Similar Outcomes After VA vs Non-VA Admissions for MI, HF

NEW HAVEN, CT — Although outcome risks do differ by both type of hospital and type of hospitalization for an acute MI, heart failure, or pneumonia, these differences are not substantially big, suggests new research^[1].

In a large, cross-sectional analysis of men older than 65 years, those who were admitted to a Veterans Affairs (VA) hospital for AMI or HF had a lower 30-day risk of all-cause mortality compared with those admitted to a non-VA hospital (13.5% vs 13.7% and 11.4% vs 11.9%, respectively).

On the other hand, 30-day risk of all-cause readmission was lower for the non-VA men who had AMI (17.2% vs 17.8%), HF (23.5% vs 24.7%), or pneumonia (18.7% vs 19.4%).

"Overall, these differences that we saw, while present and important, were relatively small," lead author Sudhakar V Nuti (Yale-New Haven Hospital, CT) told heartwire from Medscape. "Ultimately, it's a good sign that care isn't very different between VA and non-VA hospitals."

However, this doesn't mean there isn't room for improvement for both types of facilities, said principal investigator Dr Harlan M Krumholz (Yale School of Medicine). "This shouldn't lead us to become complacent."

The findings were published in the February 9, 2016 issue of the Journal of the American Medical Association.

In an accompanying editorial^[2], Dr Ashish K Jha (Harvard TH Chan School of Public Health, Boston, MA) notes optimism with the results.

"The findings are reassuring and make plain that even though the VA has much work to do, it is starting off from a substantially better place than it was in 2 decades ago," writes Jha.

"I think this shows that veterans needn't fear that somehow the VA is a dangerous place to get care," added Krumholz to heartwire . "This was just one measure, but it's showing that despite the fact that these two systems are so different, their performance was very similar."

Assessing "Real Evidence"

The researchers note that "little contemporary information is available about comparative performance" between VA and non-VA hospitals.

"Another motivation was, given how important veterans are to our country, we wanted to investigate whether we're caring well for them when they're sick and vulnerable," said Nuti.

"There's a lot of attention these days focused on the VA, a lot of questions have been raised about its performance, and there's been a lot of criticism directed at it nationally," added Krumholz. "So I think it's reasonable to ask if there's any real evidence of differences in the comparative performance."

The investigators examined data for Medicare fee-for-service beneficiaries who were admitted for one of the three before-mentioned conditions between 2010 and 2013 at VA (n=104) or non-VA (n=1513) acute-care hospitals in 92 metropolitan statistical areas (MSAs).

Mortality records were examined for 132,232 patients hospitalized for AMI; 238,194 for HF; and 211,890 for pneumonia. Readmission records were examined for 140,205, 296,087, and 226,289 patients, respectively.

As mentioned earlier, the risk-stratified 30-day mortality rate was significantly lower for those admitted to VA hospitals for AMI or HF but higher for pneumonia; whereas the 30-day readmission rate was lower for all three conditions for the men admitted to non-VA hospitals.

Difference in Mortality and 30-day Readmission Between VA and Non-VA Hospitals

Condition	VA Hospitals 30-d rate, mean % (95% CI)	Non-VA Hospitals 30-d rate, mean % (95% CI)	P
AMI
Mortality	13.52 (13.3–13.66)	13.69 (13.64–13.74	0.02
Readmission	17.84 (17.71–17.96)	17.21 (17.17–17.25)	<0.001
HF
Mortality	11.43 (11.11–11.75)	11.87 (11.80–11.93)	0.008
Readmission	24.66 (24.31-25.02)	23.46 (23.39–23.53)	<0.001
Pneumonia
Mortality	12.63 (12.19–13.07)	12.17 (12.08–12.26)	0.045
Readmission	19.44 (19.19-19.69)	18.68 (18.63–18.73)	<0.001

Further analysis, examining within-MSA comparisons, found similar percentage-point differences for all except pneumonia mortality rates. In this analysis, the mortality rates were not significantly different between VA and non-VA hospitalization.

Regarding the overall findings of lower mortality rates for the CV conditions in the VA hospitals, the investigators speculate that this could be due to the providing of a higher level of care quality because of "adherence to process measures" and the implementation of several cardiac-care improvement initiatives.

As for the higher readmission rates in VA facilities, "VA hospitals may have a higher propensity to admit," write the researchers. Also, they note that in 2012, the CMS Hospital Readmission Reduction Program introduced financial penalties and incentives for reducing readmission in non-VA hospitals.

"I think, ultimately it's reassuring for both the general public and veterans that quality of care for these key conditions, which are really markers for acute illness, were not very different" between the two hospital types, said Nuti.

"Of course we could always do better. There are opportunities for improvement across the board, and we should pursue those to provide the best care we can," he added.

Delivering Care to Sickest Patients

Jha notes in his editorial that the investigators are to be commended because they narrowed their focus to examining how well the VA's care compares with other healthcare systems for three common medical conditions.

And the findings "are important because they suggest that despite all of the challenges that VA hospitals have faced, they are still able to deliver high-quality care for some of the sickest, most complicated patients," he writes.

The study authors were supported in part by the VA Connecticut Healthcare System and the American Federation for Aging Research through its Paul B Beeson Career Development Award Program and by grants from the National Institute on Aging and the National Heart, Lung, and Blood Institute. Nuti reports no relevant financial relationships. Krumholz reports co–receiving research agreements from Medtronic and Johnson & Johnson (Janssen) to develop clinical-trial data-sharing methods, chairing a cardiac scientific advisory board for UnitedHealth, and works under contract to develop and maintain performance measures for the Centers for Medicare and Medicaid Services. Disclosures for the coauthors are listed in the article. Jha reports serving as an attending physician at the Boston VA Healthcare System and having served in the past as a special adviser to former VA Secretary Eric Shinseki.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.