Length of Stay as a Source of Bias in Comparing Performance in VA and Private Sector Facilities

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Abstract
Compare intensive care unit (ICU) mortality and length of stay (LOS) in a VA hospital and private sector hospitals and examine the impact of hospital utilization on mortality comparisons. Retrospective cohort study. Consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 to 1995. Mortality and ICU LOS were adjusted for severity of illness using a validated method that considers physiologic data from the first 24 hours of ICU admission. Mortality comparisons were made using two different multivariable techniques. Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; P = 0.01), as was hospital (28.3 vs. 11.3 days; P <0.001) and ICU (4.3 vs. 3.9 days; P <0.001) LOS. Using logistic regression to adjust for severity, the odds of death was similar in VA patients, relative to private sector patients (OR 1.16, 95% CI 0.93-1.44; P = 0.18). However, a higher proportion of VA deaths occurred after 21 hospital days (33% vs. 13%; P <0.001). Using proportional hazards regression and censoring patients at hospital discharge, the risk for death was lower in VA patients (hazard ratio 0.70; 95% CI 0.59-0.82; P <0.001). After adjusting for severity, differences in ICU LOS were no longer significant (P = 0.19). Severity-adjusted mortality in ICU patients was lower in a VA hospital than in private sector hospitals in the same health care market, based on proportional hazards regression. This finding differed from logistic regression analysis, in which mortality was similar, suggesting that comparisons of hospital mortality between systems with different hospital utilization patterns may be biased if LOS is not considered. If generalizable to other markets, our findings further suggest that ICU outcomes are at least similar in VA hospitals.