Length of stay as a source of bias in comparing performance in VA and private sector facilities: lessons learned from a regional evaluation of intensive care outcomes

The revised Atlanta criteria more accurately reflect severity of post-ERCP pancreatitis compared to the consensus criteria

Background and objective

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most prevalent complication after ERCP with an incidence of 3.5%. PEP severity is classified according to either the consensus criteria or the revised Atlanta criteria. In this international cohort study we investigated which classification is the strongest predictor of PEP-related mortality.

Methods

We reviewed 13,384 consecutive ERCPs performed between 2012 and 2017 in eight hospitals. We gathered data on all pancreatitis-related adverse events and compared the predictive capabilities of both classifications. Furthermore, we investigated the correlation between the two classifications and identified reasons underlying length of stay.

Results

The total sample consisted of 387 patients. The revised Atlanta criteria have a higher sensitivity (100 vs. 55%), specificity (98 vs. 72%) and positive predictive value (58 vs. 5%). There is a significant difference (p < 0.001) between the two classifications. In 124 patients (32%), the length of stay was influenced by concomitant diseases.

Conclusion

The revised Atlanta classification is superior in predicting mortality and better reflects PEP severity. This has important implications for researchers, clinicians and patients. For the diagnosis of PEP pancreatitis, the consensus criteria remain the golden standard. However, the revised Atlanta criteria are preferable for defining PEP severity.

Perceptions of Care of Patients Undergoing Coronary Artery Bypass Surgery in Veterans Health Administration and Private Sector Hospitals

Few studies have examined differences in patient perceptions of care between health care systems. This study compared the perceptions of male patients undergoing coronary artery bypass graft surgery in 43 Veterans Health Administration (VA) hospitals (N = 808) and 102 US private sector hospitals (N = 2271) from 1995 to 1998. Patient perceptions were measured by a validated survey that was mailed to patients after discharge. For 8 of the 9 dimensions assessed by the survey, VA patients were more likely (P < .001) than private sector patients to note a problem with care (eg, Coordination, 48% versus 40%; Patient Education and Communication, 50% versus 40%; Respect for Patient Preferences, 49% versus 41%). In comparisons limited to major teaching hospitals, VA patients were more likely to note a problem for 5 dimensions. The findings indicate that patient perceptions of care may be lower in VA than in private sector hospitals. Future studies should examine whether the VA's recent focus on improving patient satisfaction has narrowed these differences.

Fee-based care is important for access to prompt treatment of hip fractures among veterans

BACKGROUND

Hip fracture is a medical emergency for which delayed treatment increases risk of disability and death. In emergencies, veterans without access to a Veterans Administration (VA) hospital may be admitted to non-VA hospitals under fee-based (NVA-FB) care paid by the VA. The affect of NVA-FB care for treatment and outcomes of hip fractures is unknown.

QUESTIONS/PURPOSES

This research seeks to answer three questions: (1) What patient characteristics determine use of VA versus NVA-FB hospitals for hip fracture? (2) Does time between admission and surgery differ by hospital (VA versus NVA-FB)? (3) Does mortality differ by hospital?

METHODS

Veterans admitted for hip fractures to VA (n = 9308) and NVA-FB (n = 1881) hospitals from 2003 to 2008 were identified. Primary outcomes were time to surgery and death. Logistic regression identified patient characteristics associated with NVA-FB hospital admissions; differences in time to surgery and death were evaluated using Cox proportional hazards regression, controlling for patient covariates.

RESULTS

Patients admitted to NVA-FB hospitals were more likely to be younger, have service-connected disabilities, and live more than 50 miles from a VA hospital. Median days to surgery were less for NVA-FB admissions compared with VA admissions (1 versus 3 days, respectively). NVA-FB admissions were associated with 21% lower relative risk of death within 1 year compared with VA hospital admissions.

CONCLUSIONS

For veterans with hip fractures, NVA-FB hospital admission was associated with shorter time to surgery and lower 1-year mortality. These findings suggest fee-based care, especially for veterans living greater distances from VA hospitals, may improve access to care and health outcomes.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Avaliação do índice de comorbidade de Charlson em internações da região de Ribeirão Preto, São Paulo, Brasil

O objetivo deste artigo foi avaliar o uso do índice de comorbidade de Charlson (ICC) para predizer óbito hospitalar em internações da região de Ribeirão Preto, São Paulo, Brasil. Foram analisadas 54.680 hospitalizações entre janeiro de 1996 e dezembro de 1997. Duas adaptações do ICC para a Classificação Internacional de Doenças (CID) foram comparadas e as trinta condições clínicas avaliadas por Charlson foram revistas. A regressão logística foi utilizada para avaliar a capacidade dos modelos de predizer o óbito hospitalar. O modelo de base incluiu: idade, sexo e diagnóstico principal. Diferenças na adaptação para a CID-9 pouco impactaram a capacidade de discriminação dos modelos. A revisão das trinta condições clínicas aumentou a capacidade de discriminação do modelo de predição de óbito (estatística C = 0,73) quando comparado ao modelo com o ICC original (estatística C = 0,72). Todos os modelos testados tiveram efeito reduzido sobre a capacidade discriminativa do modelo de base (estatística C = 0,70). Os resultados apontam a importância de se dispor no país de um sistema de informação que permita uma descrição completa da morbidade hospitalar para o monitoramento do desempenho dos serviços.

Is lower 30-day mortality posthospital admission among blacks unique to the Veterans Affairs health care system?

BACKGROUND

Several studies have reported lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) health care system, particularly for those age 65 and older. This finding may be a result of the VA's integrated health care system, which reduces barriers to care through subsidized comprehensive health care services. However, no studies have directly compared racial differences in mortality within 30 days of hospitalization between the VA and non-VA facilities in the US health care system.

OBJECTIVE

To compare risk-adjusted 30-day mortality for black and white males after hospital admission to VA and non-VA hospitals, with separate comparisons for patients younger than age 65 and those age 65 and older.

RESEARCH DESIGN

Retrospective observational study using hospital claims data from the national VA system and all non-VA hospitals in Pennsylvania and California.

SUBJECTS

A total of 369,155 VA and 1,509,891 non-VA hospitalizations for a principal diagnosis of pneumonia, congestive heart failure, gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction between 1996 and 2001.

MEASURES

Mortality within 30 days of hospital admission.

RESULTS

Among those under age 65, blacks in VA and non-VA hospitals had similar odds ratios of 30-day mortality relative to whites for gastrointestinal bleeding, hip fracture, stroke, and acute myocardial infarction. Among those age 65 and older, blacks in both VA and non-VA hospitals had significantly reduced odds of 30-day mortality compared with whites for all conditions except pneumonia in the VA. The differences in mortality by race are remarkably similar in VA and non-VA settings.

CONCLUSIONS

These findings suggest that factors associated with better short-term outcomes for blacks are not unique to the VA.

Comparison of risk of cerebrovascular events in an elderly VA population with dementia between antipsychotic and nonantipsychotic users

INTRODUCTION

The credibility of an increased risk of cerebrovascular events (CVEs) in elderly patients with dementia being treated with second-generation antipsychotics (SGAs) is debatable. Although early published and unpublished data indicated a risk, much of the subsequent literature has not supported this initial finding. Previously published studies were flawed in part because they lacked a control group and did not stratify by dementia subtype. This study examined the risk of a CVE in patients diagnosed with Alzheimer or vascular dementia while being treated with SGA, first-generation antipsychotics, or no antipsychotic medication.

METHODS

Data from 14,029 patients aged 65 years and older were evaluated using patient information from Veterans Administration and Medicare databases. Patients who received care for dementia were categorized according to dementia subtype (vascular or Alzheimer) and antipsychotic use during an 18-month period. Patients were observed until they were admitted to a hospital for a CVE, stopped taking or switched antipsychotics, died, or until the 18-month observation period ended.

RESULTS

Overall, CVE risk did not differ whether patients were receiving a first-generation antipsychotic, SGA, or no antipsychotic therapy. However, patients with vascular dementia had an increased risk in hospitalization for a CVE. There was no increase in risk of a CVE for patients treated with quetiapine, olanzapine, or risperidone relative to haloperidol, or for patients receiving olanzapine or risperidone relative to quetiapine. Stratified subgroup analyses demonstrated no difference in risk for CVE-related admission patients with Alzheimer dementia among individual agents. However, patients with vascular dementia receiving risperidone, but not olanzapine or quetiapine, were found to be at decreased risk for CVE admission relative to haloperidol.

CONCLUSIONS

This study found no increase in overall risk for CVE-related hospital admission in patients treated with antipsychotic medications.

Mortality of Department of Veterans Affairs patients undergoing coronary revascularization in private sector hospitals

OBJECTIVE

A limitation of studies comparing outcomes of Veterans Affairs (VA) and private sector hospitals is uncertainty about the methods of accounting for risk factors in VA populations. This study estimates whether use of VA services is a marker for increased risk by comparing outcomes of VA users and other patients undergoing coronary revascularization in private sector hospitals.

DATA SOURCES

Males 67 years and older undergoing coronary artery bypass graft (CABG; n=687,936) surgery or percutaneous coronary intervention (PCI; n=664,124) during 1996-2002 were identified from Medicare administrative data. Patients using VA services during the 2 years preceding the Medicare admission were identified using VA administrative files.

STUDY DESIGN

Thirty-, 90-, and 365-day mortality were compared in patients who did and did not use VA services, adjusting for demographic and clinical risk factors using generalized estimating equations and propensity score analysis.

RESULTS

Adjusted mortality after CABG was higher (p<.001) in VA users compared with nonusers at 30, 90, and 365 days: odds ratio (OR)=1.07 (95 percent confidence interval [CI], 1.03-1.11), 1.07 (95 percent CI, 1.04-1.10), and 1.09 (95 percent CI, 1.06-1.12), respectively. For PCI, mortality at 30 and 90 days was similar (p>.05) for VA users and nonusers, but was higher at 365 days (OR=1.09; 95 percent CI, 1.06-1.12). The increased risk of death in VA users was limited to patients with service-connected disabilities or low incomes. Odds of death for VA users were slightly lower using samples matched by propensity scores.

CONCLUSIONS

A small difference in risk-adjusted outcomes for VA users and nonusers undergoing revascularization in private sector hospitals was found. This difference reflects unmeasured severity in VA users undergoing revascularization in private sector hospitals.

Health care supply for cataract in Austrian public and private hospitals

PURPOSE

This study aims to explain spatial variability or cataract and cataract surgery in Austria. The effect of the availability of health care services on spatial variation is investigated.

METHODS

A retrospective study, using routine hospital data from all Austrian public and private hospitals. Calculation of age- and gender-standardized hospitalization ratios (SHR) for all 121 Austrian districts. Poisson regression for age-specific relative risks was performed.

RESULTS

The authors found high regional variability between districts and significant differences in the hospitalization rates of cataract disease and extraction between men and women. There was a significant correlation between standardized hospitalization ratios for districts and the availability of hospitals with departments of ophthalmology. There was a significant difference in length of stay for patients with cataract surgery between public and private hospitals.

CONCLUSIONS

Use of routine hospital data in geographic analysis allows large regional studies on health care supply for cataract surgery. Differences in the supply by hospitals between districts depend on the availability of hospitals with departments of ophthalmology. The overall demand for cataract surgery in Austria finds its proper supply in many Austrian regions, but needs further development.

Mortality of Department of Veterans Affairs patients admitted to private sector hospitals for 5 common medical conditions

Whether prior use of Veterans Affairs services is a marker for increased mortality was evaluated by using Medicare data for men aged 67 years and older admitted for acute myocardial infarction, chronic heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke during 1996 to 2002. Patients using Veterans Affairs services during the 2 years preceding hospital admission were identified using Veterans Affairs encounter data, and 30-day mortality was compared in patients who did and did not use Veterans Affairs services, adjusting for patient risk factors. For most Veterans Affairs users, the odds of death were similar or slightly less than the odds of death for nonusers. For acute myocardial infarction, pneumonia, and stroke, the risk of death was slightly higher for Veterans Affairs users with low income. Results using propensity-matched samples were similar. The use of Veterans Affairs services is not a strong marker of unmeasured severity among patients in private sector hospitals.

Adrenalectomy in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study

BACKGROUND

Data from the Patient Safety in Surgery Study were used to compare preoperative risk factors, intraoperative variables, and surgical outcomes of adrenalectomy procedures performed in 81 Veterans Affairs (VA) hospitals with those performed in 14 private-sector (PS) hospitals.

STUDY DESIGN

This study is a retrospective review of prospectively collected data on all patients undergoing adrenalectomy in the VA and PS for fiscal years 2002 through 2004. Bivariate analysis compared VA and PS preoperative risk factors, intraoperative variables, and 30-day morbidity and mortality. Regression risk-adjustment analysis was used to compare 30-day postoperative morbidity in the VA and PS.

RESULTS

During the 3 years studied, 178 VA patients and 371 PS patients underwent adrenalectomy procedures with a median per site of 2 (range 1-9) and 21 (range 8-70) procedures per VA and PS hospital, respectively. The VA patients had considerably more comorbidities than PS patients. The unadjusted 30-day morbidity rate was significantly higher in VA (16.29%) than PS (6.74%) hospitals (p = 0.0003); after controlling for the higher rate of comorbidities, the adjusted odds ratio for morbidity in the VA versus the PS hospitals was no longer significant (odds ratio = 1.328; 95% CI, 0.488-3.613). Unadjusted mortality rate was VA 2.81%, PS 0.27%, p = 0.0074. The low event rate overall precluded risk adjustment for mortality.

CONCLUSIONS

The VA adrenalectomy population has more preoperative risk factors and substantially higher unadjusted 30-day postoperative morbidity and mortality rates than the PS population. After risk adjustment, there is no significant difference in morbidity between the VA and the PS. A larger study population is needed to compare risk-adjusted mortality between the VA and PS.

Variability in outcome and resource use in intensive care units

OBJECTIVE

To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use.

DESIGN AND SETTING

Cohort study, based on the SAPS 3 database in 275 ICUs worldwide.

PATIENTS

16,560 adults.

MEASUREMENTS AND RESULTS

Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant.

CONCLUSIONS

Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.

Intensive care unit physician staffing: Financial modeling of the Leapfrog standard*

OBJECTIVE

To evaluate from a hospital's perspective the costs and savings, over a 1-yr period, of implementing The Leapfrog Group's Intensive Care Unit Physician Staffing (IPS) standard compared with the existing standard of nonintensivist staffing in adult intensive care units.

DESIGN

Using published data, we developed a financial model of costs and savings for 6-, 12- and 18-bed intensive care units using conservative estimates for all variables. Sensitivity analyses, including a best-case and worst-case scenario, were performed to evaluate the impact of changing assumptions on the outcome of the model.

SETTING

Nonrural hospitals in the United States.

PATIENTS

All adult intensive care unit patients.

INTERVENTIONS

The IPS standard requires that intensive care units have a dedicated intensivist present during daytime hours. Outside of these hours, an intensivist must be immediately available by pager, and a physician or "physician extender" must be in the hospital and able to immediately reach intensive care unit patients.

MEASUREMENTS AND MAIN RESULTS

Cost savings ranged from $510,000 to $3.3 million for 6- to 18-bed intensive care units. The best-case scenario demonstrated savings of $4.2-13 million. Under the worst-case scenario, there was a net cost of $890,000 to $1.3 million.

CONCLUSIONS

Financial modeling of implementation of the IPS standard using conservative assumptions demonstrated cost savings to hospitals. Only under worst-case scenario assumptions did intensivist staffing result in additional cost to hospitals. These economic findings must be interpreted in the context of significant reductions in patient morbidity and mortality rates also associated with intensivist staffing. Given the magnitude of its clinical and financial impact, hospital leaders should be asking "how to" rather than "whether to" implement The Leapfrog Group's ICU Physician Staffing standard.

beta-Blocker therapy in veterans with asthma or chronic obstructive pulmonary disease

STUDY OBJECTIVES

To determine whether an association exists between health care resource use and beta-blocker therapy in patients with asthma or chronic obstructive pulmonary disease (COPD), and to determine whether any significant differences exist between type of beta-blocker agent administered and resource use.

DESIGN

Retrospective cohort study.

DATA SOURCE

Three Veterans Administration (VA) databases with information from hospitals and clinics in Iowa and Nebraska. Patients. A total of 8390 veterans with a diagnosis of asthma or COPD receiving treatment with a beta-blocker or another cardiovascular agent.

MEASUREMENTS AND MAIN RESULTS

Clinic visits and hospital admissions for asthma or COPD that occurred in 2000-2001 were identified using electronic administrative data files. Analyses were adjusted for comorbidity and patient demographics. Mean patient age was 67 years, and 97% of the patients were men. In unadjusted analyses, patients taking beta-blockers had more hospital admissions, similar inpatient length of stay (LOS), and fewer outpatient clinic visits for asthma or COPD. In adjusted analyses, however, no difference was noted in the odds of hospital admission or in LOS, and patients had fewer clinic visits related to asthma or COPD. The hazard ratio for hospital admission for asthma or COPD during the observation year was similar for patients taking and not taking beta-blockers, and no difference was noted with selective versus nonselective beta-blockers. However, the hospital admission rate was lower with atenolol than metoprolol.

CONCLUSION

Patients taking beta-blockers did not have more hospital admissions or clinic visits for their asthma or COPD than patients not taking these agents. When clinically indicated, beta-blockers-especially atenolol-should be considered for patients with asthma or COPD.

Cigarettes, alcohol, and depression: characterizing head and neck cancer survivors in two systems of care

Tobacco exposure is a key risk factor for head and neck cancer, and continued smoking after diagnosis negatively affects outcomes. The present study examined tobacco smoking, nicotine dependence, alcohol use, and depression in survivors of head and neck cancer. Subjects at least 6 months post-initial diagnosis of head and neck cancer (N=694) drawn from three VA otolaryngology clinics (n=309, VA patients) and a university-based otolaryngology clinic (n=385, non-VA patients) were administered questionnaires and standardized rating instruments for nicotine and alcohol dependence and for depression. Additional clinical information was extracted from chart reviews. Despite high rates of prior smoking, less than one-quarter of all subjects continued to smoke. After controlling for significant confounding variables, we found that VA patients were more likely to be current smokers (OR=1.9, 95% CI=1.3-3.0), but current VA smokers did not differ significantly from non-VA smokers on the Fagerström Test for Nicotine Dependence criterion (p=.69). The VA patients were more likely to screen positive for problem drinking on the Alcohol Use Disorder Identification Test (OR=2.1, 95% CI=1.3-3.7). After adjusting for other variables, we found no statistical difference between the groups in depression scores on the Geriatric Depression Scale-Short Form. The study provides data on smoking, alcohol use, and depression in head and neck cancer survivors indicating that VA patients are at increased risk for continued smoking and problem drinking relative to non-VA patients. Head and neck cancer patients benefit from aggressive smoking cessation efforts by the VA, but many patients need specialized services that integrate smoking interventions with treatment of comorbid alcoholism.

The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation

The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.

Intensive care unit physician staffing: financial modeling of the Leapfrog standard

OBJECTIVE

To evaluate from a hospital's perspective the costs and savings, over a 1-yr period, of implementing The Leapfrog Group's Intensive Care Unit Physician Staffing (IPS) standard compared with the existing standard of nonintensivist staffing in adult intensive care units.

DESIGN

Using published data, we developed a financial model of costs and savings for 6-, 12- and 18-bed intensive care units using conservative estimates for all variables. Sensitivity analyses, including a best-case and worst-case scenario, were performed to evaluate the impact of changing assumptions on the outcome of the model.

SETTING

Nonrural hospitals in the United States.

PATIENTS

: All adult intensive care unit patients.

INTERVENTIONS

The IPS standard requires that intensive care units have a dedicated intensivist present during daytime hours. Outside of these hours, an intensivist must be immediately available by pager, and a physician or "physician extender" must be in the hospital and able to immediately reach intensive care unit patients.

MEASUREMENTS AND MAIN RESULTS

Cost savings ranged from 510,000 to 3.3 million US dollars for 6- to 18-bed intensive care units. The best-case scenario demonstrated savings of 4.2-13 million US dollars. Under the worst-case scenario, there was a net cost of 890,000 to 1.3 million US dollars.

CONCLUSIONS

Financial modeling of implementation of the IPS standard using conservative assumptions demonstrated cost savings to hospitals. Only under worst-case scenario assumptions did intensivist staffing result in additional cost to hospitals. These economic findings must be interpreted in the context of significant reductions in patient morbidity and mortality rates also associated with intensivist staffing. Given the magnitude of its clinical and financial impact, hospital leaders should be asking "how to" rather than "whether to" implement The Leapfrog Group's ICU Physician Staffing standard.

US hospital care for patients with HIV infection and pneumonia: the role of public, private, and Veterans Affairs hospitals in the early highly active antiretroviral therapy era

STUDY OBJECTIVES

We evaluated differences in processes and outcomes of HIV-related pneumonia care among patients in Veterans Affairs (VA), public, and for-profit and not-for-profit private hospitals in the United States. We compared the results of our current study (1995 to 1997) with those of our previous study that included a sample of patients receiving care during the years 1987 to 1990 to determine how HIV-related pneumonia care had evolved over the last decade.

SETTING/PATIENTS

The sample consisted of 1,231 patients with HIV infection who received care for Pneumocystis carinii pneumonia (PCP) and 750 patients with HIV infection who received care for community-acquired pneumonia (CAP) during the years 1995 to 1997.

MEASUREMENT

We conducted a retrospective medical record review and evaluated patient and hospital characteristics, HIV-related processes of care (timely use of anti-PCP medications, adjunctive corticosteroids), non-HIV-related processes of care (timely use of CAP treatment medications, diagnostic testing, ICU utilization, rates of endotracheal ventilation, placement on respiratory isolation), length of inpatient hospital stay, and inpatient mortality.

RESULTS

Rates of timely use of antibiotics and adjunctive corticosteroids for treating PCP were high and improved dramatically from the prior decade. However, compliance with consensus guidelines that recommend < 8 h as the optimal time window for initiation of antibiotics to treat CAP was lower. For both PCP and CAP, variations in processes of care and lengths of in-hospital stays, but not mortality rates, were noted at VA, public, private not-for-profit hospitals, and for-profit hospitals.

CONCLUSIONS

This study provides the first overview of HIV-related pneumonia care in the early highly active antiretroviral therapy era, and contrasts current findings with those of a similarly conducted study from a decade earlier. Quality of care for patients with PCP improved, but further efforts are needed to facilitate the appropriate management of CAP. In the third decade of the epidemic, it will be important to monitor whether variations in processes of care for various HIV-related clinical diagnoses among different types of hospitals persist.

Differences in length of stay in Veterans Health Administration and other United States hospitals: is the gap closing?

OBJECTIVES

Compare risk-adjusted length of stay (LOS) in VA and other United States (non-VA) hospitals and determine if relative differences in LOS have changed in recent years.

RESEARCH DESIGN

Retrospective cohort study.

PATIENTS

Patients with ten common medical diagnoses admitted to all VA hospitals and to non-VA hospitals included in the National Hospital Discharge Survey (NHDS) during 1996 through 1999.

DATA

Comparable data elements were obtained from VA administrative databases and the NHDS. LOS was adjusted for age, gender, marital status, and comorbidity. Comorbidity was assessed using a validated methodology that considers 30 conditions.

RESULTS

Unadjusted mean LOS was longer in VA than non-VA patient for all 4 years, in aggregate (7.1 vs. 4.9 days, respectively; P < 0.001), and for each year individually. However, the difference in mean LOS in VA and non-VA patients declined from 2.9 days in 1996 to 1.6 days in 1999. LOS in VA patients remained longer (P < 0.001) in linear regression analyses, adjusting for demographics and comorbidity. However, the difference in LOS declined from 28.5% (95% CI, 28.1%-29.0%) in 1996 to 17.0% (95% CI, 16.6%-17.4%) in 1999. These results were similar in analyses of individual geographic regions.

CONCLUSIONS

Risk-adjusted LOS was longer in VA hospitals than in other United States hospitals. However, differences in LOS narrowed between 1996 and 1999. These findings suggest that changes in the organization and delivery of VA health care in the mid-1990s may be closing the gap between the VA and other healthcare systems in hospital utilization.

Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market

OBJECTIVE

To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market.

DESIGN

Retrospective cohort study.

SETTING

A large VA hospital and 27 private sector hospitals in the same metropolitan area.

PATIENTS

Consecutive VA (N = 1,960) and private sector (N = 157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses.

MEASUREMENTS

Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis.

MAIN RESULTS

Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P =.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P <.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P =.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P <.001), and the odds of death in VA patients were actually lower (P <.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P <.001) in VA patients for all 9 diagnoses.

CONCLUSIONS

If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.

In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals

OBJECTIVES

Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions.

RESEARCH DESIGN

Retrospective Cohort Study.

SUBJECTS

Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696).

METHODS

Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P <0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD).

RESULTS

Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P <0.001) with increasing volume (3.6% in low [<500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [>1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P <0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01).

CONCLUSIONS

VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.