Roughly three-quarters of all older veterans admitted in 2020 and 2021 for COVID-19 were treated at local community hospitals, where they suffered higher death rates than those treated at Veterans Affairs medical centers, according to a study published Tuesday in JAMA Network Open.
But patients treated at a VA hospital were more likely to be readmitted within 30 days for further medical care, according to an analysis of 64,856 veterans hospitalized for severe COVID-19.
According to the observational study, conducted by researchers with the Iowa City Veterans Affairs Health Care System, 74% of the patients reviewed were treated at a community facility while the remainder was admitted to a VA facility.
Roughly 27% of veteran patients in the community hospitals died, compared with 17.7% of veterans treated at a VA hospital. Regarding readmission, 12.7% of veteran patients in community care facilities were readmitted within 30 days, while 14% of VA patients wound up back in the hospital.
The researchers did not explain why the death rates were so different, nor did they provide a detailed breakdown of outcomes of 123 VA and 4,369 community hospitals that treated vets for COVID-19.
They noted, however, that the Veterans Health Administration was proactive in providing the most up-to-date care, while many of the community hospitals studied were in rural areas and may have been struggling with staffing or financial issues before the pandemic.
"Rural hospitals are financially stressed and closing at high rates," wrote the researchers, led by Dr. Michael Ohl, an infectious disease specialist with the Iowa VA. "It is important for the VHA to understand the role of rural community hospitals in acute care for rural VHA enrollees -- both during surges in demand for care during pandemics and overall -- so that the VHA can support and collaborate with these hospitals to maintain access to care for rural veterans."
More than 6.8 million veterans are actively enrolled at the Veterans Health Administration, which manages their medical treatment through a variety of programs, including care directly at VA facilities, through community care programs and Medicare.
The VA's community care program is widely hailed for providing timely convenient access to care for 41% of all VHA patients who live more than an hour from a VA medical facility. But, the researchers noted, roughly half the community hospitals they studied were in rural areas and a quarter were "Critical Access Hospitals," a federal designation that provides benefits to facilities whose existence is deemed essential for the nation's health care system.
For the study, the researchers looked at various databases for all hospitalizations for a primary diagnosis of COVID-19. They analyzed VA, Medicare and VA community care program admissions, outcomes and readmissions within 30 days.
They also looked at hospital locations, number of beds, including intensive care units, hospital teaching status and other factors.
They found that veterans admitted to a VA hospital were likely to be younger, live in a suburban or urban environment within proximity to a VA hospital and had more underlying health problems than those admitted to community hospitals.
Researchers noted that patients at VA hospitals had access to antiviral medications, corticosteroids and other anti-inflammatory medications that patients in smaller or financially strapped community hospitals -- especially those in rural areas -- may not have been able to access.
They added that the disparities in readmission rates may be the result of VA's ability to track veterans after hospital release and does not necessarily mean the veteran had problems with their care that required readmission.
"Future studies should assess whether higher readmission rates in VHA hospitals reflect an undesired outcome or a necessary aspect of efforts to improve access to primary care during care transitions," they wrote.
In a response to the study, Dr. Michael Klompas of Harvard Medical School, and Dr. Barbara Jones of the University of Utah, called into question the data and the analysis, noting that while the authors amassed a huge amount of data, shortcomings exist in the content and interpretation.
"These findings appear to affirm the potential strengths of VHA care. On closer look, however, all things may not be equal," wrote Klompas and Jones.
Among the issues: The difference in death rates may have been tied to vigorous VA testing protocols, which required all patients to be tested at admission, while each community hospital had its own rules.
"This allows for the possibility of ascertainment bias, where VHA hospitals were more likely to diagnose COVID-19 in patients with milder illness (and later in the pandemic, possibly even misdiagnose COVID-19 in patients with residual viral debris alone from remote prior infection)," Klompas and Jones wrote. "This too would lead to lower perceived COVID-19 mortality rates in VHA vs community hospitals."
They also noted that the lack of information on patients transferred from VHA to community hospitals, where they may have died, would skew the death rates for both types of facilities.
"Indications for transfer from VHA hospitals to non-VHA hospitals and the reverse are different," they wrote. "Many VHA hospitals are smaller than their community counterparts and may have needed to transfer patients with more severe disease to non-VHA hospitals (e.g., those requiring extracorporeal membrane oxygenation). Conversely, veterans initially admitted to non-VHA hospitals are typically transferred to VHA hospitals only once they are stabilized and recovering."
And, they said, the data left questions about why the outcomes differed, not allowing for a determination on how to improve health care delivery.
The VA researchers acknowledged their study's limitations, to include lacking certain data on illness severity at admission or discharge, vaccine data and results from admissions for veterans that were covered by Medicare Advantage or private insurance plans -- a dearth of information they said "may have underestimated the role of community hospitals."
The Iowa VA researchers said the study suggests that VHA delves into the differences in mortality rates and readmissions to better serve veteran patients should another COVID-19 surge occur or a new virus pandemic emerges.
"It is important for the VHA to understand the locations and outcomes of care for veterans with COVID-19 to inform plans to deliver accessible and high-quality care for veterans during future COVID-19 case surges and the next pandemic," Ohl wrote.
-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime