Veterans Transported to VA Hospitals by Ambulance Have Substantially Lower Mortality Rates than Veterans Taken to Non-VA Hospitals
Prompted by concerns about VA’s monolithic nature and the lack of choice Veterans had about where to obtain their care, reforms were enacted to enable Veterans to obtain care in the private sector. These reforms were based, at least in part, on a premise that Veterans could obtain better care outside VA. This retrospective cohort study analyzed a national cohort of 583,248 Veterans (age 65 and older) who were enrolled in both the VA and Medicare programs. These Veterans were transported by ambulance to either a VA or non-VA hospital for emergency treatment between 2001 and 2018. The study calculated Veterans’ risk of mortality following these visits (140 VA and 2,622 non-VA hospitals across 46 states and the District of Columbia). In addition to adjusting for characteristics of the ambulance ride (i.e., its origin, life support capabilities, primary diagnosis), investigators adjusted for patient characteristics, including comorbidities.
- Veterans transported to VA hospitals had substantially lower risk of death within one month than those transported to non-VA hospitals. The absolute difference of 2.35 deaths per 100 patients corresponds to a 20% lower mortality rate among Veterans taken to VA hospitals.
- The mortality advantage was particularly large for Hispanic patients (23% lower in VA), Black patients (26% lower), patients aged 65-74 (27% lower), and patients who arrived with a relatively low mortality risk (32% lower). Further, of the 50 subgroups of Veterans examined in this study, none experienced significantly lower mortality rates at non-VA hospitals.
- Patients taken to VA hospitals were more likely to be Black and to have used VA care in the prior year; they also were more likely to have mental health and substance use disorders.
- Enabling or encouraging Veterans to obtain care outside the VA system may lead to worse—not better—health outcomes, particularly for Veterans with established care relationships at VA facilities. At the same time, mounting evidence of superior performance justifies a redoubling of efforts to understand how the VA system achieves this, which may produce valuable lessons for VA as well as healthcare delivery systems globally.
- Despite the sensitivity analyses, there may still have been systematic differences between patients taken to VA and non-VA hospitals, and those differences may be associated with mortality risk.
This study was funded by HSR&D (IIR 18-146). Dr. Chan is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.
Chan D, Danesh K, Costantini S, Card D, Taylor L, Studdert D. Mortality among US Veterans After Emergency Visits to Veterans Affairs and Other Hospitals: Retrospective Cohort Study. The British Medical Journal. February 16, 2022; 376:e068099.