Reducing avoidable deaths among veterans: directing private-sector surgical care to high-performance hospitals

Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals?

CONTEXT

Unplanned readmission within 30 days of discharge is an indicator of hospital quality.

PURPOSE

We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts.

METHODS

We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity.

FINDINGS

Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital.

CONCLUSIONS

Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.

Rural veterans and access to high-quality care for high-risk surgeries

OBJECTIVES

To determine whether older Veterans Health Administration (VA) health care enrollees obtain most high-risk surgeries in non-VA hospitals under Medicare, whether residence in less populous areas increases this reliance on non-VA care or the likelihood of obtaining it in hospitals with higher mortality rates, and whether directing VA enrollees to better hospitals would add a substantial travel burden.

DATA SOURCES

VA and Medicare hospital discharge data from 2000 and 2001 for VA enrollees 65 years or older who received any of 14 high-risk elective procedures, including heart, vascular, and cancer surgeries. STUDY DESIGN/DATA EXTRACTION: We compared urban, suburban, and rural patients on use of VA versus non-VA hospitals, use of non-VA hospitals of higher versus lower mortality rates, travel times to get to these hospitals, and the additional travel burden if they had gone to lower mortality hospitals.

PRINCIPAL FINDINGS

Regardless of residence, VA enrollees obtained most high-risk surgeries in non-VA hospitals. Urban veterans were most likely to get heart or cancer surgeries in lower mortality hospitals, but rural veterans were most likely to get vascular surgeries in lower mortality hospitals. Average travel times to lower or higher mortality hospitals did not differ greatly.

CONCLUSIONS

Accessing better hospitals need not add a great travel burden for rural veterans.