Post-transition Complications
Despite the marked improvement in health knowledge, advocacy skills, and confidence associated with the intervention, Patel and Keefer found that gaps in care in the months following the transition from the DoD to the VA led to serious and avoidable complications.
Patients in both study arms had mean wait times of eight to nine weeks before their first primary care appointment with the VA and their first gastroenterology visit took more than 14 weeks to occur on average.
“Most of these patients needed to receive their drugs every two weeks, though some could go eight weeks,” noted Patel. Because of the lengthy wait for appointments, most participants were off their therapy before they had their first VA medical visit and 60% experienced flare ups. Some had to go to the emergency department to manage their condition before they could see a VA provider, which increased costs.
Worse, “once they saw a GI doctor, their medications were switched,” Patel noted, taking them off a medication that was working well—when they could get it.
“One kid ran a marathon in remission in the DoD. He called 10 weeks after discharge and said he was having symptoms and it was going to take another four weeks to get an appointment and another two weeks after that to get his medications. He had to go to the emergency room, where they didn’t put him back on Remicade. They thought he’d burned that drug, when, in fact, he wasn’t on any therapy at all,” Patel said.
Changing drugs unnecessarily can cause a variety of complications and increase costs. “There are many expensive medications in IBD treatment that can take up to one year to work or show improvement in the disease,” Akbar Waljee, MD, MSc, director of the Inflammatory Bowel Disease Program at the VA Ann Arbor Health System and associate professor of internal medicine at the University of Michigan told U.S. Medicine. In the interim, the patient is at elevated risk of complications and hospitalization.
Tests to determine whether a patient is responding or whether they are at risk for a flare up are expensive and not widely available, noted Waljee, who has developed a number of machine learning algorithms to reduce the cost, increase the accuracy, and speed the availability of information on IBD patients’ status.
Nationwide Issue
Because it is impossible to know which servicemembers in transition are at risk of a flare up or can safely go several months without medication, timely care once they leave the DoD is critical, according to the researchers.
“We need to find a way to bridge the gap. Companies can provide free samples for patients switching coverage in civilian care, but they can’t do that in the federal system,” Patel explained. Pharmaceutical companies and senior leaders of the Crohn’s and Colitis Foundation are advocating Congress to address the issue, not just for patients with IBD, but for anyone with a chronic, debilitating disease, he added.
The delay in appointments at the VA is likely largely driven by a lack of specialists. Gastroenterology is an occupational specialty that has been listed as a shortage area by the VA Office of the Inspector General for several years, with the 2019 survey results showing that 48 VA facilities reported a severe shortage of gastroenterologists.
While Patel noted that in San Antonio the transition team and servicemembers may be able to obtain appointments with other primary care and gastroenterology clinics that can see them faster, the situation may be an outlier. A study in The American Journal of Gastroenterology found “a disproportionately large number of GI physicians compared to population and IBD cases” in Texas and Colorado. The same study noted that 70% of U.S. states have fewer than 38 gastroenterologists who specialize in IBD.2
- Patel A, Keefer L. Patient Toolkit for Transition of Care of Active Duty Patients with Inflammatory Bowel Disease to the Veterans Administration Healthcare System.
- Tetangco EG, Lee JE, Rassmeehirann S, Bhagatwala J, Arshad HMS, Sifuentes H. State of the Gastroenterology Physician Workforce with Regard to Inflammatory Bowel Disease. Am J Gastroenterol. 2018 Oct;113:s374-s375. AMSUS 2019. 2-6 Dec 2019.
