Evaluation of Changes in Veterans Affairs Medical Centers’ Mortality Rates After Risk Adjustment for Socioeconomic Status

Amal N Trivedi,Michael J Fine,Roee Gutman,Wen-Chih Wu,Lan Jiang,Vincent Mor,Gabriella Silva,Nancy R Kressin

doi:10.1001/jamanetworkopen.2020.24345

Abstract

Socioeconomic factors are associated with worse outcomes after hospitalization, but neither the Centers for Medicare & Medicaid Services (CMS) nor the Veterans Affairs (VA) health care system adjust for socioeconomic factors in profiling hospital mortality. To evaluate changes in Veterans Affairs medical centers' (VAMCs') risk-standardized mortality rates among veterans hospitalized for heart failure and pneumonia after adjusting for socioeconomic factors. In this cross-sectional study, retrospective data were used to assess 131 VAMCs' risk-standardized 30-day mortality rates with or without adjustment for socioeconomic covariates. The study population included 42 892 veterans hospitalized with heart failure and 39 062 veterans hospitalized with pneumonia from January 1, 2012, to December 31, 2014. Data were analyzed from March 1, 2019, to April 1, 2020. The primary outcome was 30-day mortality after admission. Socioeconomic covariates included neighborhood disadvantage, race/ethnicity, homelessness, rurality, nursing home residence, reason for Medicare eligibility, Medicaid and Medicare dual eligibility, and VA priority. The study population included 42 892 veterans hospitalized with heart failure (98.2% male; mean [SD] age, 71.9 [11.4] years) and 39 062 veterans hospitalized with pneumonia (96.8% male; mean [SD] age, 71.0 [12.4] years). The addition of socioeconomic factors to the CMS models modestly increased the C statistic from 0.77 (95% CI, 0.77-0.78) to 0.78 (95% CI, 0.78-0.78) for 30-day mortality after heart failure and from 0.73 (95% CI, 0.72-0.73) to 0.74 (95% CI, 0.73-0.74) for 30-day mortality after pneumonia. Mortality rates were highly correlated (Spearman correlations of ≥0.98) in models that included or did not include socioeconomic factors. With the use of the CMS model for heart failure, VAMCs in the lowest quintile had a mean (SD) mortality rate of 6.0% (0.4%), those in the middle 3 quintiles had a mean (SD) mortality rate of 7.2% (0.4%), and those in the highest quintile had a mean (SD) mortality rate of 8.8% (0.6%). After the inclusion of socioeconomic covariates, the adjusted mean (SD) mortality was 6.1% (0.4%) for hospitals in the lowest quintile, 7.2% (0.4%) for those in the middle 3 quintiles, and 8.6% (0.5%) for those in the highest quintile. The mean absolute change in rank after socioeconomic adjustment was 3.0 ranking positions (interquartile range, 1.0-4.0) among hospitals in the highest quintile of mortality after heart failure and 4.4 ranking positions (interquartile range, 1.0-6.0) among VAMCs in the lowest quintile. Similar findings were observed for mortality rankings in pneumonia and after inclusion of clinical covariates. This study suggests that adjustments for socioeconomic factors did not meaningfully change VAMCs' risk-adjusted 30-day mortality rates for veterans hospitalized for heart failure and pneumonia. The implications of such adjustments should be examined for other quality measures and health systems.

Highlights

Most hospitals in the United States, including all Veterans Affairs medical centers (VAMCs), report mortality rates for patients hospitalized for common medical and surgical conditions.[1]
The study population included 42 892 veterans hospitalized with heart failure (98.2% male; mean [SD] age, 71.9 [11.4] years) and 39 062 veterans hospitalized with pneumonia (96.8% male; mean [SD] age, 71.0 [12.4] years)
The addition of socioeconomic factors to the Centers for Medicare & Medicaid Services (CMS) models modestly increased the C statistic from 0.77 to 0.78 for 30-day mortality after heart failure and from 0.73 to 0.74 for 30-day mortality after pneumonia

Summary

Introduction

Most hospitals in the United States, including all Veterans Affairs medical centers (VAMCs), report mortality rates for patients hospitalized for common medical and surgical conditions.[1]. The Centers for Medicare & Medicaid Services (CMS) adjust payments to hospitals based on their performance on quality-of-care measures, including hospital mortality rates after acute myocardial infarction, heart failure (HF), and pneumonia.[2] Hospital mortality rates inform the Veterans Affairs (VA) Strategic Analytic and Information Learning ratings, which the VA health system uses to measure performance in VAMCs.[3] The Veterans Access, Choice, and Accountability Act of 2014 requires the VA health system to release comprehensive data to the public on access to, quality of, and outcomes of care, including hospital mortality. Despite emerging consensus from stakeholder groups that profiling performance should include consideration of patients’ sociodemographic characteristics, neither CMS nor the VA health system include sociodemographic factors other than age and sex in risk-adjusted models of hospital mortality.[9,12,13,14,15] The 21st Century Cures Act requires CMS to adjust financial penalties (but not riskstandardized readmission rates) based on the hospitals’ proportion of patients with dual Medicaid and Medicare eligibility.[16]

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Results

Discussion

Conclusion