For vets rushed by ambulance to an ER, VA hospitals yield higher survival rates

Veterans taken by ambulance to Veterans Affairs hospitals had a roughly 20% better survival rate in the subsequent 30 days than those taken to non-VA hospitals, according to a new study by researchers at Stanford Health Policy and their colleagues.

The advantage was even greater for Black and Latino veterans, the researchers found.

For decades, there has been debate about the quality and accessibility of care provided by the VA system, in part fueled by concerns about the Veterans Health Administration’s monolithic nature and a lack of choice for vets about where they can receive care. Congress and the Obama and Trump administrations responded with reforms enabling veterans to opt for care in the private sector.

“We’ve known from many other studies that the VA provides higher-quality care, reflected in process measures, but it’s been difficult to compare patients who receive care in the VA and those who receive care outside of it,” said David Chan, MD, PhD, associate professor of health policy at Stanford and lead author of the study published in BMJ on Feb. 16.  

“Veterans tend to be sicker than nonveterans,” said Chan, who is a core faculty member of the Department of Health Policy at the Stanford University School of Medicine and an investigator at the Department of Veterans Affairs. “When we designed this study of veterans who could plausibly receive care in either a VA or non-VA setting during an emergency, we were struck by the implied mortality reduction among those going to the VA.”

The researchers acknowledge the public often perceives that the VA provides a lower quality of care, but said the data disprove those perceptions.

“Widely publicized concerns about the quality and capacity of the VA system, the largest public health delivery system in the U.S., have fueled public perceptions that the VA health system is falling short of providing good care to the many veterans who depend on it,” the authors wrote. “Our findings join those from a series of other studies in suggesting that, for the system as a whole, those perceptions do not match reality.”

Study methods and findings

The study sample consisted of some 583,000 veterans older than 65 who were rushed to a hospital for emergency care between January of 2001 and November of 2018. Because these veterans were dually enrolled for VA care and non-VA care financed by Medicare, the authors reasoned there was an element of chance in where they were taken, with many taken to the nearest hospital.

To account for differences in health status between the patients taken to VA hospitals, as opposed to non-VA hospitals, the researchers also adjusted for ZIP code of residence, demographic characteristics (age, race or ethnicity, and gender) and a slew of other variables.

“It was remarkable that, of the 50 subgroups of patients we examined, none experienced significantly lower mortality rates at non-VA hospitals,” the authors wrote.

Of the patients taken to VA hospitals, 9.3% died within 30 days, compared with 11.7% of the patients taken to non-VA hospitals. This corresponds to a 20.1% lower mortality rate among patients taken to a VA hospital. For Black and Latino patients, the mortality rates were even lower: 24.8% and 22.7% lower, respectively.

The researchers said the positive balance toward the VA emergency care is possibly a result of improved information technology systems and the integration of care.

“Enabling or encouraging veterans to obtain care outside of the VA system may lead to worse, not better, health outcomes, particularly for veterans with established care relationships at VA facilities,” the researchers said.

We were struck by the implied mortality reduction among those going to the VA.

They found that mortality rates also were lower for veterans who were taken by ambulance to hospitals where they had previously received outpatient and inpatient care.

“The extent to which VA hospitals outperform other types of hospitals, and in what specific facets of care, should continue to be studied,” the researchers wrote. “At the same time, mounting evidence of superior performance justifies a redoubling of efforts to understand how the VA system achieves this. As well as helping the VA to improve care processes and outcomes, those insights may produce valuable lessons for health care delivery systems globally.”

Largest health care system

The Veterans Health Administration is the largest health care delivery system in the country, with 171 hospitals and 1,112 clinics that provide care to more than 9 million military veterans and their families. That care is financed by the federal government, delivered by federal employees and free to enrolled veterans.

“The findings of this paper will help guide VHA Emergency Medicine to optimize emergency care in the community and inside the VA,” said Chad Kessler, MD, executive director of emergency medicine at the VHA. “Furthermore, the data helps us better understand the quality and cost of emergency care across the spectrum. The results will help define the direction and future growth of emergency medicine for veterans.”

Chan said the research “may also have lessons for rest of the U.S. about the optimal design of health care delivery.”

The researchers used data on veterans and their VA care from the Corporate Data Warehouse, a repository of administrative and clinical data for the VA. For non-VA and ambulance care, the researchers obtained data on Medicare claims associated with each veteran in the study.

Other Stanford co-authors of the study are David Studdert, LLB, ScD, professor of health policy and of law, and graduate student Sydney Costantini.

Researchers at UC Berkeley and Carnegie Mellon University contributed to the work.

The study was supported by the National Institutes of Health Director’s Early Independence Award (1DP5OD019903-01) and the VA Health Services Research and Development Merit Award.