Vaughan Sarrazin Mary, Gao Yubo, Jacobs Carly A, Jacobs Michael A, Schmidt Susanne, Davila Heather, Hadlandsmyth Katherine, Strayer Andrea L, Cashy John, Wehby George, Shireman Paula K, Hall Daniel E
Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City.
Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City.
JAMA Netw Open. 2024 Dec 2;7(12):e2452056. doi: 10.1001/jamanetworkopen.2024.52056.
The Veterans Health Administration (VHA) reports multiple indicators of hospital surgical performance, including hospital risk-standardized 30-day readmission rates (RSRRs). Currently, most routinely reported measures do not include readmissions that occur outside VHA hospitals. The impact of readmissions outside the VHA on hospital RSRR is not known.
To measure the impact of including non-VHA readmissions on VHA hospital performance rankings for 30-day readmission.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included patients aged at least 65 years from 2013 to 2019 from the Veterans Affairs Surgical Quality Improvement Program linked to patient-level data from the VHA and Medicare. Data were limited to patients with VHA and Medicare enrollment during the year prior to surgery. Data were analyzed from November 2023 through July 2024.
The main outcome was readmissions to acute care VHA or non-VHA hospitals within 30 days of discharge. VHA hospital-level RSRRs were estimated using separate generalized linear mixed-effects risk adjustment models that alternatively included VHA-only or VHA plus non-VHA readmissions. VHA hospitals were then stratified into quintiles based on RSRRs derived using VHA-only or VHA plus non-VHA readmissions. Changes in hospital performance quintiles with the addition of non-VHA readmissions were calculated, and characteristics of VHA hospitals most impacted by including non-VHA readmissions were evaluated.
The eligible cohort included 108 265 patients (mean [SD] age, 72.2 [6.5] years; 105 661 [97.6%] male) who underwent surgery in 104 VHA hospitals. The combined readmission rate was 14.0%. The proportion of readmissions occurring outside the VHA ranged from 0% to 55.3% across the 104 VHA hospitals (median, 20.9%). Using VHA and non-VHA readmissions, 24 VHA hospitals (23.1%) improved performance and 23 hospitals (22.1%) worsened performance, defined as a decrease or increase, respectively, of 1 or more RSRR quintiles. Improvements in hospital performance rank were associated with larger surgical volume (-7.48; 95% CI, -11.33 to 03.64; P < .001), urban location, greater surgical complexity (-9.86; 95% CI, -16.61 to -3.11; P = .005), and lower proportion of readmissions outside the VHA (-8.15; 95% CI, -12.75 to -3.55; P < .001).
In this cohort study, VHA hospitals whose readmission performance metric improved by including non-VHA readmissions had higher patient volume, higher complexity, and lower proportion of care outside the VHA. Thus, improving continuity of care may have a paradoxical effect of worsening VHA performance metrics.
退伍军人健康管理局（VHA）报告了多项医院手术表现指标，包括医院风险标准化30天再入院率（RSRR）。目前，大多数常规报告的指标不包括在VHA医院以外发生的再入院情况。VHA以外的再入院对医院RSRR的影响尚不清楚。
评估将非VHA再入院情况纳入考量对VHA医院30天再入院表现排名的影响。
设计、设置和参与者：这项回顾性队列研究纳入了2013年至2019年年龄在65岁及以上、参与退伍军人事务部手术质量改进计划的患者，并将其与VHA和医疗保险的患者层面数据相链接。数据仅限于手术前一年同时参加VHA和医疗保险的患者。数据于2023年11月至2024年7月进行分析。
主要结局是出院后30天内再次入住急性护理VHA或非VHA医院。使用单独的广义线性混合效应风险调整模型估计VHA医院层面的RSRR，这些模型分别纳入仅VHA或VHA加非VHA再入院情况。然后根据仅使用VHA或VHA加非VHA再入院情况得出的RSRR，将VHA医院分为五等份。计算加入非VHA再入院情况后医院表现五分位数的变化，并评估受纳入非VHA再入院情况影响最大的VHA医院的特征。
符合条件的队列包括104家VHA医院的108265例患者（平均[标准差]年龄为72.2[6.5]岁；105661例[97.6%]为男性），这些患者接受了手术。综合再入院率为14.0%。在104家VHA医院中，VHA以外发生的再入院比例从0%到55.3%不等（中位数为20.9%）。使用VHA和非VHA再入院情况，24家VHA医院（23.1%）表现改善，23家医院（22.1%）表现恶化，分别定义为RSRR五分位数下降或上升1个及以上。医院表现排名的改善与手术量较大（-7.48；95%CI，-11.33至-3.64；P<.001）、城市位置、手术复杂性较高（-9.86；9%CI，-16.61至-3.61；P=.005）以及VHA以外再入院比例较低（-8.15；95%CI，-12.75至-3.55；P<.001）相关。
在这项队列研究中，通过纳入非VHA再入院情况而使再入院表现指标得到改善的VHA医院，患者数量更多、复杂性更高，且VHA以外的护理比例更低。因此，改善护理连续性可能会产生使VHA表现指标恶化的矛盾效果。
