Methods for estimating private sector payments for VA acute inpatient stays

Level of Care Appropriateness in VA Inpatient Surgery Cases

PURPOSE OF STUDY

Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care.

PRIMARY PRACTICE SETTINGS

There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service.

METHODOLOGY AND SAMPLE

All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test.

RESULTS

A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.

The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition

Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.