VA hospitals have lower mortality than non-VA hospitals in 3 hard-case categories

VA hospitals have been objectively measured against non-VA counterparts on some key performance indicators, and the former have defied their troubled reputation: They emerge from the statistical comparison looking, on average, quite competitively competent.

The analysis, along with an accompanying editorial, is running in the Feb. 9 JAMA.

Comparing 30-day national mortality and readmission rates of three complicated conditions—acute myocardial infarction (i.e., heart attack), heart failure and pneumonia—Yale’s Sudhakar Nuti and Harlan Krumholz, MD, and colleagues found that VA hospitals have lower mortality rates for heart attack and heart failure compared with non-VA hospitals.

The VA didn’t run off with an undisputed victory, however, as its hospitals had higher readmission rates for all three sicknesses than non-VA hospitals.

The researchers drew from Medicare and VA data to look at outcomes for male Medicare fee-for-service beneficiaries, ages 65 and up, who were hospitalized between 2010 and 2013 in VA (n = 104) and non-VA (1,513) acute care hospitals across 92 metropolitan statistical areas.

They avoided skewed results owing to differences in geographic areas by standardizing risk factors and comparing hospitals within the same area or in similar areas.

Across all comparisons, the absolute differences were small. The results by the key numbers:

• Mortality rates were lower in VA hospitals than non-VA hospitals for heart attack (13.5 percent vs. 13.7 percent) and heart failure (11.4 percent vs. 11.9 percent), but VA mortality was higher for pneumonia (12.6 percent vs. 12.2 percent).
• Readmission rates were higher in VA hospitals for heart attack (17.8 percent vs. 17.2 percent), heart failure (24.7 percent vs. 23.5 percent) and pneumonia (19.4 percent vs. 18.7 percent).
• Within metropolitan statistical areas, VA hospitals had lower mortality rates for heart attack (percentage-point difference, -0.22) and heart failure (-0.63), and mortality rates for pneumonia were not significantly different (-0.03).
• In the within-areas comparisons, VA hospitals had higher readmission rates for heart attack (+0.62), heart failure (+0.97) and pneumonia (+0.66).

In their study discussion, Nuti et al. state their hope that up-to-date insights on hospital-level outcomes will lead to a better understanding of care quality for the 9 million or so veterans enrolled in the nation’s largest integrated health care system as compared with those in Medicare.

The authors note that their study is unique for its comparison of outcomes between VA and non-VA hospitals within similar geographic areas, and they posit that the finding of lower mortality rates for cardiovascular conditions in VA hospitals may reflect the VA’s tighter adherence to process measures.

Among the limitations the authors acknowledge are the study’s cohort of only elderly men, which prevents confident extrapolation of data to younger or female populations, as well as its focus on just three conditions (albeit three that CMS considers core-condition measures).

The authors hope their work will spur a benchmarking effort for quality improvement in the VA.

The data “could inform efforts to improve quality in the VA,” they write, “by identifying and learning from high-performing hospitals and disseminating best practices to lower-performing hospitals to elevate the entire performance curve.”

“The availability of this information, with equal standards of reporting, will allow for the assessment of comparative quality, which can inform targeted improvements in VA and non-VA hospitals alike,” the authors state. “It also affords a unique opportunity for the VA to partner with public and private entities to test and implement strategies to improve care.”

In the accompanying editorial, Ashish Jha, MD, MPH, of Harvard stresses the need to understand the VA as a massive healthcare-provider organization—one that has faced many challenges yet is “still able to deliver high-quality care for some of the sickest, most complicated patients.”

“That the VA, an integrated delivery system with a well-functioning information technology infrastructure, has higher readmission rates than non-VA hospitals, which are largely stand-alone entities with a high degree of fragmentation and little information sharing, is important,” writes Jha. “It is yet more evidence that readmissions primarily measure how sick and poor the patient population is, not how good or how integrated the care is.”