What are the consequences of waiting for health care in the veteran population?

Abstract

National health reform is expected to increase how long individuals have to wait between requests for appointments and when their appointment is scheduled. The increase in demand for care due to more widespread insurance will result in longer waits if there is not also a concomitant increase in supply of healthcare services. Long waits for healthcare are hypothesized to compromise health because less frequent outpatient visits result in delays in diagnosis and treatment. Research testing this hypothesis is scarce due to a paucity of data on how long individuals wait for healthcare in the United States. The main exception is the Veterans Health Administration (VA) that has been routinely collecting data on how long veterans wait for outpatient care for over a decade. This narrative review summarizes the results of studies using VA wait time data to answer two main questions: 1) How much do longer wait times decrease healthcare utilization and 2) Do longer wait times cause poorer health outcomes? Longer VA wait times lead to small, yet statistically significant decreases in utilization and are related to poorer health in elderly and vulnerable veteran populations. Both long-term outcomes (e.g. mortality, preventable hospitalizations) and intermediate outcomes such as hemoglobin A1C levels are worse for veterans who seek care at facilities with longer waits compared to veterans who visit facilities with shorter waits. Further research is needed on the mechanisms connecting longer wait times and poorer outcomes including identifying patient sub-populations whose risks are most sensitive to delayed access to care. If wait times increase for the general patient population with the implementation of national reform as expected, U.S. healthcare policymakers and clinicians will need to consider policies and interventions that minimize potential harms for all patients.

Figure 1

Conceptual model of the effect of wait times on health care utilization and health outcomes.

Figure 2

National wait times for new VA patients in primary care (2002–2010)* (*2002 was early in the collection of wait time data, which accounts for inconsistent reporting from some facilities on wait times in early 2002).

Figure 3

Individualized wait time versus exogenous^ wait time by ACSC Hospitalization Status in August 2001† (^exogenous = wait time not affected by individual health status). ±Individualized wait times reflect individual health status. Sicker patients are likely to be seen faster which creates an association between short wait times and poor health outcomes. Failure to adjust for this may lead researchers to conclude long waits are good for health. † Figure created from data reported in Prentice and Pizer (Table 1).

Figure 4

Policy simulation predicting percent decrease in VA primary care utilization with a 21-day increase in wait times among a sample of patients with diabetes* (* Abstracted from Prentice JC, Fincke BG, Miller DR and Pizer, SD. “Waiting for primary care and health outcomes among elderly patients with diabetes” Health Services Research). ^ SHC = selected health condition and is defined as anyone diagnosed with retinopathy, neuropathy, nephropathy, cardiovascular, cerebrovascular, peripheral vascular or metabolic disease according to Young et al. or anyone with congestive heart failure, cardiac arrhythmias, valvular disease, peripheral vascular disease, renal failure or obesity according to Elixhauser et al.