Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, South Carolina, USA.
Division of General Internal Medicine, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
Health Serv Res. 2024 Oct;59(5):e14332. doi: 10.1111/1475-6773.14332. Epub 2024 Jun 2.
To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation.
VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets.
Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation.
DATA COLLECTION/EXTRACTION METHODS: Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021.
Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively.
MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.
研究《维护内部系统和加强外部综合网络法案》（MISSION）实施后退伍军人住院趋势和医疗保健利用的变化。
VA 公司数据仓库和医疗保险和医疗补助服务数据集。
回顾性队列研究，根据支付方类型（VA 医疗机构住院、VA 资助社区医疗机构住院或医疗保险资助社区医疗机构住院），比较指数住院后 7 天和 30 天计划内再入院和急诊就诊率。使用分段回归模型比较支付方，并估计 MISSION 法案实施后结果水平和斜率的变化。
数据收集/提取方法：2016 年 1 月 1 日至 2021 年 12 月 31 日期间，VA 初级保健服务利用和≥1 次急性住院的退伍军人。
所有支付方的每月指数住院增加，直到 MISSION 法案实施，在此期间，VA 和 CMS 入院减少，而 CC 入院加速并超过 VA 入院。在 2021 年 12 月，CC 入院占指数入院的 54%，高于 2016 年 1 月的 25%。从调整后的模型来看，就在实施之前（2019 年 5 月），与 VA 入院相比，CC 入院的退伍军人有 47%的 7 天再入院风险增加（风险比[RR]：1.47，95%置信区间[CI]：1.43，1.51）和 20%的 30 天再入院风险增加（RR：1.20，95% CI：1.19，1.22）；这两种影响在实施后仍然存在。实施前 CC 入院还与 7 天和 30 天急诊就诊的风险增加有关，但在研究结束时（RR：0.90，95% CI：0.88，0.91）和（RR：0.89，95% CI：0.87，0.90），这两种风险都大大降低。
MISSION 法案的实施与退伍军人住院治疗场所和联邦支付方的重大转变有关。实施后，CC 和 CMS 指数入院的退伍军人再入院风险估计更高，而与 VA 指数入院相比，CC 指数入院后急诊就诊的风险估计更低。需要进一步调查这种差异的原因。
