VA offers model for achieving quality, efficiencies

Veterans Affairs hospitals simultaneously shortened hospital length of stays (LOS) and reduced readmissions for heart failure and acute MI, according to an analysis published Dec. 18 in the Annals of Internal Medicine. The results underscore how the VA system can serve as a model for the hospitals and providers, according to the lead author and the writers of an accompanying editorial.

Several factors have contributed to trends showing shorter LOS in hospitals within the VA system and without, said Peter J. Kaboli, MD, of the Iowa City Veterans Affairs Healthcare System in Iowa City, Iowa. Those include the growing practice of assigning hospitalists such as Kaboli to coordinate patient care as well as administrative pressures to reduce cost. “Because of this pressure, we were concerned that at some point we would reach this tipping point where systematically [hospitals] are sending people home too soon,” he said in an interview with Cardiovascular Business.

Kaboli and colleagues designed their study to explore trends in LOS and hospital readmission for five common conditions: heart failure, chronic obstructive pulmonary disease, acute MI, community-acquired pneumonia and gastrointestinal hemorrhage. They used administrative data in the VA Patient Treatment File to obtain admissions, demographic characteristics, diagnoses, discharge and other data for more than 4 million medical admissions at 129 VA hospitals during fiscal years 1997 to 2010. Their primary outcomes were hospital LOS and hospital readmission rate with a secondary outcome of death within 30 or 90 days of admission in the hospital or after discharge.

For all diagnoses combined, they calculated that the risk-adjusted mean LOS decreased from 5.44 to 3.98 days over the study period, with the greatest reductions in acute MI at 2.85 days. The mean LOS for heart failure decreased from 6.33 to 4.40 days.

Risk-adjusted 30-day readmission rates for all diagnoses dropped from 16.5 to 13.8 percent, with acute MI again showing the greatest reduction with a 2.8 percentage point decline.  Heart failure readmission rates fell from 20.4 to 19 percent.

All-cause mortality also was reduced by 3 percent annually. The researchers noted that hospitals with a mean risk-adjusted LOS that was a day lower than the average had a 6 percent higher readmission rate compared with hospitals with an average LOS. They also found that patients with longer than average LOS had higher readmission rates.

“Patients who stay in the hospital longer are sicker; they have more comorbidities,” Kaboli explained. “Sick people need hospitals.”

He pointed out that in some cases readmission is a proper step in a patient’s care, and reasons ranging from patient choice to financial pressures may drive trends to discharge patients who are then readmitted. “It is not a linear relationship.”

In an accompanying editorial, Eugene Z. Oddone, MD, and Morris Weinberger, PhD, both of the  Center for Health Services Research in Primary Care at the Durham Veterans Affairs Center in Durham, N.C., claimed that readmission rates may be a poor measure of quality because they fail to account for the many factors that affect a complex patient’s care. Nonetheless they wrote that efforts to reduce preventable readmission should continue. “However, we must understand that hospital readmissions are not solely, or even minimally, the fault of the hospitals.”

Oddone and Weinberger wrote that the authors listed the fact that the study was in a single healthcare system as a limitation. “That statement is included in all articles from VA administrators. Perhaps it is time to embrace the VA as the largest U.S. accountable care organization,” they proposed. “Let the VA serve as an example of how to enhance both efficiency (reduced LOS) and quality (reduced readmission rates and mortality).”

Kaboli and the editorial writers emphasized that the VA offered a model for other hospitals and providers. “You can improve efficiency and you can improve readmission at the same time if you look at quality very globally, and work at many aspects related to quality and not focus on one thing,” Kaboli said.