Association of Admission to Veterans Affairs Hospitals vs Non–Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia

Abstract

IMPORTANCE Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.OBJECTIVE To assess and compare mortality and readmission rates among men in VA and non-VA hospitals. DESIGN, SETTING, AND PARTICIPANTSCross-sectional analysis involving male Medicare fee-forservice beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA).EXPOSURES Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital. MAIN OUTCOMES AND MEASURESFor each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed. RESULTSWe studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; Ն65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; −0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; −0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, −0.22; 95% CI, −0.40 to −0.04) and HF (−0.63; 95% CI, −0.95 to −0.31), and mortality rates for pneumonia were not significantly different (−0.03; 95% CI, −0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91).CONCLUSIONS AND RELEVANCE Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small.

A review of dual health care system use by veterans with cardiometabolic disease

“…Nuti et al (11) conducted a cohort study of 30-day mortality and hospital readmission rates involving older male veterans hospitalized to VA hospitals or non-VA hospitals with AMI, CHF, and pneumonia. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs. 13.7%, P=0.02) and CHF (11.4% vs. 11.9%, P=0.008) but higher for pneumonia (12.6% vs. 12.2%, P<0.05); absolute differences between these outcomes were small.…”

“…In addition, outcomes such as survival at 30 days are not necessarily improved by dual use (14). In the study by Nuti et al (11), older male veterans hospitalized with AMI or CHF had lower 30-day mortality rates if they were treated at a VA hospital. The lower mortality rates may be due in part to quality improvement efforts implemented in the VA’s integrated delivery system (11).…”

“…In the study by Nuti et al (11), older male veterans hospitalized with AMI or CHF had lower 30-day mortality rates if they were treated at a VA hospital. The lower mortality rates may be due in part to quality improvement efforts implemented in the VA’s integrated delivery system (11). Dual use has been associated with increased health care use and worse outcomes in CHF patients (13).…”

Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Between Veterans Affairs Nursing Homes and Non–Veterans Affairs Nursing Homes

“…16–21 Studies comparing VA and non-VA patients have, for example, shown better performance on measures of chronic disease and preventive care, 16 greater rates of evidence-based drug therapy, 17 and better outcomes for older men who are hospitalized for several cardiac conditions. 18 Research has also shown that VA hospitals are leaders in the use of key practices to prevent catheter-related blood stream infections. 19–21 Consistent with these studies, we found better CAUTI surveillance practices within VA nursing homes.…”

Missing the Mark: Inaccuracy of administrative data in identification of hospitalized patients with pneumonia and results of a systematic clinical reclassification process on readmission rates

“…[6][7][8] Multiple studies have documented the discordance between claims and clinical data in the diagnosis of myocardial infarction and pneumonia. [9][10][11] For example, one study estimated the sensitivity of five different claims-based pneumonia definitions against a clinical reference standard ranging from only 48% to 66%.…”