Dataset Information

Association of Admission to Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia.

ABSTRACT: Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.To assess and compare mortality and readmission rates among men in VA and non-VA hospitals.Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA).Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital.For each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed.We studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ?65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P?=?.02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P?=?.008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P?=?.045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P?

SUBMITTER: Nuti SV

PROVIDER: S-EPMC5459395 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature

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Association of Admission to Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia.

Nuti Sudhakar V SV Qin Li L Rumsfeld John S JS Ross Joseph S JS Masoudi Frederick A FA Normand Sharon-Lise T SL Murugiah Karthik K Bernheim Susannah M SM Suter Lisa G LG Krumholz Harlan M HM

JAMA 20160201 6

<h4>Importance</h4>Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.<h4>Objective</h4>To assess and compare mortality and readmission rates among men in VA and non-VA hospitals.<h4>Design, setting, and participants</h4>Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized be ...[more]

PMID: 26864412

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Project description:IMPORTANCE:Surgical site infections (SSIs) are potentially preventable complications that are associated with excess morbidity and mortality. OBJECTIVE:To determine the excess costs associated with total, deep, and superficial SSIs among all operations and for high-volume surgical specialties. DESIGN, SETTING, AND PARTICIPANTS:Surgical patients from 129 Veterans Affairs (VA) hospitals were included. The Veterans Health Administration Decision Support System and VA Surgical Quality Improvement Program databases were used to assess costs associated with SSIs among VA patients who underwent surgery in fiscal year 2010. MAIN OUTCOMES AND MEASURES:Linear mixed-effects models were used to evaluate incremental costs associated with SSIs, controlling for patient risk factors, surgical risk factors, and hospital-level variation in costs. Costs of the index hospitalization and subsequent 30-day readmissions were included. Additional analysis determined potential cost savings of quality improvement programs to reduce SSI rates at hospitals with the highest risk-adjusted SSI rates. RESULTS:Among 54,233 VA patients who underwent surgery, 1756 (3.2%) experienced an SSI. Overall, 0.8% of the cohort had a deep SSI, and 2.4% had a superficial SSI. The mean unadjusted costs were $31,580 and $52,620 for patients without and with an SSI, respectively. In the risk-adjusted analyses, the relative costs were 1.43 times greater for patients with an SSI than for patients without an SSI (95% CI, 1.34-1.52; difference, $11,876). Deep SSIs were associated with 1.93 times greater costs (95% CI, 1.71-2.18; difference, $25,721), and superficial SSIs were associated with 1.25 times greater costs (95% CI, 1.17-1.35; difference, $7003). Among the highest-volume specialties, the greatest mean cost attributable to SSIs was $23,755 among patients undergoing neurosurgery, followed by patients undergoing orthopedic surgery, general surgery, peripheral vascular surgery, and urologic surgery. If hospitals in the highest 10th percentile (ie, the worst hospitals) reduced their SSI rates to the rates of the hospitals in the 50th percentile, the Veterans Health Administration would save approximately $6.7 million per year. CONCLUSIONS AND RELEVANCE:Surgical site infections are associated with significant excess costs. Among analyzed surgery types, deep SSIs and SSIs among neurosurgery patients are associated with the highest risk-adjusted costs. Large potential savings per year may be achieved by decreasing SSI rates.

Project description:RationaleRehospitalization is common after sepsis, but little is known about the variation in readmission patterns across patient groups and care locations.ObjectivesTo examine the variation in postsepsis readmission rates and diagnoses by patient age, nursing facility use, admission year, and hospital among U.S. Veterans Affairs (VA) beneficiaries.MethodsObservational cohort study of VA beneficiaries who survived a sepsis hospitalization (2009-2011) at 114 VA hospitals, stratified by age (<65 vs. ≥65 yr), nursing home usage (none, chronic, or acute), year of admission (2009, 2010, 2011), and hospital. In the primary analysis, sepsis hospitalizations were identified using a previously validated method. Sensitivity analyses were performed using alternative definitions with explicit International Classification of Diseases, Ninth Revision, Clinical Modification, codes for sepsis, and separately for severe sepsis and septic shock.Measurements and main resultsThe primary outcomes were rate of 90-day all-cause hospital readmission after sepsis hospitalization and proportion of readmissions resulting from specific diagnoses, including the proportion of "potentially preventable" readmissions. Readmission diagnoses were similar from 2009 to 2011, with little variation in readmission rates across hospitals. The top six readmission diagnoses (heart failure, pneumonia, sepsis, urinary tract infection, acute renal failure, and chronic obstructive pulmonary disease) accounted for 30% of all readmissions. Although about one in five readmissions had a principal diagnosis for infection, 58% of all readmissions received early systemic antibiotics. Infection accounted for a greater proportion of readmissions among patients discharged to nursing facilities compared with patients discharged to home (25.0-27.1% vs. 16.8%) and among older vs. younger patients (22.2% vs. 15.8%). Potentially preventable readmissions accounted for a quarter of readmissions overall and were more common among older patients and patients discharged to nursing facilities.ConclusionsHospital readmission rates after sepsis were similar by site and admission year. Heart failure, pneumonia, sepsis, and urinary tract infection were common readmission diagnoses across all patient groups. Readmission for infection and potentially preventable diagnoses were more common in older patients and patients discharged to nursing facilities.

Project description:ImportanceThe Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.ObjectivesTo evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).Design, setting, and participantsThis cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.ExposuresAdmission for a primary diagnosis of heart failure at discharge.Main outcomes and measuresThirty-day all-cause readmission and mortality rates.ResultsA total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.Conclusions and relevanceIn this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.

Project description:ImportanceIncreasing regionalization of cancer surgery has the inadvertent potential to lead to fragmentation of care if readmissions occur at a facility other than the index hospital. The magnitude and adverse effects of readmission to a facility other than the one where the surgery was performed are unclear.ObjectivesTo assess rates of readmission to nonindex hospitals after major cancer surgery and to compare outcomes between index and nonindex hospital readmissions.Design, setting, and participantsIn this multicenter, population-based, nationally representative study of adult patients undergoing a major cancer operation (defined as esophagectomies or gastrectomies, hepaticobiliary resections, pancreatectomies, colorectal resections, or cystectomies), retrospective analyses were performed using the Nationwide Readmissions Database (admissions from January 1 through September 30, 2013). Descriptive analyses were performed to determine 90-day readmission characteristics, including timing, cost, and outcomes. Adjusting for clustering by facility, the study used multivariate logistic regression to identify factors associated with nonindex vs index readmissions. The study also used regression models to identify differences in mortality, major complications, and subsequent readmissions between the 2 groups. Data analysis was performed from January 1 through December 31, 2013.ExposuresReadmission to index vs nonindex hospitals (defined as any hospital other than the hospital where the major cancer operation was performed).Main outcomes and measuresProportion of 90-day readmissions and nonindex readmissions after major cancer surgery, factors associated with nonindex readmissions, and difference between in-hospital mortality, hospital costs, and subsequent readmissions for patients admitted to index vs nonindex hospitals.ResultsA total of 60 970 patients were included in the study (mean [SD] age, 67 [13] years; 7619 [55.6%] male and 6075 [44.4%] female). The 90-day readmission rate was 23.0%. Of the 13 695 first readmissions, 20.1% were to a nonindex hospital. Independent factors associated with readmission to a nonindex hospital included type of procedure, comorbidities (OR, 1.40; 95% CI, 1.15-1.70), elective admission (OR, 1.21; 95% CI, 1.06-1.37), discharge to a nursing facility (OR, 1.20; 95% CI, 1.07-1.36), and surgery at a teaching hospital (OR, 1.16; 95% CI, 1.00-1.34) (all P < .05). After risk adjustment, patients readmitted to nonindex hospitals had 31.2% higher odds of mortality (odds ratio, 1.31; 95% CI, 1.05-1.64) and 27.3% higher odds of having a major complication (odds ratio, 1.27; 95% CI, 1.14-1.42). Subsequent readmissions and hospital costs were not different between the 2 groups.Conclusions and relevanceApproximately one-fifth of readmissions were to a nonindex hospital and were associated with higher mortality and morbidity than readmission to index hospitals. Factors that influence nonindex readmissions have been identified to target interventions.

Project description:ImportancePrior studies have reported declines in mortality for patients admitted to Veterans Health Administration (VA) and non-VA hospitals using claims-based risk adjustment. These apparent mortality reductions may be influenced by changes in coding practices.ObjectiveTo compare trends in the VA for 30-day mortality following hospitalization for heart failure (HF) and pneumonia using claims-based and clinical risk-adjustment models.Design, setting, and participantsThis observational time-trend study analyzed admissions to a VA Medical Center with a principal diagnosis of HF, pneumonia, or sepsis/respiratory failure (RF) with a secondary diagnosis of pneumonia. Exclusion criteria included having less than 12 months of VA enrollment, being discharged alive within 24 hours, leaving against medical advice, and hospice utilization.ExposuresAdmission to a VA hospital from January 2009 through September 2015.Main outcomes and measuresThe primary outcome was 30-day, all-cause mortality. All models included age and sex. Claims-based covariates included 22 (30) comorbidities for HF (pneumonia). Clinical covariates included vital signs, laboratory values, and ejection fraction.ResultsAmong the 146 924 HF admissions, the mean (SD) age was 71.6 (11.4) years and 144 502 (98.4%) were men; among the 131 325 admissions for pneumonia, the mean (SD) age was 70.8 (12.3) years and 127 491 (97.1%) were men. Unadjusted 30-day mortality rates were 6.45% (HF) and 11.22% (pneumonia). Claims-based models showed an increased predicted risk of 30-day mortality over time (0.019 percentage points per quarter for HF [95% CI, 0.015 to 0.023]; 0.053 percentage points per quarter for pneumonia [95% CI, 0.043 to 0.063]). Clinical models showed declines or no change in predicted risk (-0.014 percentage points per quarter for HF [95% CI, -0.020 to -0.008]; -0.004 percentage points per quarter for pneumonia [95% CI, -0.017 to 0.008]). Claims-based risk adjustment yielded declines in 30-day mortality of 0.051 percentage points per quarter for HF (95% CI, -0.074 to -0.027) and 0.084 percentage points per quarter for pneumonia (95% CI, -0.111 to -0.056). Models adjusting for clinical covariates attenuated or eliminated these changes for HF (-0.017 percentage points per quarter; 95% CI, -0.039 to 0.006) and for pneumonia (-0.026 percentage points per quarter; 95% CI, -0.052 to 0.001). Compared with the claims-based models, the clinical models for HF and pneumonia more accurately differentiated between patients who died after 30 days and those who did not.Conclusions and relevanceAmong HF and pneumonia hospitalizations, adjusting for clinical covariates attenuated declines in mortality rates identified using claims-based models. Assessments of temporal trends in 30-day mortality using claims-based risk adjustment should be interpreted with caution.

Dataset Information

Association of Admission to Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia.

Publications

Association of Admission to Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia.

Similar Datasets

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