Veterans Mortality Risk Reduced When Given Ambulatory Care at VA Hospitals

David C. Chan, MD, PhD

Veterans treated for emergency care at Veterans Affairs (VA) hospitals have a significantly reduced risk of death versus those treated at non-VA hospitals, according to findings from a new retrospective cohort analysis.

The findings from a team of Stanford-based investigators showed the mortality risk benefit was even more pronounced with minority veterans treated at VA hospitals at which they were previously treated—bucking the notion that the VA system is generally lackluster for veteran patients.

Led by David C. Chan, MD, PhD, a Professor of Health Policy at Stanford University and an investigator with the Department of Veterans Affairs in Palo Alto, the investigators sought to measure and compare mortality outcomes with dually-eligible veterans receiving ambulatory care at a VA hospital versus those transported to a non-VA hospital.

As they noted, the VA—currently comprised of 171 hospitals and 1112 clinics providing care to 9 million-plus military veterans and their families—has been debated for its quality and accessibility of care since its inception as the federally-funded health service.

Concerns regarding the VA’s “monolithic nature” and limited care options for veterans have led national discourse, investigators wrote, and previous presidential administrations enacted reforms that enabled veterans to opt for privately-insured health care.

“The reforms are based, at least in part, on a premise that veterans can obtain better care outside the VA healthcare system,” Chan and colleagues wrote. “Available evidence calls this premise into question.”

The team sought to complement such evidence with their assessment, which included retrospective cohort data from emergency visits by ambulance to 140 VA and 2622 non-VA hospitals across 46 US states and Washington, DC, from 2001 to 2018.

The data derived from medical charts and administrative files included 583,247 veterans aged ≥65 years old. Eligible patients were enrolled in both the Veterans Health Administration and Medicare programs and resided within 20 miles of ≥1 VA hospital and ≥1 non-VA hospital.

Investigators sought a primary outcome of deaths in the 30 days following the patient’s initial ambulance ride. Chan and colleagues used linear probability models of mortality, adjusting for demographics, area of residence, comorbid conditions, and other relevant variables.

Of the team’s observed 1,470,517 ambulance rides, 231,611 (15.8%) went to VA hospitals while the remaining (84.2%) went to non-VA hospitals. Investigators observed 20.1% lower adjusted mortality rate at 30 days among older veteran patients taken to VA hospitals versus those taken to a non-VA hospital. Comparatively, VA hospitals observed 9.32 deaths per 100 ambulatory patients (95% CI, 9.15 - 9.50), versus 11.67 (95% CI, 11.58 - 11.76) at non-VA hospitals.

Additionally, investigators observed even greater reduced mortality among Black and Hispanic veteran patients treated at VA hospitals when they were familiar with the hospital—reductions of 25.8% and 22.7%, respectively, compared to similar patients treated at non-VA hospitals.

Investigators observed 50 patient subgroups in the analyses; none reported a significantly lower mortality rate when treated for ambulatory care at a non-VA hospital versus a VA hospital.

The team did acknowledge limitations including risk of confounding data and uncertainty of similar outcomes being observed for younger veteran patients. Though they can only speculate as to what mechanisms may inform the observed correlation, they conceived several ideas of note.

“The VA has long provided integrated healthcare, supported by an advanced health information technology system, whereas movement toward electronic health records at non-VA hospitals has been substantially delayed,” they explained. “ Other distinctive features of the VA system include organization around primary care, minimal cost sharing for veterans, and a salaried approach to physician payment that avoids incentives to over-treat or under-treat that are common in private payment models.”

The team concluded that the findings support the continued benefit of VA hospital systems—at least for mortality risk reduction in ambulatory, older patients—at the risk of considering privately-insured non-VA hospital care.

“At the same time, increasing evidence of superior performance justifies a redoubling of efforts to understand how the VA system achieves this,” they wrote. “As well as helping the VA to improve care processes and outcomes, those insights could produce valuable lessons for healthcare delivery systems globally.”

The study, “Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study,” was published online in The BMJ.