Thirty-Day Mortality Higher for Older Veterans Hospitalized with COVID-19 in Community Hospitals vs. VA Hospitals
VA operates 123 acute care hospitals in the U.S. that are capable of providing inpatient care for Veterans with severe COVID-19; however, more than one-third (41%) of VA patients age 65+ live more than a one-hour drive to the nearest acute care VA hospital. Poor geographic access to VA hospitals means that community hospitals likely played a large role in caring for acutely ill Veterans with severe COVID-19, but little is known about the outcomes of care in VA vs. community hospitals. This retrospective cohort study compared outcomes among Veterans (ages 65+) admitted for COVID-19 in VA (n = 121) and community hospitals (n = 4,369). Using VA, Medicare, CDC, and American Hospital Association data from March 2020 through December 2021, investigators identified 64,856 Veterans dually enrolled in VA and Medicare. Outcomes were mortality within 30 days of admission among all patients and time to readmission to either a VA or community hospital within 30 days of discharge. Patient demographics (race/ethnicity were self-reported) and comorbidities were assessed. Hospital-level variables also were examined (i.e., urban vs. rural locations, number of acute care and ICU beds).
- Admission to community hospitals was associated with higher unadjusted (27% vs. 18%) and risk adjusted 30-day mortality compared to admission to VA hospitals.
- Readmission within 30 days was less common following admission to community compared to VA hospitals (13% vs. 14%). Note: This difference was not sensitive to adjustment for patient characteristics, suggesting that higher readmission in VA hospitals may reflect a feature of the VA healthcare system and not case-mix.
- Veterans admitted to community hospitals were older (mean age 78 vs. 76), more likely to be white (82% vs. 69%), less likely to live in urban areas (54% vs. 67%), and less likely to live in census tracts with high social vulnerability (6% vs. 10%).
- Community hospitals played a disproportionate role in care for rural Veterans with COVID-19, likely because of poor geographic access to VA hospitals among this population: 46% of community hospitals caring for VA enrollees with COVID-19 were in rural areas.
- VA must understand sources of the mortality difference to plan care for VA patients during future COVID-19 surges, as well as the next pandemic.
- Investigators lacked detailed data on illness severity at admission – and did not have data on illness severity on day of discharge for risk-adjustment in readmission analyses.
- Investigators lacked data on community hospital admissions paid for through Managed Medicare or private insurance and therefore may have under-estimated the role of community hospitals.
This study was supported by VA’s Office of Rural Health (ORH) and HSR&D. All authors are with HSR&D’s Center for Access & Delivery Research and Evaluation.
Ohl M, Richardson K, Beck B, Mecham B, Bailey G, Mengeling M, and Vaughan-Sarrazin M. Mortality among US Veterans Admitted to Community vs Veterans Health Administration Hospitals for COVID-19. JAMA Network Open. May 30, 2023; 6(5):e2315902.