The impact of health care strikes on patient mortality: A systematic review and meta‐analysis of observational studies

ObjectiveThis study sought to evaluate the impact of health care strike action on patient mortality.Data SourcesEMBASE, PubMed CINAHL, BIOETHICSLINE, EconLit, WEB OF SCIENCE, and grey literature were searched up to December 2021.Study DesignA systematic review and meta‐analysis were utilized.Data Collection/ExtractionRandom‐effects meta‐analysis was used to compare mortality rate during strike versus pre‐ or post‐strike, with meta‐regression employed to identify factors that might influence the potential impact of strike action. Studies were included if they were observational studies that examined in‐hospital/clinic or population mortality during a strike period compared with a control period where there was no strike action.Principal FindingsSeventeen studies examined mortality: 14 examined in‐hospital mortality and three examined population mortality. In‐hospital studies represented 768,918 admissions and 7191 deaths during strike action and 1,034,437 admissions and 12,676 deaths during control periods. The pooled relative risk (RR) of in‐hospital mortality did not significantly differ during strike action versus non‐strike periods (RR = 0.91, 95% confidence interval 0.63, 1.31, p = 0.598). Meta‐regression also showed that mortality RR was not significantly impacted by country (p = 0.98), profession on strike (p = 0.32 for multiple professions, p = 0.80 for nurses), the duration of the strike (p = 0.26), or whether multiple facilities were on strike (p = 0.55). Only three studies that examined population mortality met the inclusion criteria; therefore, further analysis was not conducted. However, it is noteworthy that none of these studies reported a significant increase in population mortality attributable to strike action.ConclusionsBased on the data available, this review did not find any evidence that strike action has any significant impact on in‐hospital patient mortality.     

Health center use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid, 2012–2018

ObjectiveTo examine the relationship between federally qualified health center (FQHC) use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid.Data SourcesData were obtained from 2012 to 2018 Medicare claims.Study DesignWe modeled hospital‐based care as a function of FQHC use, person‐level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30‐day unplanned returns. We stratified all models on the basis of eligibility and rurality.Data Extraction MethodsOur sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end‐stage renal disease.Principal FindingsAfter the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person‐years among both age‐eligible (−14.8 [−17.5, −12.1]; −6.6 [−7.5, −5.6]) and disability‐eligible duals (−11.3 [−14.4, −8.3]; −6 [−7.4, −4.6]) as well as a lower probability of observation stays (−0.8 pp age‐eligible; −0.4 pp disability‐eligible) and unplanned returns (−2.1 pp age‐eligible; −1.9 pp disability‐eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person‐years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability‐eligible duals (a decrease of more than 60% compared with the pre‐PPS period) and increases in the probability of hospitalization (1.1 pp age‐eligible; 0.8 pp disability‐eligible) and ACS hospitalization (0.5 pp age‐eligible; 0.3 pp disability‐eligible) (a decrease of roughly 50% compared with the pre‐PPS period).ConclusionsFQHC use is associated with reductions in hospital‐based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.     

Does preventive dental care reduce nonpreventive dental visits and expenditures among Medicaid‐enrolled adults?

ObjectiveTo determine whether preventive dental visits are associated with fewer subsequent nonpreventive dental visits and lower dental expenditures.Data SourcesIndiana Medicaid enrollment and claims data (2015–2018) and the Area Health Resource File.Study DesignA repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and nonpreventive dental visits (NPVs) and dental expenditures.Data Collection/Extraction MethodsNot applicable.Principal FindingsOf 28,152 adults (108,349 observation‐years) meeting inclusion criteria, 36.0% had a dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = −0.13; 95% CI –0.12, −0.11), lower NPV expenditures (β = −$29.12.53; 95% CI –28.07, −21.05), and lower total dental expenditures (−$70.12; 95% –74.92, −65.31), as well as fewer PDVs (β = −0.24; 95% CI –0.26, −0.23).ConclusionsOur findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid‐enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low‐income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.     

Did Medicaid slow declines in access to health care during the great recession?

ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.     

Health insurance coverage and self‐employment

BackgroundSelf‐employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self‐employed workers, who do not have access to employer‐sponsored coverage, is unclear.ObjectiveTo determine whether self‐employment is associated with lack of health insurance coverage.Data SourcesSecondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014‐2017.Study DesignParticipants were working age (18‐64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014‐2017. We compared those who were employees vs those who were self‐employed. Key outcomes were self‐report of health insurance coverage, and of delaying needed medical care.Data Extraction MethodsLongitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self‐employment in year 2.Principal Findings16 335 individuals, representing 121 473 345 working‐age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self‐employment. In unadjusted analyses, 25.7% of those who became self‐employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self‐employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time‐by‐employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self‐employment. Self‐employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003).ConclusionsOne in four self‐employed workers lack health insurance coverage. Given the rise in self‐employment, it is imperative to identify ways to improve health care insurance access for self‐employed working‐age US adults.     

Medicaid expansions,preconception insurance,and unintended pregnancy among new parents

ObjectiveTo assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first‐time parents.Data SourceThis study used individual‐level data from the national Pregnancy Risk Assessment Monitoring System (2006‐2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.Study DesignOutcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female‐identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.Data Collection/Extraction MethodsThe sample included all individuals aged 20‐44 with a first live birth in 2009‐2017.Principal FindingsAmong all first‐time parents, a 10‐percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high‐school degree or less.ConclusionsIncreasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first‐time parents.     

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness

ObjectiveTo evaluate the impact of Maryland''s behavioral health homes (BHHs) on receipt of follow‐up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI).Data SourcesMaryland Medicaid administrative claims for 12 232 individuals.Study DesignWeighted marginal structural models were estimated to account for time‐varying exposure to BHH enrollment and time‐varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow‐up care within 7 and 30 days following hospitalization.Data Collection/Extraction MethodsEligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21‐64 years; and use of psychiatric rehabilitation services.Principal FindingsOver three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow‐up service within 7 days of discharge from a mental illness–related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow‐up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission.ConclusionsBHHs may improve follow‐up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.     

Advance care directive prevalence among older Australians and associations with person‐level predictors and quality indicators

BackgroundAdvance care planning (ACP) conversations may result in preferences for medical care being documented.ObjectiveTo explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person‐level predictors and ACD quality indicators.Design and SettingNational multi‐centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF).ParticipantsA total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389).Main Outcome MeasuresACP documentation prevalence by setting and type including person‐completed ACDs and non‐ACD documents (completed by a health professional or someone else); person‐level predictors and quality indicators of ACDs.ResultsOverall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing.Conclusions and ContributionLow ACP documentation prevalence and a lack of accessible, person‐completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.     

Opt‐in or opt‐out health‐care communication? A cross‐sectional study

BackgroundPatients need medication and medical condition‐related information to better self‐manage their health. Health‐care professionals (HCPs) should be able to actively provide information outside of one‐on‐one consultations; however, patient consent may be required.ObjectiveTo investigate the Australian public''s preferences, and factors that may influence their preferences, towards an opt‐in versus an opt‐out approach to health communication.DesignA cross‐sectional study using a structured questionnaire administered via Computer‐Assisted Telephone Interviewing.Setting and participantsParticipants across Australia who were adults, English‐speaking and had a long‐term medical condition.Main outcome measuresPreferences for opt‐in vs opt‐out approach to receiving follow‐up tailored information.ResultsA total of 8683 calls were made to achieve the required sample size of 589 completed surveys. Many (346/589; 58.7%) indicated that they were interested in receiving tailored, ongoing follow‐up information from their HCP. Nearly half (n = 281; 47.7%) preferred an opt‐in service and 293/589 (49.7%) an opt‐out service for receiving follow‐up information. Reasons for preferring an opt‐in service were being in control of the information received (n = 254); able to make a decision that is best for them (n = 245); opt‐in service would save time for HCPs (n = 217); they may not want or need the information (n = 240). Many (n = 255) felt that an opt‐out service should be part of the normal duty of care of their HCP and believed (n = 267) that this approach would ensure that everyone has access to information.ConclusionsRespondents were interested in receiving tailored information outside of consultation times. However, preferences for an opt‐in or opt‐out approach were divided.     

Awareness of diagnosis,treatment and risk of late effects in Chinese survivors of childhood cancer in Hong Kong

BackgroundFor survivors of childhood cancer, awareness of personal health risks is a critical component of long‐term health management.ObjectiveTo evaluate the awareness of the diagnosis, treatment and risk of late effects among survivors of childhood cancer in Hong Kong.MethodsBetween June 2019 and March 2020, this cross‐sectional study recruited 155 adult survivors (mean age = 26.9, standard deviation [SD] = 6.4 years) and 45 parents of paediatric survivors (mean age = 11.1, SD = 3.6 years) from a long‐term follow‐up clinic. At >10 years post‐treatment (mean = 13.4, SD = 7.6 years), they completed a structured questionnaire to report their cancer‐specific knowledge. Multiple linear regression analysis was conducted to identify clinical, socioeconomic and behavioural factors associated with poor awareness.ResultsThe majority of participants accurately recalled their diagnoses (73.5%) and major treatment modalities (chemotherapy 92.4%, radiation 82.9% and surgery 88.2%). However, less than half (45%) of the participants recognized more than 25% of the total late effects for which they were at risk. The highest levels of awareness were reported for endocrine problems (49%), neurocognitive impairment (44%) and secondary cancers (43%), and the lowest for peripheral neuropathy (21%) and vision problems (23%). Compared with survivors of haematological malignancies, those of central nervous system (CNS) tumours (standardized estimate [B] = −9.33, 95% confidence interval [95% CI]: −13.41 to −5.26) and non‐CNS solid tumours (B = −8.47, 95% CI: −12.39 to −4.94) had less knowledge about their diagnosis. Retaining medical records (P < .0001) and better medical information‐seeking habits (P = .048) were associated with better awareness.ConclusionsSurvivors of childhood cancer in Hong Kong have deficient awareness of their personal health risks. They may benefit from the provision of a survivorship care plan and personalized education regarding treatment‐related late effects.Patient ContributionPatients contributed in designing the study tools. Results were presented at a non‐governmental organization.     

A qualitative study of nurse‐patient communication and information provision during surgical pre‐admission clinics

BackgroundHealth‐care service users are often being described as ‘co‐producers’ with an active role in their care. However, there are challenges associated with this approach, including how standardization affects personalized care, and the ability of patients to retain high volumes of information.ObjectiveOur study explores patient and nursing perspectives of information provision in the pre‐admission element of an Enhanced Recovery After Surgery programme, an evidence‐based approach implemented to improve the quality of surgical care. Our analysis has been informed by an evidence‐based model developed by Grande et al Patient Educ Couns. 2014;95:281.Design/Setting and participantsThis was a qualitative study including observations of pre‐admission clinics and semi‐structured interviews across three surgical wards. Patients (n = 21) and registered nurses (n = 21) were purposively selected for interviews.ResultsPatients welcomed the opportunity for active involvement in their care. However, we also identified informational boundaries and how illness and treatment‐related anxieties were barriers to patient engagement with the information provided.DiscussionWe recommend that to support a patient‐centred and individualized approach to patient involvement the ‘information (giving) + activation’ element of Grande et al Patient Educ Couns. 2014;95:281 model be reconfigured to allow for ‘information (giving) + exploration +activation’.ConclusionNurses need to feel empowered to adopt strategies that allow for different informational needs, rather than adopting a one‐size‐fits‐all paternalistic approach.Patient contributionThis study focused on patient involvement and we give thanks to all the patients who took part in interviews and those who allowed us to observe their care.     

An equivalence analysis of provider education in youth mental health care

ObjectiveTo test for equivalence between providers with and without advanced degrees in multiple domains related to delivery of evidence‐based treatment.Data SourceProvider and client data from an effectiveness trial of Alternatives for Families: A Cognitive Behavioral Therapy (AF‐CBT) in a major metropolitan area in the United States.Study DesignWe tested for equivalence between providers (N = 182) with and without advanced degrees in treatment‐related knowledge, practices, and attitudes; job demands and stress; and training engagement and trainer‐rated competence in AF‐CBT. We also conducted exploratory analyses to test for equivalence in family clinical outcomes.Data CollectionProviders completed measures prior to randomization and at 6‐month follow‐up, after completion of training and consultation in AF‐CBT. Children and caregivers completed assessments at 0, 6, 12, and 18 months.Principal FindingsProviders without advanced degrees were largely non‐inferior to those with advanced degrees in treatment‐related knowledge, practices, and attitudes, while findings for job demands and stress were mixed. Providers without advanced degrees were non‐inferior to providers with advanced degrees in consultation attendance (B = −1.42; confidence interval (CI) = −3.01‐0.16; margin of equivalence (Δ) = 2), number of case presentations (B = 0.64; CI = −0.49‐1.76; Δ = 2), total training hours (B = −4.57; CI = −10.52‐1.37; Δ = 3), and trainer‐rated competence in AF‐CBT (B = −0.04; CI = −3.04‐2.96; Δ = 4), and they were significantly more likely to complete training (odds ratio = 0.66; CI = 0.10‐0.96; Δ = 30%). Results for clinical outcomes were largely inconclusive.ConclusionsProvider‐level outcomes for those with and without advanced degrees were generally comparable. Additional research is needed to examine equivalence in clinical outcomes. Expanding evidence‐based treatment training to individuals without advanced degrees may help to reduce workforce shortages and improve reach of evidence‐based treatments.     

Perspectives of Vietnamese,Sudanese and South Sudanese immigrants on targeting migrant communities for latent tuberculosis screening and treatment in low‐incidence settings: A report on two Victorian community panels

BackgroundTuberculosis (TB) elimination strategies in Australia require a focus on groups who are at highest risk of TB infection, such as immigrants from high‐burden settings. Understanding attitudes to different strategies for latent TB infection (LTBI) screening and treatment is an important element of justifiable elimination strategies.MethodTwo community panels were conducted in Melbourne with members of the Vietnamese (n = 11), Sudanese and South Sudanese communities (n = 9). Panellists were provided with expert information about LTBI and different screening and health communication strategies, then deliberated on how best to pursue TB elimination in Australia.FindingsBoth panels unanimously preferred LTBI screening to occur pre‐migration rather than in Australia. Participants were concerned that post‐migration screening would reach fewer migrants, noted that conducting LTBI screening in Australia could stigmatize participants and that poor awareness of LTBI would hamper participation. If targeted screening was to occur in Australia, the Vietnamese panel preferred ‘place‐based’ communication strategies, whereas the Sudanese and South Sudanese panel emphasized that community leaders should lead communication strategies to minimize stigma. Both groups emphasized the importance of maintaining community trust in Australian health service providers, and the need to ensure targeting did not undermine this trust.ConclusionPre‐migration screening was preferred. If post‐migration screening is necessary, the potential for stigma should be reduced, benefit and risk profile clearly explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.     

The one‐year impact of accountable care networks among Washington State employees

ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.     

Changes in health insurance coverage,access to care,and health services utilization by sexual minority status in the United States, 2013‐2018

ObjectiveTo examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013‐2014 and 2017‐2018.Data SourcesData on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18‐64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study DesignUnadjusted and regression‐adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression‐adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal FindingsUninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013‐2014 and 2017‐2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017‐2018 compared with 2013‐2014. Low‐income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.ConclusionsSexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.     

Continuity of care and health care cost among community‐dwelling older adult veterans living with dementia

ObjectivesTo estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community‐dwelling older veterans with dementia.Data SourcesCombined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014‐2015.Study DesignFY 2014 COC was measured by the Bice‐Boxerman Continuity of Care (BBC) index on a 0‐1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long‐/short‐stay nursing home, and noninstitutional long‐term care (LTC) cost for medical (like skilled‐) and social (like unskilled‐) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.Data CollectionCommunity‐dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).Principal FindingsMean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long‐stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short‐stay nursing home cost.ConclusionsCOC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.