October 22, 2003
HOUSTON, TX - Survival rates among chronically ill veterans remained constant in the mid-1990s despite a sharp reduction in hospital-based care provided by the Veterans Affairs (VA) health care system, report researchers in the Oct. 23 New England Journal of Medicine. The study is the largest assessment to-date of the impact on veterans of VA's shift nearly a decade ago from a hospital-based system to one focused on primary and outpatient care.
Researchers at VA's Houston Center for Quality of Care and Utilization Studies (HCQCUS) and Baylor College of Medicine studied the records of 342,300 chronically ill veterans to track their health care and survival between 1994 and 1998. A reorganization of VA health care began in 1995, geared toward reducing hospital usage and emphasizing more efficient and comprehensive care through VA primary care physicians and outpatient clinics.
According to the study, VA hospital stays fell by 50 percent and outpatient care increased moderately. Patient survival rates remained largely unchanged. The researchers also found no increase in the use of non-VA hospitals by those VA beneficiaries also covered by Medicare. That would have meant taxpayer savings on VA health care were eaten up by larger Medicare expenses.
"One remarkable finding was that Medicare-eligible veterans in our study did not significantly increase their use of Medicare-paid hospital days during the time when VA hospitalization rates were falling" said lead author Dr. Carol Ashton, director of HCQCUS and a professor of medicine at Baylor.
The researchers also found no hike in emergency-room visits. The patients included in the study had serious illnesses such as lung, kidney or heart disease, so scaling back regular hospital admissions might have forced the need for more emergency care.
"We thought emergency and urgent-care visits would increase or survival rates would drop if access to hospital care was reduced too much, or if decreased hospital use was not balanced by improvements in outpatient care," said Ashton.
The researchers studied VA's sickest patients because they reasoned any adverse effects from the reduction in hospital services would be felt most by those with serious chronic illnesses. They cite at least three possible reasons why these veterans did not appear to suffer from the hospital cutbacks: First, VA was providing more hospital care than patients really needed, so the cutbacks merely reduced waste without affecting vital services. Second, the reorganization resulted in improved and expanded primary and outpatient care. Third, advances in health care during the study period-such as the advent of angiotensin-converting-enzyme (ACE) inhibitors for congestive heart failure-might have saved patients from hospital visits and enhanced their survival.
"These findings reflect well on the efforts undertaken by VA in the mid-1990s to make care more efficient and effective for veterans," said senior author Dr. Nelda P. Wray, formerly a physician and health services researcher in Houston and today VA's chief research and development officer. "We're continuing to make changes today, in research and clinical practice, to ensure that veterans receive the highest quality of care."
Statistics available from VA underscore the dramatic changes in VA health care referred to in the study. The number of veterans treated each year as inpatients decreased 40 percent from 1989 to 1999, from 617,288 to 367,486. Over the same period, the number of outpatients increased 31 percent, from 2,596,756 in 1989 to 3,391,276 in 1999.
The Veterans Health Administration (VHA), one of three branches in the Department of Veterans Affairs, is the nation's largest health care system, with 163 hospitals, 859 clinics and 134 nursing homes. Some 5 million of the nation's roughly 25 million veterans currently use VA health care.
VHA includes the nation's largest health research program integrated with patient care. In 2002, VA funded studies by more than 3,000 scientists at more than 115 VA facilities nationwide.
Collaborating on the study with Drs. Ashton and Wray were Drs. Julianne Souchek, Nancy Petersen, Terri Menke and Tracie Collins in Houston; and Drs. Steven Wright and Kenneth Kizer, former VA undersecretary for health, in Washington, DC. The study was supported by VA and Baylor College of Medicine.
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