- VA Patients Have Fewer Potentially Avoidable Hospitalizations Post-Chemotherapy than Medicare Patients
The Centers for Medicare and Medicaid Services (CMS) released a new quality measure to reduce potentially avoidable hospital admissions among patients receiving outpatient chemotherapy. In this study, investigators used this CMS measure to compare the quality of care received by chemotherapy patients treated through traditional Fee-for-Service Medicare versus VA, using a cohort of dually-enrolled Veterans. Findings showed that Veterans with cancer receiving chemotherapy through VA have higher-quality care with respect to avoidable hospitalizations than Veterans receiving chemotherapy through Medicare. Roughly 7% of Veterans treated through Medicare had potentially avoidable hospitalizations in the 30 days following chemotherapy compared with approximately 5% of Veterans treated by VA. In the entire cohort, the top reasons for an avoidable hospitalization were
pneumonia (41%), sepsis (24%), anemia (21%), and pain (11%), though the order of frequency changed when evaluating Medicare versus VA treatment. This study was driven by recent legislation (Choice Act of 2014, MISSION Act of 2018) allowing Veterans to seek care in the private sector if VA care is difficult to access. As these policy changes are implemented, it is critical to understand whether this shift in system of care will impact care quality, especially for conditions as serious as cancer.
Date: July 15, 2020
- Anti-MRSA Therapy Associated with Greater 30-day Mortality Compared with Standard Therapy for Veterans with
This study sought to determine the association of empirical anti-MRSA therapy with 30-day mortality for Veterans hospitalized with
pneumonia. Findings showed that empirical anti-MRSA therapy was significantly associated with greater 30-day mortality compared with standard therapy alone. There was a significant increase in 30-day mortality associated with empirical anti-MRSA therapy plus standard therapy, compared with standard therapy alone, among patients admitted to the intensive care unit (ICU) and those with a high clinical risk for MRSA. Thus, investigators could establish no benefit of empirical anti-MRSA therapy, even when risk factors for MRSA were present or clinical severity warranted admission to the ICU. The use of anti-MRSA therapy also was associated with increased risk of kidney injury and secondary infections.
Date: February 17, 2020
- Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD
More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Of the Veterans with COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of
pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions.
Date: August 8, 2019
- Using Yelp, VA Hospitals Rated Higher than Affiliated Non-VA Hospitals
Online patient ratings of hospitals (e.g., Yelp) have been shown to correlate strongly with more conventional measures of patient satisfaction, as well as patient outcomes. Therefore, this study compared online hospital ratings from Yelp between VA hospitals and their local affiliated hospitals. Findings showed that VA hospitals had significantly higher Yelp ratings than non-VA-affiliated hospitals, suggesting better patient satisfaction. This was not explained by bed size or teaching status of the hospital. Although Yelp reviews describe patient experience, they also may be a marker of patient outcome. This study was not powered to detect differences in outcome; however, a different study found that high Yelp ratings were significantly associated with lower 30-day all-cause mortality following an admission for myocardial infarction or
pneumonia – and lower 30-day all-cause readmissions following a discharge for myocardial infarction, heart failure, or
Date: June 28, 2017
- ICU Treatment for Medicare Patients with
Pneumonia Associated with Better Outcomes without Increased Costs
This study sought to determine the association between ICU admission and outcomes, 30-day mortality, and costs among Medicare beneficiaries hospitalized for
pneumonia. To account for unmeasured confounding between groups (ICU vs. general ward admission), an instrumental variable (IV) was used – the differential distance to a high-ICU use hospital. Findings showed that ICU admission of those patients for whom the decision appeared to be discretionary (those meeting the IV criteria above, approximately 13% of the total sample) was associated with improved survival and no significant difference in costs. Patients living closer (<3 miles) to a high-ICU hospital were significantly more likely to be admitted to the ICU than patients living farther away (36% vs. 23%) – this was the basis of the IV analysis. In the IV analysis, ICU admission was associated with significantly lower 30-day mortality compared to general ward admission (15% vs. 21%), with a reduction in 30-day mortality of 6%. In the IV analysis, ICU admission was not associated with significant differences in total payment to Medicare or total hospital costs.
Date: September 22, 2015
- Comparing High-Dose Influenza Vaccine to Standard-Dose Vaccine among Elderly Veterans
This study assessed the relative effectiveness of high-dose (HD) influenza vaccination compared to standard-dose (SD) vaccination among Veterans 65 years and older who received either HD or SD vaccine during the 2010-2011 flu season. Findings showed that high-dose influenza vaccine was not more effective than standard-dose vaccine in protecting against hospitalization for influenza or
pneumonia in Veterans = 65 years of age; however, subgroup analysis found that it was more effective in Veterans =85 years of age. The rate of hospitalization for influenza or
pneumonia was 0.3% for Veterans in both the HD and SD groups during the influenza season. There were no significant differences in all-cause hospitalization and mortality between Veterans in the HD and SD groups.
Date: March 31, 2015
- Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and
pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and
pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
- Majority of Unplanned VA Hospital Readmissions Unrelated to Index Hospitalization
This study examined unplanned VA hospital readmissions – and compared the leading reasons for unplanned readmission between medical and surgical discharges. Findings showed that after excluding planned readmissions, 12% of all discharges were followed by an unplanned readmission within 30 days. Although nearly 42% of unplanned readmissions were identified as clinically related, the majority of unplanned VA hospital readmissions were unrelated to the index hospitalization for both surgical and medical discharges. The top five reasons for hospital readmission among medical discharges included: non-hypertensive heart failure (HF; 8%),
pneumonia (5%), chronic obstructive pulmonary disease (5%), urinary tract infections (UTI, 3%), and fluid and electrolyte disorders (3%). Among surgical discharges, complications of surgical procedures or medical care (22%) or devices (7%) accounted for nearly 75% of the top five reasons for readmissions; the remaining three included HF, UTI, and
pneumonia. These findings suggest that most hospital readmissions might reflect clinical and social factors, including the severity of the patient’s condition, inadequate social support, or post-discharge factors (e.g., lack of coordination between inpatient and outpatient settings). Thus, quality improvement interventions should target those processes of care that may decrease related risks.
Date: March 1, 2014
- Improvement in VA Patient Outcomes Related to Pay-for-Performance Remains after Removal of Incentives
This study sought to investigate the sustainability of performance levels following removal of performance-based incentives. Findings showed that performance improvements that occurred across 128 VA hospitals for three common conditions among Veterans – acute coronary syndrome, heart failure, and
pneumonia – were sustained for up to three years after performance-based incentives were removed. For six of the seven performance measures, mean performance was over 90% prior to removal of the incentives. The only measure that did not demonstrate significant improvement over the study period was the heart failure measure for ACE-inhibitor/ARB therapy prior to admission.
Date: August 9, 2013
- Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization
The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure,
pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics.
Date: March 26, 2013
- Previous Hospital Readmission Rates for Three Common Conditions are Poor Predictors for Future Readmission
This study sought to assess whether historic hospital readmission rates predict risk-adjusted patient readmission – and to measure the costs of readmission. Findings showed that previous hospital readmission rates are poor predictors of readmission for future individual patients, so policies using these meaures to guide subsequent reimbursement might prove problematic.
Patients who are readmitted do have substantially higher episode costs, even after conventional risk adjustment. Being readmitted increased total episode cost by 53% for Veterans with acute myocardial infarction, 83% for Veterans with community-acquired
pneumonia, and 80% for Veterans with congestive heart failure.
Date: January 1, 2013
- Decreases in VA Hospital Length-of-Stay and Readmission Rates over 14 Years
This study sought to determine trends in hospital length of stay (LOS) and 30-day readmission rates in the VA healthcare system. Findings showed that VA hospitals demonstrated simultaneous improvements in hospital LOS and readmission rates from 1997 to 2010. This demonstrates that LOS reductions have not, thus far, adversely affected the likelihood of hospital readmission. For all medical diagnoses combined, the risk-adjusted mean hospital LOS decreased by 2% annually. Reductions in LOS also were observed for five specific common diagnoses, with the greatest reductions for acute myocardial infarction (2.9 days) and
pneumonia (2.2 days). Risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 17% to 14%. Reductions also were observed for the five common diagnoses, with greatest reductions for AMI (23% to 20%) and COPD (18% to 15%). All-cause mortality 90 days after admission was reduced by 3% annually.
Date: December 18, 2012
- Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for
pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
Date: August 24, 2011
- Adverse Post-Operative Events More Common among Current Veteran Smokers Compared with Prior or Non-Smokers
This study assessed the attributable risk and potential benefits of smoking cessation on surgical outcomes for Veterans who underwent non-cardiac, elective surgery in a VA hospital between 2002 and 2008. Findings showed that compared with both never and prior smokers – and controlling for patient and procedure risk factors – Veterans who were current smokers had significantly more post-operative
pneumonia and surgical-site infection, despite being younger and having fewer comorbidities. Moreover, current smokers had increased odds of dying up to one year after surgery compared with prior smokers or Veterans who had never smoked. There was a dose-dependent increase in pulmonary complications based on pack-year exposure (one pack-year equals smoking 20 cigarettes a day for one year), with greater than 20 pack-years leading to a significant increase in smoking-related surgical complications. Previous literature suggests that pre-operative quit smoking interventions may reduce the risk of post-operative complications. Authors suggest that smoking cessation intervention be considered for Veterans who are current smokers, with greater than 20 pack-years of exposure, who undergo major surgical procedures.
Date: August 24, 2011
- Positive Effect of Pay-for-Performance May Not be Long Term
The Affordable Care Act of 2010 establishes a pay-for-performance program for hospitals. This program, which will take effect in 2013, includes all U.S. acute care hospitals and will be similar to an ongoing hospital pay-for-performance demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS). This study examined the results of the CMS demonstration project in non-VA hospitals in order to inform efforts to implement pay-for-performance across all U.S. hospitals through the Affordable Care Act. Findings showed that although hospital performance improved under the pay-for-performance demonstration project, the effect was short-lived. By the end of the five-year study period, performance in control hospitals matched that in pay-for-performance hospitals. Over the first three years of the pay-for-performance demonstration project, participating hospitals had better average overall performance than hospitals that did not participate for all three conditions (acute myocardial infarction, heart failure,
pneumonia). However, non-pay-for-performance hospitals caught up by the fourth and fifth years of this study. Performance scores were highest among hospitals that were eligible for larger bonuses, were well-financed, or operated in less competitive markets.
Date: April 1, 2011
- Relationship between Cost of Care and Quality of Care for Two Conditions in Non-VA Hospitals
The relationship between (non-VA) hospitals’ cost of care and quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or
pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher quality-of-care scores and lower mortality. For
pneumonia, the opposite was true: high-cost hospitals had lower quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and
pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
Date: February 22, 2010
- Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial
Date: October 1, 2009
- Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with
Time to first antibiotic dose (TFAD) is an important quality indicator for
pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted quality improvement approaches and a top-down hospital leadership style to improve performance on this
pneumonia quality measure.
Date: October 1, 2009
- ACE Inhibitors May Benefit Patients with
Prior outpatient use of lipophilic, but not hydrophilic ACE inhibitors was associated with decreased 30-day mortality for patients hospitalized with community-acquired
pneumonia. Study results also provide further support demonstrating that ACE inhibitor use, in general, is associated with decreased mortality for patients with
Date: December 1, 2008
- Quality Improvement Collaborative Improves ICU Care for Veterans
This study focused on two “bundles” (ventilator bundle and central line insertion bundle) – tools designed to facilitate the application of best practices and evidence-based care at the bedside. Using these bundles, the goals were to increase adherence with specific evidence-based ICU practices, and to determine whether this would promote additional and sustained quality improvement across VISN 23. Adherence with all five elements of the ventilator bundle improved to 82% in the final three months of the intervention. The use of a central line insertion checklist to monitor adherence with the central line bundle increased to 74% in the final three months of the intervention. In addition, the implementation of the ventilator and central line bundles was associated with a reduction in rates of ventilator-associated
pneumonias and catheter-related blood stream infections, respectively.
Date: November 1, 2008