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Kelley AT, Torre MP, Wagner TH, Rosen AK, Shwartz M, Lu CC, Brown TK, Zheng T, Beilstein-Wedel E, Vanneman ME. Trends in Bundled Outpatient Behavioral Health Services in VA-Direct Versus VA-Purchased Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:998-1010. [PMID: 39115648 PMCID: PMC11489023 DOI: 10.1007/s10488-024-01404-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 09/01/2024]
Abstract
The Veterans Health Administration (VA) increasingly purchases community-based care (CC) to improve healthcare access, including behavioral health. In 2018, VA introduced standardized episodes of care (SEOCs) to guide authorization and purchase of CC services for specific indications in a defined timeframe without bundling payment. In this retrospective cross-sectional study, we describe trends in VA and CC behavioral healthcare utilization using the VA Outpatient Psychiatry SEOC definition. Counts of Outpatient Psychiatry SEOC-allowable service and procedure codes during fiscal years 2016-2019 were organized according to four SEOC-defined service types (evaluation and management, laboratory services, psychiatry services, transitional care) and measured as percentages of all included codes. Trends comparing behavioral healthcare utilization between Veterans using any CC versus VA only were analyzed using a linear mixed effects model. We identified nearly 3 million Veterans who registered 60 million qualifying service and procedure codes, with overall utilization increasing 77.8% in CC versus 5.2% in VA. Veterans receiving any CC comprised 3.9% of the cohort and 4.7% of all utilization. When examining service type as a percent of all Outpatient Psychiatry SEOC-allowable care among Veterans using CC, psychiatry services increased 12.2%, while transitional care decreased 8.8%. In regression analysis, shifts in service type utilization reflected descriptive results but with attenuated effect sizes. In sum, Outpatient Psychiatry SEOC-allowable service utilization grew, and service type composition changed, significantly more in CC than in VA. The role of SEOCs and their incentives may be important when evaluating future behavioral healthcare quality and value in bundled services.
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Affiliation(s)
- A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Michael P Torre
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Operations and Technology Management, Boston University Questrom School of Business, Boston, MA, USA
| | - Chao-Chin Lu
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Todd K Brown
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tianyu Zheng
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Erin Beilstein-Wedel
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
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Slatore CG, Scott JY, Hooker ER, Disher N, Golden S, Govier D, Hynes DM. Motivators, Barriers, and Facilitators to Choosing Care in VA Facilities Versus VA-Purchased Care. Med Care Res Rev 2024; 81:395-407. [PMID: 39075797 DOI: 10.1177/10775587241264594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.
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Affiliation(s)
- Christopher G Slatore
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
- Division of Pulmonary, Allergy and Critical Care, Oregon Health & Science University, Portland, OR, USA
- Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Jennifer Y Scott
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Natalie Disher
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Sara Golden
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
- Division of Pulmonary, Allergy and Critical Care, Oregon Health & Science University, Portland, OR, USA
| | - Diana Govier
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
- Department of Health Systems Management & Policy, Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, USA
- Health Management and Policy Program, College of Health and Center for Quantitative Life Sciences, Oregon State University; Corvallis, OR, USA
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
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Kintzle S, Alday E, Sutherland A, Castro CA. Drivers of Veterans' Healthcare Choices and Experiences with Veterans Affairs and Civilian Healthcare. Healthcare (Basel) 2024; 12:1852. [PMID: 39337193 PMCID: PMC11430980 DOI: 10.3390/healthcare12181852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 09/10/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Access to quality healthcare is essential to the well-being of U.S. veterans. Little is known about what drives veterans' healthcare decisions. The purpose of this study was to explore factors that drive healthcare choices in veterans, and their experiences in the Veterans Health Administration (VA) and non-VA healthcare settings. METHODS Fifty-nine veterans participated in eight focus groups. Participants were asked to discuss factors that led to their choice of provider and their healthcare experiences. Thematic analysis was conducted to reveal themes around healthcare choices and use. RESULTS VA and non-VA users described positive experiences with care. VA users reported cost, quality, and ease of care as reasons for use. Non-VA healthcare setting users reported eligibility issues, negative perceptions of the VA, administrative bureaucracy, and lack of continuity of care as reasons they chose not to use VA care. VA users reported difficulty with red tape, continuity of care, limitations to gender specific care, and having to advocate for themselves. CONCLUSIONS Veterans were satisfied with care regardless of where they received it. Experiences with civilian providers indicate that more could be done to provide veterans with choices in the care they receive. Despite positive experiences with the VA, the veterans highlighted needed improvements in key areas.
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Affiliation(s)
- Sara Kintzle
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Eva Alday
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Aubrey Sutherland
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Carl A Castro
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
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Coetzee D, Wray CM. Quality of care in Veterans Health Administration hospitals: Helping veterans decide "Should I stay, or should I go?". J Hosp Med 2024. [PMID: 39237473 DOI: 10.1002/jhm.13503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 08/28/2024] [Indexed: 09/07/2024]
Affiliation(s)
- Donna Coetzee
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Charlie M Wray
- Department of Medicine, University of California, San Francisco, California, USA
- Section of Hospital Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Beckman AL, Jacobs J, Elnahal SM. The PACT Act-Expanding Coverage and Access for Veterans. JAMA 2024:2822174. [PMID: 39120963 DOI: 10.1001/jama.2024.16013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Abstract
This Viewpoint examines the implementation of the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act, known as the PACT Act, which expanded health care for millions of veterans from any era exposed to toxic hazards.
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Affiliation(s)
- Adam L Beckman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Yoon J, Chow A, Jiang H, Wong E, Chang ET. Comparing Quality, Costs, and Outcomes of VA and Community Primary Care for Patients with Diabetes. J Gen Intern Med 2024:10.1007/s11606-024-08968-4. [PMID: 39103601 DOI: 10.1007/s11606-024-08968-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 07/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded access to independent community providers outside the Veterans Health Administration (VA). Little is known how quality, costs, and outcomes of primary care received in the community compare to that of the VA. OBJECTIVE To compare quality, costs, and outcomes of community and VA-provided primary care for patients with diabetes over a 12-month episode. DESIGN A cross-sectional study using VA administrative data and community care claims. Adjusted analyses were conducted using inverse probability weighted regression adjustment to balance patient characteristics. PARTICIPANTS Veterans with diabetes receiving primary care in the VA or community. MAIN MEASURES Quality measures included receipt of hemoglobin A1C tests, eye exams, microalbumin urine tests, and flu shots. Outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC). Costs were measured for VA and community outpatient care, inpatient care, and prescription drugs. KEY RESULTS There were 652,648 VA patients and 3650 community care patients. VA patients were less likely to be White, had shorter mean drive time to VA primary care, and were less likely to be rural than community care patients. In adjusted analyses, community care patients had significantly lower probability of receiving a hemoglobin A1C test, eye exam, microalbumin urine test, and flu shot compared to the VA group. There was no difference in probability of an ACSC hospitalization. Community care patients had higher mean total costs ($1741 [95% CI, $431, $3052]), driven by higher inpatient and prescription drug costs but lower emergency care costs than VA patients. CONCLUSION Patients receiving community primary care had worse diabetes quality and higher costs than patients receiving VA primary care. There was no difference in health outcomes. Care provided by an integrated delivery system may have advantages in quality and value.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
| | - Adam Chow
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Hao Jiang
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Emily Wong
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Geppert CMA. Has the VA Fulfilled its Commitment to Trust and Healing? Fed Pract 2024; 41:234-235. [PMID: 39410920 PMCID: PMC11473032 DOI: 10.12788/fp.0508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024]
Affiliation(s)
- Cynthia M A Geppert
- Editor-in-Chief and Senior Ethicist Veterans Affairs National Center for Ethics in Health Care and Consultation-Liaison Psychiatrist, New Mexico Veterans Affairs Health Care System
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Wong MS, Tseng CH, Moy E, Jones KT, Kothari AJ, Washington DL. Relationship between health system quality and racial and ethnic equity in diabetes care. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae073. [PMID: 38989064 PMCID: PMC11235325 DOI: 10.1093/haschl/qxae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/02/2024] [Accepted: 05/16/2024] [Indexed: 07/12/2024]
Abstract
Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement.
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Affiliation(s)
- Michelle S Wong
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
| | - Ernest Moy
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Kenneth T Jones
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Amit J Kothari
- Office of the Chief of Staff, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Donna L Washington
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
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Baran DA, Snipelisky D. Hard Work and Talent in the Battle Against Heart Failure. JACC. HEART FAILURE 2024; 12:1071-1072. [PMID: 38839150 DOI: 10.1016/j.jchf.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 06/07/2024]
Affiliation(s)
- David A Baran
- Section of Heart Failure, Transplant and Mechanical Circulatory Support, Heart Vascular and Thoracic Institute, Cleveland Clinic-Florida, Weston, Florida, USA.
| | - David Snipelisky
- Section of Heart Failure, Transplant and Mechanical Circulatory Support, Heart Vascular and Thoracic Institute, Cleveland Clinic-Florida, Weston, Florida, USA
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Dizon MP, Chow A, Ong MK, Phibbs CS, Vanneman ME, Zhang Y, Yoon J. Lower comorbidity scores and severity levels in Veterans Health Administration hospitals: a cross-sectional study. BMC Health Serv Res 2024; 24:601. [PMID: 38714970 PMCID: PMC11077812 DOI: 10.1186/s12913-024-11063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Previous studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change. METHODS Using repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans' admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012-2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics. RESULTS Following adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34-4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56-5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)). CONCLUSIONS More effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.
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Affiliation(s)
- Matthew P Dizon
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, USA.
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA.
| | - Adam Chow
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Ciaran S Phibbs
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Yue Zhang
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jean Yoon
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Department of General Internal Medicine, School of Medicine, University of California at San Francisco, San Francisco, CA, USA
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George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024; 159:501-509. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
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Hanson J, Hui M, Strawbridge JC, Chatterjee S, Goodyear K, Giaconi JA, Tsui I. High Rates of Eye Surgery Cancellation in Veterans Related to Mental Health. Mil Med 2024:usae230. [PMID: 38687601 DOI: 10.1093/milmed/usae230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Approximately 9 million veterans receive health care at the Veterans Health Administration, many of whom have psychiatric illnesses. The military continues to have higher rates of psychiatric illness compared to the civilian population. Having a diagnosis such as posttraumatic stress disorder or depression may create challenges in using health care services, such as surgery. The aim of this study was to evaluate eye surgery cancellation, risk factors for cancellation, and areas for intervention within the VA. MATERIALS AND METHODS This was a single-center retrospective cohort study. The Veteran Health Information Systems and Technology Architecture were queried to identify all surgical requests at the West Los Angeles VA in 2019. Data collection included sociodemographic information and comorbid medical conditions, including psychiatric illness. Exploratory analyses using univariate logistic regression were used to evaluate factors associated with surgery cancellation. RESULTS A total of 1,115 surgical requests were identified with a cancellation rate of 23.7% (n = 270). Sociodemographic factors were similar between those with completed and cancelled surgery. However, having a psychiatric diagnosis correlated with surgery cancellation. For all subspecialties, patients with schizophrenia were more likely to have cancellation (odds ratio [OR], 2.53, P = .04). For retina surgery, patients with posttraumatic stress disorder were more likely to have cancellation (OR, 4.23, P = .01). Glaucoma patients with anxiety (OR, 5.78, P = .05) and depression (OR, 4.05, P = .04) were more likely to have cancellation. CONCLUSIONS There was a significant amount of eye surgery cancellations in veterans with variation by subspecialty and comorbid conditions. Having a psychiatric illness was correlated with increased rates of surgery cancellation amongst veterans. Areas to improve surgical utilization include risk stratification and increased support of vulnerable patients before surgery.
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Affiliation(s)
- Justin Hanson
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
| | - Maggie Hui
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
| | - Jason C Strawbridge
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
| | - Sayan Chatterjee
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
| | - Kendall Goodyear
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
| | - JoAnn A Giaconi
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
- Division of Ophthalmology, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073 , USA
| | - Irena Tsui
- Department of Ophthalmology, David Geffen School of Medicine, Stein Eye Institute and Doheny Eye Institute, University of California, Los Angeles, CA 90095, USA
- Division of Ophthalmology, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073 , USA
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Wadhwa A, Roscoe C, Duran EA, Kwan L, Haroldsen CL, Shelton JB, Cullen J, Knudsen BS, Rettig MB, Pyarajan S, Nickols NG, Maxwell KN, Yamoah K, Rose BS, Rebbeck TR, Iyer HS, Garraway IP. Neighborhood Deprivation, Race and Ethnicity, and Prostate Cancer Outcomes Across California Health Care Systems. JAMA Netw Open 2024; 7:e242852. [PMID: 38502125 PMCID: PMC10951732 DOI: 10.1001/jamanetworkopen.2024.2852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/25/2024] [Indexed: 03/20/2024] Open
Abstract
Importance Non-Hispanic Black (hereafter, Black) individuals experience worse prostate cancer outcomes due to socioeconomic and racial inequities of access to care. Few studies have empirically evaluated these disparities across different health care systems. Objective To describe the racial and ethnic and neighborhood socioeconomic status (nSES) disparities among residents of the same communities who receive prostate cancer care in the US Department of Veterans Affairs (VA) health care system vs other settings. Design, Setting, and Participants This cohort study obtained data from the VA Central Cancer Registry for veterans with prostate cancer who received care within the VA Greater Los Angeles Healthcare System (VA cohort) and from the California Cancer Registry (CCR) for nonveterans who received care outside the VA setting (CCR cohort). The cohorts consisted of all males with incident prostate cancer who were living within the same US Census tracts. These individuals received care between 2000 and 2018 and were followed up until death from any cause or censoring on December 31, 2018. Data analyses were conducted between September 2022 and December 2023. Exposures Health care setting, self-identified race and ethnicity (SIRE), and nSES. Main Outcomes and Measures The primary outcome was all-cause mortality (ACM). Cox proportional hazards regression models were used to estimate hazard ratios for associations of SIRE and nSES with prostate cancer outcomes in the VA and CCR cohorts. Results Included in the analysis were 49 461 males with prostate cancer. Of these, 1881 males were in the VA cohort (mean [SD] age, 65.3 [7.7] years; 833 Black individuals [44.3%], 694 non-Hispanic White [hereafter, White] individuals [36.9%], and 354 individuals [18.8%] of other or unknown race). A total of 47 580 individuals were in the CCR cohort (mean [SD] age, 67.0 [9.6] years; 8183 Black individuals [17.2%], 26 206 White individuals [55.1%], and 13 191 individuals [27.8%] of other or unknown race). In the VA cohort, there were no racial disparities observed for metastasis, ACM, or prostate cancer-specific mortality (PCSM). However, in the CCR cohort, the racial disparities were observed for metastasis (adjusted odds ratio [AOR], 1.36; 95% CI, 1.22-1.52), ACM (adjusted hazard ratio [AHR], 1.13; 95% CI, 1.04-1.24), and PCSM (AHR, 1.15; 95% CI, 1.05-1.25). Heterogeneity was observed for the racial disparity in ACM in the VA vs CCR cohorts (AHR, 0.90 [95% CI, 0.76-1.06] vs 1.13 [95% CI, 1.04-1.24]; P = .01). No evidence of nSES disparities was observed for any prostate cancer outcomes in the VA cohort. However, in the CCR cohort, heterogeneity was observed for nSES disparities with ACM (AHR, 0.82; 95% CI, 0.80-0.84; P = .002) and PCSM (AHR, 0.86; 95% CI, 0.82-0.89; P = .007). Conclusions and Relevance Results of this study suggest that racial and nSES disparities were wider among patients seeking care outside of the VA health care system. Health systems-related interventions that address access barriers may mitigate racial and socioeconomic disparities in prostate cancer.
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Affiliation(s)
- Ananta Wadhwa
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
| | - Charlotte Roscoe
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Elizabeth A. Duran
- VA San Diego Healthcare System, San Diego, California
- Department of Radiation Oncology, University of California, San Diego, San Diego
- Center for Health Equity Education and Research, University of California, San Diego, La Jolla
| | - Lorna Kwan
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
| | - Candace L. Haroldsen
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
- IDEAS Center (COIN), VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Jeremy B. Shelton
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences, Case Western Reserve, Cleveland, Ohio
| | - Beatrice S. Knudsen
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
- IDEAS Center (COIN), VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Mathew B. Rettig
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- Department of Medicine, Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
| | | | - Nicholas G. Nickols
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
| | - Kara N. Maxwell
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- James A. Haley Veterans Hospital, Tampa, Florida
| | - Brent S. Rose
- VA San Diego Healthcare System, San Diego, California
- Department of Radiation Oncology, University of California, San Diego, San Diego
- Center for Health Equity Education and Research, University of California, San Diego, La Jolla
| | - Timothy R. Rebbeck
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hari S. Iyer
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Isla P. Garraway
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
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Roman Souza G, Nooruddin Z, Lee S, Boyle L, Lucero KT, Ananth S, Franklin K, Mader M, Toro Velez E, Naqvi A, Kaur S. The Impact of Time From Diagnosis to Initiation of Chemotherapy on Survival of Patients With Newly Diagnosed Diffuse Large B-Cell Lymphoma in the Veterans Health Administration. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e67-e77. [PMID: 38151390 DOI: 10.1016/j.clml.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/18/2023] [Accepted: 11/19/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Our retrospective study evaluates the impact of time from diagnosis to treatment (TDT) on outcomes of patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) treated within the Veterans Health Administration (VHA). METHODS VHA patients diagnosed with DLBCL between 2011 and 2019 were included, while those with primary central nervous system lymphoma were excluded. The median overall survival and progression-free survival were estimated with the Kaplan-Meier method. Univariate, bivariate, and multivariable analyses were performed using the Cox proportional hazards model. The odds ratio for refractory outcomes was calculated using logistic regression. RESULTS A total of 2448 patients were included. The median time from diagnosis to treatment of the cohort was 19 days. When comparing median progression-free survival, median overall survival, and the 2-year overall survival between the group that started treatment within 1 week and each of the other groups individually, there was a significant difference favoring improved survival in all groups with a TDT longer than 1 week (P < .0001). These patients also had a lower odds ratio for refractory outcomes. On multivariable analysis, TDT remained an independent prognostic factor. CONCLUSION Our study shows that a TDT equal to or less than 1 week is associated with adverse clinical factors, worse outcomes, and response in DLBCL, even after adjusting for multiple known poor prognostic factors. This was the first time that response to first-line therapy was correlated to time to treatment. Our findings support ongoing efforts to improve currently standardized prognostic tools and the incorporation of TDT into clinical trials to avoid selection bias.
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Affiliation(s)
| | - Zohra Nooruddin
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Sophia Lee
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Lauren Boyle
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Kana Tai Lucero
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | | | | | - Michael Mader
- South Texas Veterans Health Care System, San Antonio, TX
| | | | - Amna Naqvi
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Supreet Kaur
- University of Texas Health Science Center San Antonio, San Antonio, TX
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15
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Yoon J, Phibbs CS, Ong MK, Vanneman ME, Chow A, Redd A, Kizer KW, Dizon MP, Wong E, Zhang Y. Outcomes of Veterans Treated in Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals. JAMA Netw Open 2023; 6:e2345898. [PMID: 38039003 PMCID: PMC10692833 DOI: 10.1001/jamanetworkopen.2023.45898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023] Open
Abstract
Importance Many veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations. Objective To compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data. Design, Setting, and Participants This cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023. Exposures Treatment in VA or non-VA hospital. Main Outcome and Measures Thirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older). Results There was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age ≥65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age ≥65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age ≥65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients. Conclusions and Relevance In this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco
| | - Ciaran S. Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, California
| | - Michael K. Ong
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
| | - Adam Chow
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Andrew Redd
- Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | | | - Matthew P. Dizon
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Emily Wong
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Yue Zhang
- Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
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