant information about their care to all their providers, because of VHA regulations and patient privacy laws. “[The] patient should tell the primary doctor to send them [medical records] because we can’t get the medical records without the patient’s permission,” said one provider.

Another provider utilized the nursing staff to call patients after their appointments to remind them to give their medical records to their non-VHA provider. The data suggest that responsibility for maintaining communication between providers ultimately falls on the patient. From the perspective of a nurse practitioner, “We just keep trying to educate the community…. I’ve been told that if the patient wants that privilege of using the VA for a pharmacy for an outside provider that we’re glad to do that. But it is their responsibility to communicate with their [non-VHA] physician. I think we just need to keep educating the patients.”

Rules and Regulations

VHA policies governing prescriptions, hospitalizations at outside facilities, and release of patient information regulate, and in some cases hinder, information flow between VHA and non-VHA providers. Many patients use VHA to obtain medications for lower out-of-pocket costs. This contributes to the number of dual-use patients in VHA and results in several challenges for VHA providers trying to manage patients’ prescriptions. For example, patients will ask to fill a prescription at a VHA pharmacy from their non-VHA providers; however, VHA pharmacies can only fill prescriptions from VHA providers.

Many VHA providers are willing to rewrite these prescriptions, but they may need to see the patient before adding or changing the prescription and require documentation to address contraindications, adverse reactions and/or therapeutic failure, and associated risks before making the authorization. VHA providers noted that because the VHA formulary does not contain all medications, non-VHA providers are often unfamiliar with the VHA National Formulary specifics and will write prescriptions for nonformulary medications, which require a nonformulary request from a VHA provider.

Clinic staff also mentioned difficulty in obtaining records from non-VHA providers. This can be particularly problematic if the patient lives a distance away from a VHA facility and does not have the necessary authorization to share records on file.

Barriers and Education Recommendations

Clinic staff identified coordination of care for dual-use patients as a barrier to providing care. Specifically, providers identified coordination as complicated by communication difficulties, inefficient medical record exchange, short staffing in VHA clinics, duplication of diagnostic services, and non-VHA providers’ lack of understanding regarding the services that VHA provides. Specific to rural clinics, comanagement was reportedly hindered by limitations in technology (eg, consistent Internet access), access to routine diagnostic services, and lack of relationships with non-VHA providers. Providers most frequently reported that the critical piece missing in comanagement is a relationship—and implied communication—between VHA clinics and non-VHA community clinics. The concept of a relationship between providers is evoked as a critical element to comanaging dual-use patients; however, clinic staff had a difficult time articulating what that relationship would actually look like if put into practice.

Related: Patients Benefit From ICU Telemedicine

In spite of the numerous barriers identified by clinic staff, the recommendation for education to improve comanagement was consistent across study sites and clinic staff roles. Education was proposed for patients and non-VHA providers as the best intervention. In response to a question about ideas and recommendations to improve comanagement, clinic staff drew on varied experiences. To illustrate this theme, a provider gave this example of dual-use patients seeking prescription medication from VHA and its impact on comanagement: “I would [recommend] an outreach program to community resources and [non-VHA] providers. To let them know more about how the VA works and the resources that are available, and how specifically to coordinate care through the VA, would be a significant benefit.… If the [non-VHA] providers knew how to—who to—talk to, what information the VA needs, for example, for medication changes, it would help the patients make it work…without having to overburden the patients with having to physically hand carry their blood test results, or their notes, discharge summaries, procedure notes.”

Along with providing outreach and education on working with the VHA, clinic staff addressed the need to educate patients more effectively, because they are seen as central to the information exchange. There is motivation on the part of patients to learn the system. “Just making sure that the patients realize that they need to tell their local providers to send us the records and make sure that there is an exchange going on consistently,” explained a case manager. “If the patient wants to get those medications that are costly, then they figure out pretty quick what they have to have, what they need to send to us.” The need for education is an ongoing process; who is responsible for this continues to be a point of debate.

Discussion

In order to better understand comanagement of dual-use patients, this study focused on the experiences and perceptions of staff at VHA primary care clinics in the upper Midwest. The data indicated that:

Distance to health care and perceived convenience were clearly seen by clinic staff as the driving factors behind their patients’ dual use. In the authors’ prior work, interviews with veterans and their VA providers supported this assertion as well; however, it was also found that distance must not be understood in isolation of other contingencies, such as urgency of need.⁴

Clinic staff identified institutional and individual barriers that lead to miscommunication and confusion on the part of patients and reported misunderstandings with non-VHA providers, including 3 potential barriers to comanagement. These included (1) inconsistent communication and flow of information between VHA and non-VHA providers; (2) uncertainty about who will (and should) be responsible for information flow between providers; and (3) VHA and federal regulations over patient privacy. Throughout the interviews, access to less expensive prescription medications in VHA was considered an additional driver of dual use. According to clinic staff interviewed, education of patients and non-VHA providers could facilitate efficient and safe comanagement for dual-use patients.⁷

This study suggests both advantages and disadvantages for patients choosing to use multiple health care systems from the perspective of the clinic staff. The primary advantage is better overall health care access, especially for rural patients and those with longer travel times to VHA facilities. The primary disadvantage of dual use is discontinuity of care between multiple care sites. Specifically, this study identified concerns regarding poor communication between providers and transfer of patient medical records. An underlying theme was a concern for quality of care and patient safety, which are recognized by others in the literature as potential consequences of inadequate comanagement.^8-12

If there is one aspect of co-management for dual-use patients to target, this study’s findings point to developing strategies to improve communication between providers caring for dual-use patients and, more specifically, cultivating relationships that are currently underdeveloped. This will necessitate a clearer articulation of what constitutes a relationship between comanaging providers and is a direction for further research that would have applicability beyond VHA to any comanagement of patients using multiple health care systems.

There are 3 simultaneous, yet unrelated, factors that may contribute to increasing dual use. First is the rise in VHA eligible veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.^13,14 All returning veterans who meet minimal requirements are eligible for 5 years of VHA health care. A large proportion of these individuals are in the Reserve and National Guard, most of whom have nonmilitary jobs that may provide employer-based health insurance. Thus, these veterans have a greater opportunity for dual use. Second, with the aging cohort of Vietnam-era veterans, a greater proportion is becoming Medicare eligible. Third, with the recent passing of the ACA, more patients, including veterans, may choose to purchase insurance through ACA health exchanges. Taken individually or collectively, these factors will likely have effects reaching beyond VHA, especially when veterans receiving care in non-VHA health care systems engage in dual use.^3,13,15,16

Limitations

This study has a number of limitations. First, it was limited to VHA facilities located in the upper Midwest, which may limit generalizability to other parts of the country. The convenience sample of clinic staff at VHA clinics may not represent the full range of perspectives among HCPs generally. This study did not interview clinic staff in non-VHA clinics, although this has been the focus of other studies.^17,18 Although dual use also applies to specialty care and related access issues in rural areas, this was not a focus of this study. Last, the data were collected in 2009, prior to the implementation of the patient-aligned care team (PACT) model and prior to the recently revealed issues regarding patient wait times for VHA care. Thus, perceptions may have changed, and additional study is needed.

Conclusions

The results of this study support prior assumptions of barriers to care, but also introduce previously unreported challenges. Dual use is perceived to have both positive and negative impacts, but for the positives to outweigh the negatives, thoughtful comanagement is critical. This may be particularly so in rural areas where dual use is encouraged as a way to overcome distance and increase convenience in accessing care.

As demonstrated by recent events, there are still VHA health care access issues for veterans. Recently, VA leadership and the U.S. Congress proposed that veterans have greater access to community providers as well as VHA in order to overcome delays in care.¹⁹ As this option is explored and put into practice, it is more important than ever to consider the need for care coordination and management of dual-use patients, to ensure good communication and care that is timely, safe, and high quality.

Few models exist in which 2 PCPs coordinate across health care systems, and greater understanding of this dual use is needed. This information is important in designing interventions to improve care coordination across systems to ensure continuity of care, patient safety, and patient satisfaction. Although some work has been done to examine the perspectives of non-VA PCPs, little is known about VHA provider perspectives on rural veteran dual use.^17,18 This study explores VHA provider perspectives and identifies areas where interventions to improve care coordination across systems might be targeted.

Next steps for intervention studies would be to improve communication and develop educational tools to aid in the coordination of care between VHA and non-VHA providers. A recent example of this is the Co-Management Toolkit developed by the Veterans Rural Health Resource Center-Central Region, which provides information on VHA policies and targets non-VHA providers.²⁰ Although VHA perceptions of comanageing dual-use patients were the target, a similar study of non-VHA providers is important to understand this complex and multifaceted dynamic. Additional work is needed to measure the impact of dual use on clinical outcomes, patient safety and quality, and efficient use of resources, as these are understudied. As dual use continues and potentially increases with the ACA and changing health care in the U.S., it is important to understand the management of patients using multiple health care systems. This is salient as primary care adopts the PACT model and to inform interventions to improve quality and safety while eliminating duplicative health care and costs.

Acknowledgements
The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Central Region (VRHRC-CR) and the VA Health Services Research and Development (HSR&D) Service, the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, and Center to Improve Veteran Involvement in Care (CIVIC) at VA Portland Health Care System. Dr. Reisinger was supported by a Research Career Development Award from the Health Services Research and Development Service, Department of Veterans Affairs (CD1 08-013-1).

We would like to thank all health care providers who graciously agreed to participate in this study and VRHRC-CR staff, in particular Monica Paez for assistance on this manuscript.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

The VHA assigns all enrolled veterans to a primary care provider (PCP). However, almost 80% of veterans enrolled in VHA have another form of health care coverage, including Medicare, Medicaid, private insurance, and TRICARE for Life program.¹ Consequently, veterans may choose to use more than 1 health care system to manage their health care needs.

Studies based on merged VHA and Medicare claims data have demonstrated substantial dual use by VHA enrollees with Medicare. Petersen and colleagues reported that about 80% of VHA enrollees with Medicare chose to use services in both systems and that greater distance to VHA facilities and lower priority level for VHA care predicted lower VHA reliance.² Among those aged < 65 years who had Medicare due to disability, 58% weredual users. These dual users relied more on private sector care for many health conditions, with the notable exception of substance abuse and mental health disorders, for which reliance on VHA care was greater.² Another study found that over half of VHA enrollees assigned to a PCP at a community-based outpatient clinic (CBOC) received some or all of their care outside VHA and that reliance on VHA outpatient care declined over the 4-year study period.³

Related: Mutual Alignment Trumps Merger for Joint VA/DoD Health Care Programs

This use of multiple health care providers (HCPs), facilities, and modalities is often described as dual use or comanagement. Dual use in the case of veterans refers to use of both VHA and non-VHA health care, whereas comanagement implies an expectation of shared decision making and open communication between VHA and non-VHA providers. In addition to VHA PCPs, rural veterans frequently receive care from local, non-VHA HCPs in the community where they live. As health care in the U.S. evolves and patients have increasing choices through the Affordable Care Act (ACA), the challenge of comanagement for patients receiving care in multiple systems is likely to increase both within and outside VHA.

This study was part of a qualitative rural health needs assessment designed to ascertain the issues facing rural veterans and their providers in the upper Midwest.⁴ The objective was to examine VHA primary care clinic staff perspectives on dual users, perceived barriers that inhibit comanagement, and factors that contribute to the need for dual use in rural areas.

Methods

A qualitative study design with in-person interviews was used to elicit the perspective of VHA clinic staff on the current and ideal states of comanagement. Clinics were selected using a stratified purposeful sample of 15 urban and rural primary care clinics at VHA CBOCs and VAMCs in 8 Midwestern states (Illinois, Iowa, Minnesota, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming). The stratification criteria included (1) urban and rural; (2) geographic coverage of VISN 23; and (3) VHA-managed and contract clinics, resulting in a purposeful sample of 2 urban VAMC clinics, 3 urban CBOCs, 7 rural VHA-managed CBOCs, and 3 rural contract CBOCs. The distance from the CBOC to the closest VAMC ranged from 32 to 242 miles.

Related: VA Relaxes Rules for Choice Program

Interview guides were developed and tested by the research team for comprehension, length, and timing prior to data collection and iteratively revised as analysis evolved and new topics emerged. Clinic staff were asked about their perceptions of rural veteran use of VHA care; barriers and facilitators to accessing care; and their personal experience working within VHA. Several questions focused on dual use and why rural veterans use multiple health care systems, their perspectives of dual use, their expectations of patients’ role(s) in health care coordination, and the perceived barriers that inhibit comanagement. Interviewers used comanagement and dual use interchangeably to discuss patients with multiple care providers, allowing interviewees to use their preferred terminology; assigned meanings were probed for clarification but not corrected by interviewers.

Between June and October 2009, teams of 2 to 3 researchers visited 15 clinics for 1 to 2 business days each. Researchers conducted interviews with a convenience sample of clinical staff. Consent forms and an explanation of the study were distributed, and those electing to participate voluntarily came to a designated room to complete an interview. All interviews were audio recorded for accuracy.

Interview recordings were transcribed verbatim and reviewed for accuracy. Prior to coding, transcripts were imported into a qualitative data management software program. A codebook, including a priori research hypotheses and de novo themes, was developed based on a systematic review of a randomly selected subset of interview transcripts.⁵ Four coders were responsible for coding all transcripts and validating coding through tests of agreement at predetermined intervals.

Regular meetings were conducted with coders and the lead qualitative investigator to discuss disagreements, clarify code definitions, or add new codes as needed. As codes were added, previous transcripts were coded/recoded for content related to the new codes. An audit trail was maintained, and iterative mediation of codes continued throughout the process. The final codebook contained 42 thematic codes, which reached saturation or data redundancy.⁶ Detailed analysis of the codes dual use, distance, and care coordination were used to inform this study.

Results

Among the 15 sites, 64 in-depth individual interviews were conducted, ranging from 5 to 53 minutes (average 26 minutes). Clinic staff demographic characteristics are depicted in the Table. Analysis of data captured in the codes dual use, distance, and care coordination resulted in notable concentration in 4 thematic areas: (1) clinic staff perceptions of the influence of access, convenience, and distance on dual use for rural patients; (2) communication and patient’s role in comanagement; (3) rules and regulations related to comanagement from the VHA perspective; and (4) barriers to comanagement and recommendations for education.

Influence of Access, Convenience, and Distance

Access to health care was central to the discussion of dual use and comanagement by clinic staff. Convenience was identified as the primary reason for rural patients’ use of non-VHA services, as many rural patients must travel outside their local community to access VHA care. Thus, dual use was most often noted for services typically available in patients’ local communities, especially management of chronic conditions.

The CBOCs provide important services for primary care and management of chronic conditions but are not available in all communities and may have limited hours/days that do not fit with patients’ schedules. The CBOCs are often unable to provide needed services, including but not limited to emergency care, diagnostic tests, physical and occupational therapy, and other specialty care services. As one VHA provider put it, “The biggest factor for [dual use] is availability, access, convenience.… It’s a lot more convenient to go to the hospital down the street than it is to go 120 miles to [the VAMC], or for some guys who live 30, 40 minutes the other side of here it becomes 150, 160-mile one-way trip.”

Related to access, distance and transportation barriers were identified by clinic staff as obstacles to care for rural patients. Despite efforts to offset the expense of travel through reimbursement to qualified veterans and coordinated van transport with Veterans Service Organizations, travel costs—both time and money—were seen as significant barriers to accessing VHA care, as was an inability to travel for those who are ill or frail and elderly. “We send people … in the van and for the most part that works, but eventually it gets expensive, or you’ve got somebody with chronic pain that can’t tolerate the van ride for 2 hours,” one interviewee
reported.

According to clinic staff, dual-use patients also rely on non-VHA providers in particular for urgent or emergency care, while relying on VHA primary care for reduced-cost medications, diagnostic testing, chronic disease management, or annual exams. When asked why rural patients may choose to see more than 1 provider, VHA providers responded. “[It’s] more convenient to have a local doctor just in case something went wrong and they need to see a doctor right away. So distance to this clinic would be the number one reason.” Another reported, “If it’s once or twice a year routine appointments they’ll come here, but… they’d rather go to a walk-in clinic nearby than spend so much [money] on gas.”

Communication and Patients’ Role

Communication between VHA and non-VHA providers is a necessary element of comanagement. Although phone calls or faxing patient medical records are available options, clinic staff reported it was more common to encounter patients hand carrying their records between providers. For dual-use patients, clinic staff indicated it was often unclear who was responsible for relaying information between providers. There is often ambiguity about who will (and should) fulfill this role and not enough time to adequately address or clarify how this is done. Some clinic staff believed that acting as the main conduits of information placed an undue burden on the patients, particularly asking them to be able to accurately relay medical information about tests or prescriptions that they may not fully understand. Others said that it was primarily the patients’ responsibility to give relevant information about their care to all their providers, because of VHA regulations and patient privacy laws. “[The] patient should tell the primary doctor to send them [medical records] because we can’t get the medical records without the patient’s permission,” said one provider.

Another provider utilized the nursing staff to call patients after their appointments to remind them to give their medical records to their non-VHA provider. The data suggest that responsibility for maintaining communication between providers ultimately falls on the patient. From the perspective of a nurse practitioner, “We just keep trying to educate the community…. I’ve been told that if the patient wants that privilege of using the VA for a pharmacy for an outside provider that we’re glad to do that. But it is their responsibility to communicate with their [non-VHA] physician. I think we just need to keep educating the patients.”

Rules and Regulations

VHA policies governing prescriptions, hospitalizations at outside facilities, and release of patient information regulate, and in some cases hinder, information flow between VHA and non-VHA providers. Many patients use VHA to obtain medications for lower out-of-pocket costs. This contributes to the number of dual-use patients in VHA and results in several challenges for VHA providers trying to manage patients’ prescriptions. For example, patients will ask to fill a prescription at a VHA pharmacy from their non-VHA providers; however, VHA pharmacies can only fill prescriptions from VHA providers.

Many VHA providers are willing to rewrite these prescriptions, but they may need to see the patient before adding or changing the prescription and require documentation to address contraindications, adverse reactions and/or therapeutic failure, and associated risks before making the authorization. VHA providers noted that because the VHA formulary does not contain all medications, non-VHA providers are often unfamiliar with the VHA National Formulary specifics and will write prescriptions for nonformulary medications, which require a nonformulary request from a VHA provider.

Clinic staff also mentioned difficulty in obtaining records from non-VHA providers. This can be particularly problematic if the patient lives a distance away from a VHA facility and does not have the necessary authorization to share records on file.

Barriers and Education Recommendations

Clinic staff identified coordination of care for dual-use patients as a barrier to providing care. Specifically, providers identified coordination as complicated by communication difficulties, inefficient medical record exchange, short staffing in VHA clinics, duplication of diagnostic services, and non-VHA providers’ lack of understanding regarding the services that VHA provides. Specific to rural clinics, comanagement was reportedly hindered by limitations in technology (eg, consistent Internet access), access to routine diagnostic services, and lack of relationships with non-VHA providers. Providers most frequently reported that the critical piece missing in comanagement is a relationship—and implied communication—between VHA clinics and non-VHA community clinics. The concept of a relationship between providers is evoked as a critical element to comanaging dual-use patients; however, clinic staff had a difficult time articulating what that relationship would actually look like if put into practice.

Related: Patients Benefit From ICU Telemedicine

In spite of the numerous barriers identified by clinic staff, the recommendation for education to improve comanagement was consistent across study sites and clinic staff roles. Education was proposed for patients and non-VHA providers as the best intervention. In response to a question about ideas and recommendations to improve comanagement, clinic staff drew on varied experiences. To illustrate this theme, a provider gave this example of dual-use patients seeking prescription medication from VHA and its impact on comanagement: “I would [recommend] an outreach program to community resources and [non-VHA] providers. To let them know more about how the VA works and the resources that are available, and how specifically to coordinate care through the VA, would be a significant benefit.… If the [non-VHA] providers knew how to—who to—talk to, what information the VA needs, for example, for medication changes, it would help the patients make it work…without having to overburden the patients with having to physically hand carry their blood test results, or their notes, discharge summaries, procedure notes.”

Along with providing outreach and education on working with the VHA, clinic staff addressed the need to educate patients more effectively, because they are seen as central to the information exchange. There is motivation on the part of patients to learn the system. “Just making sure that the patients realize that they need to tell their local providers to send us the records and make sure that there is an exchange going on consistently,” explained a case manager. “If the patient wants to get those medications that are costly, then they figure out pretty quick what they have to have, what they need to send to us.” The need for education is an ongoing process; who is responsible for this continues to be a point of debate.

Discussion

In order to better understand comanagement of dual-use patients, this study focused on the experiences and perceptions of staff at VHA primary care clinics in the upper Midwest. The data indicated that:

Distance to health care and perceived convenience were clearly seen by clinic staff as the driving factors behind their patients’ dual use. In the authors’ prior work, interviews with veterans and their VA providers supported this assertion as well; however, it was also found that distance must not be understood in isolation of other contingencies, such as urgency of need.⁴

Clinic staff identified institutional and individual barriers that lead to miscommunication and confusion on the part of patients and reported misunderstandings with non-VHA providers, including 3 potential barriers to comanagement. These included (1) inconsistent communication and flow of information between VHA and non-VHA providers; (2) uncertainty about who will (and should) be responsible for information flow between providers; and (3) VHA and federal regulations over patient privacy. Throughout the interviews, access to less expensive prescription medications in VHA was considered an additional driver of dual use. According to clinic staff interviewed, education of patients and non-VHA providers could facilitate efficient and safe comanagement for dual-use patients.⁷

This study suggests both advantages and disadvantages for patients choosing to use multiple health care systems from the perspective of the clinic staff. The primary advantage is better overall health care access, especially for rural patients and those with longer travel times to VHA facilities. The primary disadvantage of dual use is discontinuity of care between multiple care sites. Specifically, this study identified concerns regarding poor communication between providers and transfer of patient medical records. An underlying theme was a concern for quality of care and patient safety, which are recognized by others in the literature as potential consequences of inadequate comanagement.^8-12

If there is one aspect of co-management for dual-use patients to target, this study’s findings point to developing strategies to improve communication between providers caring for dual-use patients and, more specifically, cultivating relationships that are currently underdeveloped. This will necessitate a clearer articulation of what constitutes a relationship between comanaging providers and is a direction for further research that would have applicability beyond VHA to any comanagement of patients using multiple health care systems.

There are 3 simultaneous, yet unrelated, factors that may contribute to increasing dual use. First is the rise in VHA eligible veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.^13,14 All returning veterans who meet minimal requirements are eligible for 5 years of VHA health care. A large proportion of these individuals are in the Reserve and National Guard, most of whom have nonmilitary jobs that may provide employer-based health insurance. Thus, these veterans have a greater opportunity for dual use. Second, with the aging cohort of Vietnam-era veterans, a greater proportion is becoming Medicare eligible. Third, with the recent passing of the ACA, more patients, including veterans, may choose to purchase insurance through ACA health exchanges. Taken individually or collectively, these factors will likely have effects reaching beyond VHA, especially when veterans receiving care in non-VHA health care systems engage in dual use.^3,13,15,16

Limitations

This study has a number of limitations. First, it was limited to VHA facilities located in the upper Midwest, which may limit generalizability to other parts of the country. The convenience sample of clinic staff at VHA clinics may not represent the full range of perspectives among HCPs generally. This study did not interview clinic staff in non-VHA clinics, although this has been the focus of other studies.^17,18 Although dual use also applies to specialty care and related access issues in rural areas, this was not a focus of this study. Last, the data were collected in 2009, prior to the implementation of the patient-aligned care team (PACT) model and prior to the recently revealed issues regarding patient wait times for VHA care. Thus, perceptions may have changed, and additional study is needed.

Conclusions

The results of this study support prior assumptions of barriers to care, but also introduce previously unreported challenges. Dual use is perceived to have both positive and negative impacts, but for the positives to outweigh the negatives, thoughtful comanagement is critical. This may be particularly so in rural areas where dual use is encouraged as a way to overcome distance and increase convenience in accessing care.

As demonstrated by recent events, there are still VHA health care access issues for veterans. Recently, VA leadership and the U.S. Congress proposed that veterans have greater access to community providers as well as VHA in order to overcome delays in care.¹⁹ As this option is explored and put into practice, it is more important than ever to consider the need for care coordination and management of dual-use patients, to ensure good communication and care that is timely, safe, and high quality.

Few models exist in which 2 PCPs coordinate across health care systems, and greater understanding of this dual use is needed. This information is important in designing interventions to improve care coordination across systems to ensure continuity of care, patient safety, and patient satisfaction. Although some work has been done to examine the perspectives of non-VA PCPs, little is known about VHA provider perspectives on rural veteran dual use.^17,18 This study explores VHA provider perspectives and identifies areas where interventions to improve care coordination across systems might be targeted.

Next steps for intervention studies would be to improve communication and develop educational tools to aid in the coordination of care between VHA and non-VHA providers. A recent example of this is the Co-Management Toolkit developed by the Veterans Rural Health Resource Center-Central Region, which provides information on VHA policies and targets non-VHA providers.²⁰ Although VHA perceptions of comanageing dual-use patients were the target, a similar study of non-VHA providers is important to understand this complex and multifaceted dynamic. Additional work is needed to measure the impact of dual use on clinical outcomes, patient safety and quality, and efficient use of resources, as these are understudied. As dual use continues and potentially increases with the ACA and changing health care in the U.S., it is important to understand the management of patients using multiple health care systems. This is salient as primary care adopts the PACT model and to inform interventions to improve quality and safety while eliminating duplicative health care and costs.

Acknowledgements
The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Central Region (VRHRC-CR) and the VA Health Services Research and Development (HSR&D) Service, the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Health Care System, and Center to Improve Veteran Involvement in Care (CIVIC) at VA Portland Health Care System. Dr. Reisinger was supported by a Research Career Development Award from the Health Services Research and Development Service, Department of Veterans Affairs (CD1 08-013-1).

We would like to thank all health care providers who graciously agreed to participate in this study and VRHRC-CR staff, in particular Monica Paez for assistance on this manuscript.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Homeless individuals and IV drug users are susceptible to hepatitis A, B, and C infections, and co-infection with these diseases may complicate treatment and result in poor medical outcomes.¹ Vaccination offers the best protection against hepatitis A and B, particularly among high-risk populations.^2,3 Immunization against hepatitis A and B is of even greater importance for patients with hepatitis C, because there is no specific hepatitis C vaccine, and concomitant infections of B with C are damaging to the liver.⁴

Veterans have a rate of hepatitis C infection that is 3 times that of the general population.⁵ Some evidence exists that veterans with serious mental illness (SMI) have a higher rate of hepatitis C infection relative to patients without SMI. Co-occurring substance abuse may add another layer of vulnerability to hepatitis C infection, particularly for homeless veterans.^5-7

Mental Health and Primary Care Integration

Substance abuse and dual-diagnosis treatment programs (ie, those programs that treat both substance abuse and co-occurring serious mental health problems, such as bipolar disorder, severe major depressive disorder, psychotic disorders, and posttraumatic stress disorder [PTSD]) that have integrated mental health and primary care into their treatment programs may offer a window of opportunity for risk-reducing interventions. These interventions include testing and education of patients regarding infectious diseases, such as viral hepatitis and HIV, and completion of the hepatitis A/B immunization series.

The James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida, has demonstrated some limited success in the past with integrating a standard dosing schedule for hepatitis A/B vaccination into its substance abuse treatment program (SATP), though recent evidence points to more promising results using an accelerated regimen as indicated by a high completion rate for hepatitis B vaccination in a methadone clinic.^8,9 A relatively low proportion of SATPs in the U.S. provide testing, education, or vaccination for hepatitis A and B, especially considering the public health importance of controlling these diseases in the substance abusing populations.^10,11

Related: Combination Pill Approved for HCV

In 1999, a primary care team was added to the alcohol and drug abuse treatment program at JAHVH.In 2005, the nurses in the program began scheduling vaccinations and screening patients for medical and psychiatric issues, pain, hypertension, diabetes, hepatitis C, alcohol use, depression, PTSD, prostate and colorectal cancers.¹² Such a multidisciplinary approach provides many treatment advantages for patients and may save lives.¹³

Even with a multidisciplinary approach, the nurses found it difficult to provide adequate hepatitis A/B immunization within the 3- to 6-week intensive SATP, because standard immunization dosing regimens are spread over 6 months.¹⁴ As with all types of immunizations, long dosing schedules may reduce patient adherence and result in inadequate seroprotection.¹⁵ Thus, there is a need to provide a completed immunization series in a more expeditious fashion, and an accelerated dosing regimen makes that possible.^15,16

Hepatitis A/B Vaccination

Twinrix (GlaxoSmithKline, Brentford, United Kingdom) is a vaccine that provides dual immunization for hepatitis A and B. Whereas the standard vaccination schedule takes 6 months to complete, the accelerated dosing schedule can be used to complete the first 3 doses in less than a month. The accelerated dosing schedule was incorporated into the JAHVH clinic to capture as many patients as possible in the 3- to 6-week time frame: The first dose is administered and followed by a second dose 7 days later. The third dose is administered 21 to 30 days after the first dose. Twelve months after the first dose, a booster dose is given. 

After the first 3 accelerated doses, > 98% of patients show a sustained immune response to hepatitis A, and > 63% demonstrate immunity to hepatitis B. If a 12-month booster injection is given, 100% of patients may receive immunity to hepatitis A and > 96% may have immunity to hepatitis B.¹⁶ Another study of the combined vaccine showed even greater seroprotection for hepatitis A and B after only 1 month, 100% and 82%, respectively.¹⁷

Related: Viral Hepatitis Awareness

This JAHVH retrospective feasibility study describes a risk-reduction program for hepatitis A/B prevention that was implemented within a 3- to 4-week intensive outpatient SATP and a 6-week dual-diagnosis treatment program. The study includes the development and implementation of the program, designed to vaccinate patients using the accelerated Twinrix schedule. To ascertain the feasibility of this vaccination approach, historical medical records were used to describe and examine the vaccination initiation and follow-up rates of the treatment program participants who received the hepatitis A/B immunization series during their intensive SATP.

Study Design

A retrospective review of medical records was conducted for all participants who were admitted to the intensive JAHVH SATP between October 1, 2008, and September 30, 2009. This study was reviewed and approved by the JAHVH research and development committee and its associated University of South Florida institutional review board. Informed consent to participate was not obtained, because the study was retrospective.

Patient Identification and Education

All program participants were offered testing for HIV and hepatitis A, B, and C. Program participants were educated about hepatitis and HIV transmission, as well as about the long-term effects of continued substance abuse on the progression of hepatitis C. Education about hepatitis, HIV, and substance abuse was provided in a group setting by a member of the program’s nursing staff. One-on-one risk education counseling was also provided when requested or otherwise indicated.

Laboratory testing was performed following each participant’s initial physical examination (within 3 to 5 days of program admission), and the nursing staff reviewed the results before vaccination. Explanation of laboratory results and an individualized immunization regimen were provided to each participant. On review of participants’ laboratory results, those with seroconversion of both hepatitis A and B were not given the combined immunization. Participants who had seroconversion of hepatitis A were offered the hepatitis B vaccination series, and vice versa.

Immunization Process

Participants who lacked prior immunization for hepatitis A and B and had no seroconversion of either hepatitis A or B were offered vaccination. Some patients declined vaccination, even though they were eligible. Their reasons were not formally assessed.

Related: Nivolumab Approved for Expanded Indication

Patients who accepted the vaccination were given the accelerated regimen.¹⁶ Participants were educated on the importance of compliance with the vaccination series and provided with follow-up immunization dates and a reminder for the 1-year booster vaccine. The immunizations were ordered by the program’s primary care NP and administered by a licensed practical nurse. The nurse who administered the injections took responsibility for scheduling the patients for all their subsequent injections, including the 1-year booster.

Follow-up Care

If the third injection was not completed before discharge, patients were given a follow-up appointment with the nurse if they remained in the JAHVH service area. If they were leaving the area, they were given instructions on how to follow-up at another VA facility to continue their immunization schedule. A note was written in the electronic medical record documenting their abbreviated hepatitis A/B immunization schedule, which could be accessed by other providers at other VA facilities. Patients who did not show up for any follow-up appointments (third injection or the 1-year booster injection) were contacted and reminded about the importance of completing the immunization series and to schedule an appointment.

Statistical Analysis

All data were analyzed using IBM Statistical Package for the Social Sciences (IBM SPSS, Armonk, New York) with a focus on identifying differences between vaccination-eligible patients (n = 269) who did (n = 128) and did not (n = 141) initiate the immunization schedule during the treatment program. Chi-square and Fisher exact tests were used to assess statistical differences in initiation of the immunization schedule related to categoric variables (ie, marital status, race, history of IV drug abuse, cigarette smoking status, housing status, legal status, history of combat, having a psychiatric or medical diagnosis, and program track). Independent sample t tests were used to test for differences between these 2 groups on the continuous variables, including age, number of previous treatment programs, Global Assessment of Functioning score, severity of smoking dependence as measured by the Fagerström Test for Nicotine Dependence, and the Addiction Severity Index scales.^18-20

Results

The sample consisted of 284 successive admissions to an intensive outpatient program for veterans with substance use disorders. About one-third of the patients were homeless at the time of admission to the treatment, and 87% required contracted housing while completing treatment for reasons related to lack of housing, transportation, clinical necessity, or a combination of those factors (Table 1). The most common substance problems were alcohol and cocaine dependence, and 21% (n = 59) of the patients acknowledged a history of IV drug use during their initial psychiatric evaluation. Seventy percent were dually diagnosed with some other Axis I disorder, and 40% had a history of serious mental illness. More than one-fourth (n = 77) of the patients admitted to the intensive outpatient SATP were seropositive for hepatitis A, B and/or C, and the most common hepatitis diagnosis was hepatitis C (n = 71).

Accelerated Immunization Regimen

Patients were eligible to receive the accelerated vaccination schedule only if they had no prior immunization for hepatitis A or B and if they had no seroconversion for either hepatitis A or B. Six people had hepatitis B alone, 7 had hepatitis B and C, 1 had hepatitis A and C, and 1 had all 3 (Table 2). Thus, 15 participants were ineligible to receive the accelerated hepatitis A/B immunization. Chi-square, Fisher exact, and independent sample t tests showed that among those who were vaccination-eligible (269), there were no significant differences in any of the demographic or clinical characteristics between those who initiated the vaccination schedule and those who did not. Among those who completed the first 3 vaccine injections, those who received the 1-year booster injection (54) did not differ (on any demographic or clinical variables) from those who did not (58).

Nearly half (48%) of all the eligible patients admitted to the program began the accelerated immunization schedule for hepatitis A and B.  Of those, 88% completed the first 3 injections in the series. Among the patients who received the first 3 injections, 48% received the 1-year booster injection—a 20% completion rate for the vaccination-eligible sample overall (Table 3).

Of the 74 patients who did not complete their vaccinations once initiating the accelerated schedule, the most common reason identified was that the patient moved away (37), or no reason could be identified (33). It was uncommon for a patient not to complete the vaccination schedule because of terminating treatment prematurely (4).

Compared with the vaccine-eligible patients without hepatitis C (207), patients with hepatitis C were less likely to receive any vaccination injections (Table 3). Specifically, 51% of the vaccination-eligible patients who did not have hepatitis C began the vaccination regimen. However, only 22 patients with hepatitis C, or
35% of all vaccination-eligible patients with hepatitis C, began the vaccination regimen. Patients with hepatitis C were also less likely than those without hepatitis C to complete the first 3 injections of the vaccination series once they had initiated it (77%, vs 90%, respectively). This difference continued to be apparent at the time of the 12-month booster injection. Only 35% of vaccine-eligible individuals with hepatitis C received the 12-month booster injection, whereas 51% of vaccination-eligible individuals without hepatitis C received the 12-month booster injection. As with the sample overall, the most common reason patients with hepatitis C did not complete the vaccination regimen was because they moved away (9), followed by no identified reason (5), and premature termination of treatment (2).

Discussion

Individuals abusing alcohol and drugs have an increased vulnerability for infectious diseases, and homeless veterans with substance use disorders may be at a particularly heightened risk.^21,22 This study describes a sample of veterans, many were homeless and most were dually diagnosed, in an intensive outpatient SATP that offered an accelerated dosing regimen for hepatitis A and B vaccination. Almost half (48%) of the vaccination-eligible patients began the accelerated regimen for hepatitis A/B vaccination. Moreover, 88% of those who started the vaccination regimen received the first 3 injections of the series, thus possibly conferring substantial immunity to hepatitis A and B and demonstrating the feasibility of an accelerated vaccination schedule in an intensive outpatient SATP.

It is especially important to demonstrate the successful integration of a hepatitis screening and immunization program within a SATP, given that many such programs do not offer screening or immunization for hepatitis, even though substance abusers are disproportionately affected by the disease and contribute greatly to the ongoing hepatitis epidemic.^10,11 This study’s results were in line with another study of rapid vaccination for hepatitis B in IV drug users being treated in a methadone clinic, where 83% of the vaccination initiators completed the first 3 injections of the series.⁹

Unvaccinated Patients

The treatment team in the current study seemed to be less effective at reaching the subset of vaccination-eligible veterans with hepatitis C (almost one-quarter of the sample) in order to administer the accelerated vaccination schedule, as indicated by the lower rate of vaccination initiation as well as a lower rate of completion of the vaccination series among those patients. This replicates a finding from another study that also indicated a low rate of hepatitis A and B vaccination among patients with hepatitis C.²³ Only 35% of the vaccination-eligible patients with hepatitis C in the current study initiated the vaccination series, compared with 51% of the patients without hepatitis C. However, the rate of completion of the first 3 injections of the series in the hepatitis C group was respectably high (77%), especially given the high relapse rate and psychosocial instability of individuals with addictive disorders. Initiation seems to be a bigger obstacle than completion of at least the first 3 injections of the vaccination series in both patients with and without hepatitis C.

The study investigators did not formally assess the reasons that more than half the patients in the study did not begin the vaccination series, but anecdotal evidence from the nurses indicated that many patients were afraid of needles. In addition, other patients felt that they simply did not need the vaccination. Some also insisted that they had already had the vaccination despite a blood test showing no evidence for either hepatitis A or B immunization.

Although the nursing team provided group and individual risk-based education as well as information about the effects of continued substance abuse on hepatitis C, it is possible that patients still underestimated their own risk of hepatitis infection and its consequences, or perhaps the information was simply not retained.²⁴

Patient Education

A recent study showed that there is a positive relationship between the amount of hepatitis counseling received and knowledge of hepatitis.²⁵ Possibly, increased intensity of education efforts may make an impact on initiation rates. Encouragingly, there is also evidence that prompting people to predict their future vaccination behavior may increase vaccination initiation rates despite a high-degree of short-term barriers, such as perceived pain or inconvenience.²⁶ A brief intervention to induce people to formulate their future intentions would be relatively easy to incorporate into a vaccination program, and the study team is considering options for this to improve vaccination initiation rates.

Patients can expect to achieve substantial immunity from hepatitis A and, to a lesser degree, hepatitis B after completing the first 3 injections of the series, although the best seroprotection from both is obtained by completing the 12-month booster injection as well.¹⁷ Overall, about half of all patients who completed the first 3 injections returned for the booster shot, but only 35% of the patients with hepatitis C did so. The most common known cause of any patient not receiving the booster was movement out of the geographic area. However, much of the time the investigators were unable to determine the reasons patients did not return for the booster shot.

Medication adherence is a difficult problem with vaccination in high-risk samples, although Stitzer and colleagues found a significant improvement in follow-up for a 6-month vaccination protocol by using monetary incentives.²⁷ In addition to ensuring medication adherence, it would also be of value for future immunization efforts to include testing to assess whether seroconversion has occurred once the vaccinations are complete, which is the ultimate measure of the success of a vaccination program. Most patients in the current study did not receive such testing at the completion of their vaccination schedules, and thus, seroconversion rates could not be determined. However, existing studies suggest high rates of seroprotection after the first 3 doses of the combined vaccine.^10,17

Limitations

The retrospective nature of the study is its most significant limitation. Any conclusions about the results must be made with caution. However, this design allowed for a naturalistic and potentially generalizable investigation into the application of a vaccination program in a real-world treatment setting. As such, the investigators were able to demonstrate the feasibility of conducting a rapid vaccination program within a 3- to 6-week SATP.

The retrospective nature of the study also limited a full investigation into the reasons behind the lack of vaccination initiation and vaccination noncompletion among the study’s treatment population, especially with regard to the follow-up booster injection. Initial statistical comparisons of initiators and noninitiators and completers and noncompleters showed no significant statistical differences between the groups. Future prospective designs should take into account the need to successfully initiate and complete vaccinations for all eligible patients and include assessment measures to determine the specific reasons that patients did not initiate or complete their vaccinations.

Conclusions

Many patients began and completed the accelerated vaccination schedule for hepatitis A and B in the context of a 3- to 6-week SATP at JAHVH. The overall vaccination rate, including the 12-month booster injection, was one-fifth of the entire vaccination-eligible sample. Additionally, 88% of the vaccination-eligible patients who began the vaccination schedule (or 42% of the whole sample) completed at least the first 3 doses, which may confer substantial immunity from hepatitis A and B. For reasons not entirely clear, a little less than half the vaccination-eligible patients began the vaccination schedule, and only about 50% of those returned to receive their 12-month booster injection. Future prospective studies may be able to determine barriers to both the initiation of and adherence to the vaccination protocol.

The results of this study are also a testament to having primary care nursing staff available and actively involved in the care of patients in a SATP. It seems likely that additional interventions might be needed for outreach to and retention of patients in need of vaccination for hepatitis A and B, and particularly those patients with hepatitis C. It is important to find ways to increase the rates of 12-month booster vaccinations, both for veterans who continue to receive services at JAHVH and for those who transfer care to other VA facilities. Finally, testing to confirm serologic immunity to hepatitis A and hepatitis B would be the next step in the effort to eliminate the risk of hepatitis A and hepatitis B and minimize additional harm for those with hepatitis C in the population receiving treatment for addictive disorders.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Homeless individuals and IV drug users are susceptible to hepatitis A, B, and C infections, and co-infection with these diseases may complicate treatment and result in poor medical outcomes.¹ Vaccination offers the best protection against hepatitis A and B, particularly among high-risk populations.^2,3 Immunization against hepatitis A and B is of even greater importance for patients with hepatitis C, because there is no specific hepatitis C vaccine, and concomitant infections of B with C are damaging to the liver.⁴

Veterans have a rate of hepatitis C infection that is 3 times that of the general population.⁵ Some evidence exists that veterans with serious mental illness (SMI) have a higher rate of hepatitis C infection relative to patients without SMI. Co-occurring substance abuse may add another layer of vulnerability to hepatitis C infection, particularly for homeless veterans.^5-7

Mental Health and Primary Care Integration

Substance abuse and dual-diagnosis treatment programs (ie, those programs that treat both substance abuse and co-occurring serious mental health problems, such as bipolar disorder, severe major depressive disorder, psychotic disorders, and posttraumatic stress disorder [PTSD]) that have integrated mental health and primary care into their treatment programs may offer a window of opportunity for risk-reducing interventions. These interventions include testing and education of patients regarding infectious diseases, such as viral hepatitis and HIV, and completion of the hepatitis A/B immunization series.

The James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida, has demonstrated some limited success in the past with integrating a standard dosing schedule for hepatitis A/B vaccination into its substance abuse treatment program (SATP), though recent evidence points to more promising results using an accelerated regimen as indicated by a high completion rate for hepatitis B vaccination in a methadone clinic.^8,9 A relatively low proportion of SATPs in the U.S. provide testing, education, or vaccination for hepatitis A and B, especially considering the public health importance of controlling these diseases in the substance abusing populations.^10,11

Related: Combination Pill Approved for HCV

In 1999, a primary care team was added to the alcohol and drug abuse treatment program at JAHVH.In 2005, the nurses in the program began scheduling vaccinations and screening patients for medical and psychiatric issues, pain, hypertension, diabetes, hepatitis C, alcohol use, depression, PTSD, prostate and colorectal cancers.¹² Such a multidisciplinary approach provides many treatment advantages for patients and may save lives.¹³

Even with a multidisciplinary approach, the nurses found it difficult to provide adequate hepatitis A/B immunization within the 3- to 6-week intensive SATP, because standard immunization dosing regimens are spread over 6 months.¹⁴ As with all types of immunizations, long dosing schedules may reduce patient adherence and result in inadequate seroprotection.¹⁵ Thus, there is a need to provide a completed immunization series in a more expeditious fashion, and an accelerated dosing regimen makes that possible.^15,16

Hepatitis A/B Vaccination

Twinrix (GlaxoSmithKline, Brentford, United Kingdom) is a vaccine that provides dual immunization for hepatitis A and B. Whereas the standard vaccination schedule takes 6 months to complete, the accelerated dosing schedule can be used to complete the first 3 doses in less than a month. The accelerated dosing schedule was incorporated into the JAHVH clinic to capture as many patients as possible in the 3- to 6-week time frame: The first dose is administered and followed by a second dose 7 days later. The third dose is administered 21 to 30 days after the first dose. Twelve months after the first dose, a booster dose is given. 

After the first 3 accelerated doses, > 98% of patients show a sustained immune response to hepatitis A, and > 63% demonstrate immunity to hepatitis B. If a 12-month booster injection is given, 100% of patients may receive immunity to hepatitis A and > 96% may have immunity to hepatitis B.¹⁶ Another study of the combined vaccine showed even greater seroprotection for hepatitis A and B after only 1 month, 100% and 82%, respectively.¹⁷

Related: Viral Hepatitis Awareness

This JAHVH retrospective feasibility study describes a risk-reduction program for hepatitis A/B prevention that was implemented within a 3- to 4-week intensive outpatient SATP and a 6-week dual-diagnosis treatment program. The study includes the development and implementation of the program, designed to vaccinate patients using the accelerated Twinrix schedule. To ascertain the feasibility of this vaccination approach, historical medical records were used to describe and examine the vaccination initiation and follow-up rates of the treatment program participants who received the hepatitis A/B immunization series during their intensive SATP.

Study Design

A retrospective review of medical records was conducted for all participants who were admitted to the intensive JAHVH SATP between October 1, 2008, and September 30, 2009. This study was reviewed and approved by the JAHVH research and development committee and its associated University of South Florida institutional review board. Informed consent to participate was not obtained, because the study was retrospective.

Patient Identification and Education

All program participants were offered testing for HIV and hepatitis A, B, and C. Program participants were educated about hepatitis and HIV transmission, as well as about the long-term effects of continued substance abuse on the progression of hepatitis C. Education about hepatitis, HIV, and substance abuse was provided in a group setting by a member of the program’s nursing staff. One-on-one risk education counseling was also provided when requested or otherwise indicated.

Laboratory testing was performed following each participant’s initial physical examination (within 3 to 5 days of program admission), and the nursing staff reviewed the results before vaccination. Explanation of laboratory results and an individualized immunization regimen were provided to each participant. On review of participants’ laboratory results, those with seroconversion of both hepatitis A and B were not given the combined immunization. Participants who had seroconversion of hepatitis A were offered the hepatitis B vaccination series, and vice versa.

Immunization Process

Participants who lacked prior immunization for hepatitis A and B and had no seroconversion of either hepatitis A or B were offered vaccination. Some patients declined vaccination, even though they were eligible. Their reasons were not formally assessed.

Related: Nivolumab Approved for Expanded Indication

Patients who accepted the vaccination were given the accelerated regimen.¹⁶ Participants were educated on the importance of compliance with the vaccination series and provided with follow-up immunization dates and a reminder for the 1-year booster vaccine. The immunizations were ordered by the program’s primary care NP and administered by a licensed practical nurse. The nurse who administered the injections took responsibility for scheduling the patients for all their subsequent injections, including the 1-year booster.

Follow-up Care

If the third injection was not completed before discharge, patients were given a follow-up appointment with the nurse if they remained in the JAHVH service area. If they were leaving the area, they were given instructions on how to follow-up at another VA facility to continue their immunization schedule. A note was written in the electronic medical record documenting their abbreviated hepatitis A/B immunization schedule, which could be accessed by other providers at other VA facilities. Patients who did not show up for any follow-up appointments (third injection or the 1-year booster injection) were contacted and reminded about the importance of completing the immunization series and to schedule an appointment.

Statistical Analysis

All data were analyzed using IBM Statistical Package for the Social Sciences (IBM SPSS, Armonk, New York) with a focus on identifying differences between vaccination-eligible patients (n = 269) who did (n = 128) and did not (n = 141) initiate the immunization schedule during the treatment program. Chi-square and Fisher exact tests were used to assess statistical differences in initiation of the immunization schedule related to categoric variables (ie, marital status, race, history of IV drug abuse, cigarette smoking status, housing status, legal status, history of combat, having a psychiatric or medical diagnosis, and program track). Independent sample t tests were used to test for differences between these 2 groups on the continuous variables, including age, number of previous treatment programs, Global Assessment of Functioning score, severity of smoking dependence as measured by the Fagerström Test for Nicotine Dependence, and the Addiction Severity Index scales.^18-20

Results

The sample consisted of 284 successive admissions to an intensive outpatient program for veterans with substance use disorders. About one-third of the patients were homeless at the time of admission to the treatment, and 87% required contracted housing while completing treatment for reasons related to lack of housing, transportation, clinical necessity, or a combination of those factors (Table 1). The most common substance problems were alcohol and cocaine dependence, and 21% (n = 59) of the patients acknowledged a history of IV drug use during their initial psychiatric evaluation. Seventy percent were dually diagnosed with some other Axis I disorder, and 40% had a history of serious mental illness. More than one-fourth (n = 77) of the patients admitted to the intensive outpatient SATP were seropositive for hepatitis A, B and/or C, and the most common hepatitis diagnosis was hepatitis C (n = 71).

Accelerated Immunization Regimen

Patients were eligible to receive the accelerated vaccination schedule only if they had no prior immunization for hepatitis A or B and if they had no seroconversion for either hepatitis A or B. Six people had hepatitis B alone, 7 had hepatitis B and C, 1 had hepatitis A and C, and 1 had all 3 (Table 2). Thus, 15 participants were ineligible to receive the accelerated hepatitis A/B immunization. Chi-square, Fisher exact, and independent sample t tests showed that among those who were vaccination-eligible (269), there were no significant differences in any of the demographic or clinical characteristics between those who initiated the vaccination schedule and those who did not. Among those who completed the first 3 vaccine injections, those who received the 1-year booster injection (54) did not differ (on any demographic or clinical variables) from those who did not (58).

Nearly half (48%) of all the eligible patients admitted to the program began the accelerated immunization schedule for hepatitis A and B.  Of those, 88% completed the first 3 injections in the series. Among the patients who received the first 3 injections, 48% received the 1-year booster injection—a 20% completion rate for the vaccination-eligible sample overall (Table 3).

Of the 74 patients who did not complete their vaccinations once initiating the accelerated schedule, the most common reason identified was that the patient moved away (37), or no reason could be identified (33). It was uncommon for a patient not to complete the vaccination schedule because of terminating treatment prematurely (4).

Compared with the vaccine-eligible patients without hepatitis C (207), patients with hepatitis C were less likely to receive any vaccination injections (Table 3). Specifically, 51% of the vaccination-eligible patients who did not have hepatitis C began the vaccination regimen. However, only 22 patients with hepatitis C, or
35% of all vaccination-eligible patients with hepatitis C, began the vaccination regimen. Patients with hepatitis C were also less likely than those without hepatitis C to complete the first 3 injections of the vaccination series once they had initiated it (77%, vs 90%, respectively). This difference continued to be apparent at the time of the 12-month booster injection. Only 35% of vaccine-eligible individuals with hepatitis C received the 12-month booster injection, whereas 51% of vaccination-eligible individuals without hepatitis C received the 12-month booster injection. As with the sample overall, the most common reason patients with hepatitis C did not complete the vaccination regimen was because they moved away (9), followed by no identified reason (5), and premature termination of treatment (2).

Discussion

Individuals abusing alcohol and drugs have an increased vulnerability for infectious diseases, and homeless veterans with substance use disorders may be at a particularly heightened risk.^21,22 This study describes a sample of veterans, many were homeless and most were dually diagnosed, in an intensive outpatient SATP that offered an accelerated dosing regimen for hepatitis A and B vaccination. Almost half (48%) of the vaccination-eligible patients began the accelerated regimen for hepatitis A/B vaccination. Moreover, 88% of those who started the vaccination regimen received the first 3 injections of the series, thus possibly conferring substantial immunity to hepatitis A and B and demonstrating the feasibility of an accelerated vaccination schedule in an intensive outpatient SATP.

It is especially important to demonstrate the successful integration of a hepatitis screening and immunization program within a SATP, given that many such programs do not offer screening or immunization for hepatitis, even though substance abusers are disproportionately affected by the disease and contribute greatly to the ongoing hepatitis epidemic.^10,11 This study’s results were in line with another study of rapid vaccination for hepatitis B in IV drug users being treated in a methadone clinic, where 83% of the vaccination initiators completed the first 3 injections of the series.⁹

Unvaccinated Patients

The treatment team in the current study seemed to be less effective at reaching the subset of vaccination-eligible veterans with hepatitis C (almost one-quarter of the sample) in order to administer the accelerated vaccination schedule, as indicated by the lower rate of vaccination initiation as well as a lower rate of completion of the vaccination series among those patients. This replicates a finding from another study that also indicated a low rate of hepatitis A and B vaccination among patients with hepatitis C.²³ Only 35% of the vaccination-eligible patients with hepatitis C in the current study initiated the vaccination series, compared with 51% of the patients without hepatitis C. However, the rate of completion of the first 3 injections of the series in the hepatitis C group was respectably high (77%), especially given the high relapse rate and psychosocial instability of individuals with addictive disorders. Initiation seems to be a bigger obstacle than completion of at least the first 3 injections of the vaccination series in both patients with and without hepatitis C.

The study investigators did not formally assess the reasons that more than half the patients in the study did not begin the vaccination series, but anecdotal evidence from the nurses indicated that many patients were afraid of needles. In addition, other patients felt that they simply did not need the vaccination. Some also insisted that they had already had the vaccination despite a blood test showing no evidence for either hepatitis A or B immunization.

Although the nursing team provided group and individual risk-based education as well as information about the effects of continued substance abuse on hepatitis C, it is possible that patients still underestimated their own risk of hepatitis infection and its consequences, or perhaps the information was simply not retained.²⁴

Patient Education

A recent study showed that there is a positive relationship between the amount of hepatitis counseling received and knowledge of hepatitis.²⁵ Possibly, increased intensity of education efforts may make an impact on initiation rates. Encouragingly, there is also evidence that prompting people to predict their future vaccination behavior may increase vaccination initiation rates despite a high-degree of short-term barriers, such as perceived pain or inconvenience.²⁶ A brief intervention to induce people to formulate their future intentions would be relatively easy to incorporate into a vaccination program, and the study team is considering options for this to improve vaccination initiation rates.

Patients can expect to achieve substantial immunity from hepatitis A and, to a lesser degree, hepatitis B after completing the first 3 injections of the series, although the best seroprotection from both is obtained by completing the 12-month booster injection as well.¹⁷ Overall, about half of all patients who completed the first 3 injections returned for the booster shot, but only 35% of the patients with hepatitis C did so. The most common known cause of any patient not receiving the booster was movement out of the geographic area. However, much of the time the investigators were unable to determine the reasons patients did not return for the booster shot.

Medication adherence is a difficult problem with vaccination in high-risk samples, although Stitzer and colleagues found a significant improvement in follow-up for a 6-month vaccination protocol by using monetary incentives.²⁷ In addition to ensuring medication adherence, it would also be of value for future immunization efforts to include testing to assess whether seroconversion has occurred once the vaccinations are complete, which is the ultimate measure of the success of a vaccination program. Most patients in the current study did not receive such testing at the completion of their vaccination schedules, and thus, seroconversion rates could not be determined. However, existing studies suggest high rates of seroprotection after the first 3 doses of the combined vaccine.^10,17

Limitations

The retrospective nature of the study is its most significant limitation. Any conclusions about the results must be made with caution. However, this design allowed for a naturalistic and potentially generalizable investigation into the application of a vaccination program in a real-world treatment setting. As such, the investigators were able to demonstrate the feasibility of conducting a rapid vaccination program within a 3- to 6-week SATP.

The retrospective nature of the study also limited a full investigation into the reasons behind the lack of vaccination initiation and vaccination noncompletion among the study’s treatment population, especially with regard to the follow-up booster injection. Initial statistical comparisons of initiators and noninitiators and completers and noncompleters showed no significant statistical differences between the groups. Future prospective designs should take into account the need to successfully initiate and complete vaccinations for all eligible patients and include assessment measures to determine the specific reasons that patients did not initiate or complete their vaccinations.

Conclusions

Many patients began and completed the accelerated vaccination schedule for hepatitis A and B in the context of a 3- to 6-week SATP at JAHVH. The overall vaccination rate, including the 12-month booster injection, was one-fifth of the entire vaccination-eligible sample. Additionally, 88% of the vaccination-eligible patients who began the vaccination schedule (or 42% of the whole sample) completed at least the first 3 doses, which may confer substantial immunity from hepatitis A and B. For reasons not entirely clear, a little less than half the vaccination-eligible patients began the vaccination schedule, and only about 50% of those returned to receive their 12-month booster injection. Future prospective studies may be able to determine barriers to both the initiation of and adherence to the vaccination protocol.

The results of this study are also a testament to having primary care nursing staff available and actively involved in the care of patients in a SATP. It seems likely that additional interventions might be needed for outreach to and retention of patients in need of vaccination for hepatitis A and B, and particularly those patients with hepatitis C. It is important to find ways to increase the rates of 12-month booster vaccinations, both for veterans who continue to receive services at JAHVH and for those who transfer care to other VA facilities. Finally, testing to confirm serologic immunity to hepatitis A and hepatitis B would be the next step in the effort to eliminate the risk of hepatitis A and hepatitis B and minimize additional harm for those with hepatitis C in the population receiving treatment for addictive disorders.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Homeless individuals and IV drug users are susceptible to hepatitis A, B, and C infections, and co-infection with these diseases may complicate treatment and result in poor medical outcomes.¹ Vaccination offers the best protection against hepatitis A and B, particularly among high-risk populations.^2,3 Immunization against hepatitis A and B is of even greater importance for patients with hepatitis C, because there is no specific hepatitis C vaccine, and concomitant infections of B with C are damaging to the liver.⁴

Veterans have a rate of hepatitis C infection that is 3 times that of the general population.⁵ Some evidence exists that veterans with serious mental illness (SMI) have a higher rate of hepatitis C infection relative to patients without SMI. Co-occurring substance abuse may add another layer of vulnerability to hepatitis C infection, particularly for homeless veterans.^5-7

Mental Health and Primary Care Integration

Substance abuse and dual-diagnosis treatment programs (ie, those programs that treat both substance abuse and co-occurring serious mental health problems, such as bipolar disorder, severe major depressive disorder, psychotic disorders, and posttraumatic stress disorder [PTSD]) that have integrated mental health and primary care into their treatment programs may offer a window of opportunity for risk-reducing interventions. These interventions include testing and education of patients regarding infectious diseases, such as viral hepatitis and HIV, and completion of the hepatitis A/B immunization series.

The James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida, has demonstrated some limited success in the past with integrating a standard dosing schedule for hepatitis A/B vaccination into its substance abuse treatment program (SATP), though recent evidence points to more promising results using an accelerated regimen as indicated by a high completion rate for hepatitis B vaccination in a methadone clinic.^8,9 A relatively low proportion of SATPs in the U.S. provide testing, education, or vaccination for hepatitis A and B, especially considering the public health importance of controlling these diseases in the substance abusing populations.^10,11

Related: Combination Pill Approved for HCV

In 1999, a primary care team was added to the alcohol and drug abuse treatment program at JAHVH.In 2005, the nurses in the program began scheduling vaccinations and screening patients for medical and psychiatric issues, pain, hypertension, diabetes, hepatitis C, alcohol use, depression, PTSD, prostate and colorectal cancers.¹² Such a multidisciplinary approach provides many treatment advantages for patients and may save lives.¹³

Even with a multidisciplinary approach, the nurses found it difficult to provide adequate hepatitis A/B immunization within the 3- to 6-week intensive SATP, because standard immunization dosing regimens are spread over 6 months.¹⁴ As with all types of immunizations, long dosing schedules may reduce patient adherence and result in inadequate seroprotection.¹⁵ Thus, there is a need to provide a completed immunization series in a more expeditious fashion, and an accelerated dosing regimen makes that possible.^15,16

Hepatitis A/B Vaccination

Twinrix (GlaxoSmithKline, Brentford, United Kingdom) is a vaccine that provides dual immunization for hepatitis A and B. Whereas the standard vaccination schedule takes 6 months to complete, the accelerated dosing schedule can be used to complete the first 3 doses in less than a month. The accelerated dosing schedule was incorporated into the JAHVH clinic to capture as many patients as possible in the 3- to 6-week time frame: The first dose is administered and followed by a second dose 7 days later. The third dose is administered 21 to 30 days after the first dose. Twelve months after the first dose, a booster dose is given. 

After the first 3 accelerated doses, > 98% of patients show a sustained immune response to hepatitis A, and > 63% demonstrate immunity to hepatitis B. If a 12-month booster injection is given, 100% of patients may receive immunity to hepatitis A and > 96% may have immunity to hepatitis B.¹⁶ Another study of the combined vaccine showed even greater seroprotection for hepatitis A and B after only 1 month, 100% and 82%, respectively.¹⁷

Related: Viral Hepatitis Awareness

This JAHVH retrospective feasibility study describes a risk-reduction program for hepatitis A/B prevention that was implemented within a 3- to 4-week intensive outpatient SATP and a 6-week dual-diagnosis treatment program. The study includes the development and implementation of the program, designed to vaccinate patients using the accelerated Twinrix schedule. To ascertain the feasibility of this vaccination approach, historical medical records were used to describe and examine the vaccination initiation and follow-up rates of the treatment program participants who received the hepatitis A/B immunization series during their intensive SATP.

Study Design

A retrospective review of medical records was conducted for all participants who were admitted to the intensive JAHVH SATP between October 1, 2008, and September 30, 2009. This study was reviewed and approved by the JAHVH research and development committee and its associated University of South Florida institutional review board. Informed consent to participate was not obtained, because the study was retrospective.

Patient Identification and Education

All program participants were offered testing for HIV and hepatitis A, B, and C. Program participants were educated about hepatitis and HIV transmission, as well as about the long-term effects of continued substance abuse on the progression of hepatitis C. Education about hepatitis, HIV, and substance abuse was provided in a group setting by a member of the program’s nursing staff. One-on-one risk education counseling was also provided when requested or otherwise indicated.

Laboratory testing was performed following each participant’s initial physical examination (within 3 to 5 days of program admission), and the nursing staff reviewed the results before vaccination. Explanation of laboratory results and an individualized immunization regimen were provided to each participant. On review of participants’ laboratory results, those with seroconversion of both hepatitis A and B were not given the combined immunization. Participants who had seroconversion of hepatitis A were offered the hepatitis B vaccination series, and vice versa.

Immunization Process

Participants who lacked prior immunization for hepatitis A and B and had no seroconversion of either hepatitis A or B were offered vaccination. Some patients declined vaccination, even though they were eligible. Their reasons were not formally assessed.

Related: Nivolumab Approved for Expanded Indication

Patients who accepted the vaccination were given the accelerated regimen.¹⁶ Participants were educated on the importance of compliance with the vaccination series and provided with follow-up immunization dates and a reminder for the 1-year booster vaccine. The immunizations were ordered by the program’s primary care NP and administered by a licensed practical nurse. The nurse who administered the injections took responsibility for scheduling the patients for all their subsequent injections, including the 1-year booster.

Follow-up Care

If the third injection was not completed before discharge, patients were given a follow-up appointment with the nurse if they remained in the JAHVH service area. If they were leaving the area, they were given instructions on how to follow-up at another VA facility to continue their immunization schedule. A note was written in the electronic medical record documenting their abbreviated hepatitis A/B immunization schedule, which could be accessed by other providers at other VA facilities. Patients who did not show up for any follow-up appointments (third injection or the 1-year booster injection) were contacted and reminded about the importance of completing the immunization series and to schedule an appointment.

Statistical Analysis

All data were analyzed using IBM Statistical Package for the Social Sciences (IBM SPSS, Armonk, New York) with a focus on identifying differences between vaccination-eligible patients (n = 269) who did (n = 128) and did not (n = 141) initiate the immunization schedule during the treatment program. Chi-square and Fisher exact tests were used to assess statistical differences in initiation of the immunization schedule related to categoric variables (ie, marital status, race, history of IV drug abuse, cigarette smoking status, housing status, legal status, history of combat, having a psychiatric or medical diagnosis, and program track). Independent sample t tests were used to test for differences between these 2 groups on the continuous variables, including age, number of previous treatment programs, Global Assessment of Functioning score, severity of smoking dependence as measured by the Fagerström Test for Nicotine Dependence, and the Addiction Severity Index scales.^18-20

Results

The sample consisted of 284 successive admissions to an intensive outpatient program for veterans with substance use disorders. About one-third of the patients were homeless at the time of admission to the treatment, and 87% required contracted housing while completing treatment for reasons related to lack of housing, transportation, clinical necessity, or a combination of those factors (Table 1). The most common substance problems were alcohol and cocaine dependence, and 21% (n = 59) of the patients acknowledged a history of IV drug use during their initial psychiatric evaluation. Seventy percent were dually diagnosed with some other Axis I disorder, and 40% had a history of serious mental illness. More than one-fourth (n = 77) of the patients admitted to the intensive outpatient SATP were seropositive for hepatitis A, B and/or C, and the most common hepatitis diagnosis was hepatitis C (n = 71).

Accelerated Immunization Regimen

Patients were eligible to receive the accelerated vaccination schedule only if they had no prior immunization for hepatitis A or B and if they had no seroconversion for either hepatitis A or B. Six people had hepatitis B alone, 7 had hepatitis B and C, 1 had hepatitis A and C, and 1 had all 3 (Table 2). Thus, 15 participants were ineligible to receive the accelerated hepatitis A/B immunization. Chi-square, Fisher exact, and independent sample t tests showed that among those who were vaccination-eligible (269), there were no significant differences in any of the demographic or clinical characteristics between those who initiated the vaccination schedule and those who did not. Among those who completed the first 3 vaccine injections, those who received the 1-year booster injection (54) did not differ (on any demographic or clinical variables) from those who did not (58).

Nearly half (48%) of all the eligible patients admitted to the program began the accelerated immunization schedule for hepatitis A and B.  Of those, 88% completed the first 3 injections in the series. Among the patients who received the first 3 injections, 48% received the 1-year booster injection—a 20% completion rate for the vaccination-eligible sample overall (Table 3).

Of the 74 patients who did not complete their vaccinations once initiating the accelerated schedule, the most common reason identified was that the patient moved away (37), or no reason could be identified (33). It was uncommon for a patient not to complete the vaccination schedule because of terminating treatment prematurely (4).

Compared with the vaccine-eligible patients without hepatitis C (207), patients with hepatitis C were less likely to receive any vaccination injections (Table 3). Specifically, 51% of the vaccination-eligible patients who did not have hepatitis C began the vaccination regimen. However, only 22 patients with hepatitis C, or
35% of all vaccination-eligible patients with hepatitis C, began the vaccination regimen. Patients with hepatitis C were also less likely than those without hepatitis C to complete the first 3 injections of the vaccination series once they had initiated it (77%, vs 90%, respectively). This difference continued to be apparent at the time of the 12-month booster injection. Only 35% of vaccine-eligible individuals with hepatitis C received the 12-month booster injection, whereas 51% of vaccination-eligible individuals without hepatitis C received the 12-month booster injection. As with the sample overall, the most common reason patients with hepatitis C did not complete the vaccination regimen was because they moved away (9), followed by no identified reason (5), and premature termination of treatment (2).

Discussion

Individuals abusing alcohol and drugs have an increased vulnerability for infectious diseases, and homeless veterans with substance use disorders may be at a particularly heightened risk.^21,22 This study describes a sample of veterans, many were homeless and most were dually diagnosed, in an intensive outpatient SATP that offered an accelerated dosing regimen for hepatitis A and B vaccination. Almost half (48%) of the vaccination-eligible patients began the accelerated regimen for hepatitis A/B vaccination. Moreover, 88% of those who started the vaccination regimen received the first 3 injections of the series, thus possibly conferring substantial immunity to hepatitis A and B and demonstrating the feasibility of an accelerated vaccination schedule in an intensive outpatient SATP.

It is especially important to demonstrate the successful integration of a hepatitis screening and immunization program within a SATP, given that many such programs do not offer screening or immunization for hepatitis, even though substance abusers are disproportionately affected by the disease and contribute greatly to the ongoing hepatitis epidemic.^10,11 This study’s results were in line with another study of rapid vaccination for hepatitis B in IV drug users being treated in a methadone clinic, where 83% of the vaccination initiators completed the first 3 injections of the series.⁹

Unvaccinated Patients

The treatment team in the current study seemed to be less effective at reaching the subset of vaccination-eligible veterans with hepatitis C (almost one-quarter of the sample) in order to administer the accelerated vaccination schedule, as indicated by the lower rate of vaccination initiation as well as a lower rate of completion of the vaccination series among those patients. This replicates a finding from another study that also indicated a low rate of hepatitis A and B vaccination among patients with hepatitis C.²³ Only 35% of the vaccination-eligible patients with hepatitis C in the current study initiated the vaccination series, compared with 51% of the patients without hepatitis C. However, the rate of completion of the first 3 injections of the series in the hepatitis C group was respectably high (77%), especially given the high relapse rate and psychosocial instability of individuals with addictive disorders. Initiation seems to be a bigger obstacle than completion of at least the first 3 injections of the vaccination series in both patients with and without hepatitis C.

The study investigators did not formally assess the reasons that more than half the patients in the study did not begin the vaccination series, but anecdotal evidence from the nurses indicated that many patients were afraid of needles. In addition, other patients felt that they simply did not need the vaccination. Some also insisted that they had already had the vaccination despite a blood test showing no evidence for either hepatitis A or B immunization.

Although the nursing team provided group and individual risk-based education as well as information about the effects of continued substance abuse on hepatitis C, it is possible that patients still underestimated their own risk of hepatitis infection and its consequences, or perhaps the information was simply not retained.²⁴

Patient Education

A recent study showed that there is a positive relationship between the amount of hepatitis counseling received and knowledge of hepatitis.²⁵ Possibly, increased intensity of education efforts may make an impact on initiation rates. Encouragingly, there is also evidence that prompting people to predict their future vaccination behavior may increase vaccination initiation rates despite a high-degree of short-term barriers, such as perceived pain or inconvenience.²⁶ A brief intervention to induce people to formulate their future intentions would be relatively easy to incorporate into a vaccination program, and the study team is considering options for this to improve vaccination initiation rates.

Patients can expect to achieve substantial immunity from hepatitis A and, to a lesser degree, hepatitis B after completing the first 3 injections of the series, although the best seroprotection from both is obtained by completing the 12-month booster injection as well.¹⁷ Overall, about half of all patients who completed the first 3 injections returned for the booster shot, but only 35% of the patients with hepatitis C did so. The most common known cause of any patient not receiving the booster was movement out of the geographic area. However, much of the time the investigators were unable to determine the reasons patients did not return for the booster shot.

Medication adherence is a difficult problem with vaccination in high-risk samples, although Stitzer and colleagues found a significant improvement in follow-up for a 6-month vaccination protocol by using monetary incentives.²⁷ In addition to ensuring medication adherence, it would also be of value for future immunization efforts to include testing to assess whether seroconversion has occurred once the vaccinations are complete, which is the ultimate measure of the success of a vaccination program. Most patients in the current study did not receive such testing at the completion of their vaccination schedules, and thus, seroconversion rates could not be determined. However, existing studies suggest high rates of seroprotection after the first 3 doses of the combined vaccine.^10,17

Limitations

The retrospective nature of the study is its most significant limitation. Any conclusions about the results must be made with caution. However, this design allowed for a naturalistic and potentially generalizable investigation into the application of a vaccination program in a real-world treatment setting. As such, the investigators were able to demonstrate the feasibility of conducting a rapid vaccination program within a 3- to 6-week SATP.

The retrospective nature of the study also limited a full investigation into the reasons behind the lack of vaccination initiation and vaccination noncompletion among the study’s treatment population, especially with regard to the follow-up booster injection. Initial statistical comparisons of initiators and noninitiators and completers and noncompleters showed no significant statistical differences between the groups. Future prospective designs should take into account the need to successfully initiate and complete vaccinations for all eligible patients and include assessment measures to determine the specific reasons that patients did not initiate or complete their vaccinations.

Conclusions

Many patients began and completed the accelerated vaccination schedule for hepatitis A and B in the context of a 3- to 6-week SATP at JAHVH. The overall vaccination rate, including the 12-month booster injection, was one-fifth of the entire vaccination-eligible sample. Additionally, 88% of the vaccination-eligible patients who began the vaccination schedule (or 42% of the whole sample) completed at least the first 3 doses, which may confer substantial immunity from hepatitis A and B. For reasons not entirely clear, a little less than half the vaccination-eligible patients began the vaccination schedule, and only about 50% of those returned to receive their 12-month booster injection. Future prospective studies may be able to determine barriers to both the initiation of and adherence to the vaccination protocol.

The results of this study are also a testament to having primary care nursing staff available and actively involved in the care of patients in a SATP. It seems likely that additional interventions might be needed for outreach to and retention of patients in need of vaccination for hepatitis A and B, and particularly those patients with hepatitis C. It is important to find ways to increase the rates of 12-month booster vaccinations, both for veterans who continue to receive services at JAHVH and for those who transfer care to other VA facilities. Finally, testing to confirm serologic immunity to hepatitis A and hepatitis B would be the next step in the effort to eliminate the risk of hepatitis A and hepatitis B and minimize additional harm for those with hepatitis C in the population receiving treatment for addictive disorders.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.