Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era

IF 3.1 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research Pub Date : 2024-06-02 DOI:10.1111/1475-6773.14332

R. Neal Axon MD, Ralph Ward PhD, Ahmed Mohamed PhD, Charlene Pope PhD, Michela Stephens MPH, Patrick D. Mauldin PhD, Mulugeta Gebregziabher PhD

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引用次数: 0

Abstract

Objective

To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation.

Data Sources and Study Setting

VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets.

Study Design

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.

Principal Findings

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.

Conclusions

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.

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MISSION 法案实施期间退伍军人住院治疗及相关再入院和急诊就诊的趋势。

目的：研究退伍军人在《维护内部系统和加强外部综合网络法案》（MISSION）实施后的住院趋势和医疗利用率的变化：研究退伍军人在《维护内部系统和加强外部综合网络（MISSION）法案》实施后住院趋势和医疗保健利用率的变化：研究设计：研究设计：回顾性队列研究，根据支付方类型（退伍军人事务部设施住院、退伍军人事务部资助的社区设施住院[CC]或医疗保险资助的社区住院[CMS]），比较指数住院后 7 天和 30 天的意外再入院率和急诊就诊率。采用分段回归模型对支付方进行比较，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 日期间使用退伍军人事务部初级医疗服务且急性住院次数≥1 次的退伍军人：在《MISSION 法案》实施之前，所有支付方的月指数住院时间均有所增加，此时退伍军人事务部和 CMS 的住院时间有所下降，而 CC 的住院时间则加快并超过了退伍军人事务部的住院时间。2021 年 12 月，CC 住院人数占指数住院人数的 54%，高于 2016 年 1 月的 25%。从调整后的模型来看，就在实施前（2019 年 5 月），与 VHA 入院的退伍军人相比，CC 入院的退伍军人 7 天再入院的风险高出 47%（风险比 [RR]：1.47，95% 置信区间 [CI]：1.43, 1.51），30 天再入院的风险高出 20%（RR：1.20，95% 置信区间 [CI]：1.19, 1.22）；实施后，这两种效应持续存在。实施前的 CC 入院也与较高的 7 天和 30 天急诊就诊率有关，但在研究终止时，这两种风险都大幅降低（RR：0.90，95% CI：0.88，0.91）和（RR：0.89，95% CI：0.87，0.90）：MISSION 法案的实施与退伍军人住院治疗地点和联邦支付方的重大转变有关。据估计，CC 和 CMS 指数入院者实施该法案后的再入院风险较高，而与 VHA 指数入院者相比，CC 入院者实施该法案后使用急诊室的风险较低。造成这种差异的原因需要进一步研究。

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来源期刊

Health Services Research 医学-卫生保健

CiteScore

4.80

自引率

5.90%

发文量

193

审稿时长

4-8 weeks

期刊介绍： Health Services Research (HSR) is a peer-reviewed scholarly journal that provides researchers and public and private policymakers with the latest research findings, methods, and concepts related to the financing, organization, delivery, evaluation, and outcomes of health services. Rated as one of the top journals in the fields of health policy and services and health care administration, HSR publishes outstanding articles reporting the findings of original investigations that expand knowledge and understanding of the wide-ranging field of health care and that will help to improve the health of individuals and communities.