Evaluation of changes in Veterans Affairs medical centers' mortality rates after risk adjustment for socioeconomic status

Importance: 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. Objective: 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. Design, Setting, and Participants: 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. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.