Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans' Health Administration.
BACKGROUND
The Medicare Advantage Program (MAP) and the Veterans' Health Administration (VHA) currently provide many services that benefit the elderly, and a comparative study of their risk-adjusted mortality rates has the potential to provide important information regarding these 2 systems of care.


OBJECTIVE
The objective of this retrospective study was to compare mortality rates between the MAP and the VHA after controlling for case-mix differences.


METHODS
This study consisted of 584,294 MAP patients and 420,514 VHA patients.


METHODS
We used the Death Master File to ascertain the vital status of each study subject over approximately 4 years. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the MAP compared with VHA patients.


RESULTS
The average age for male MAP patients was 73.8 years (+/- 5.6) and for male VHA patients was 74.05 years (+/- 6.3). Unadjusted mortality rates of males for VHA and MAP were 25.7% and 22.8%, respectively, over approximately 4 years (P < 0.0001), respectively. The case-mix of VHA patients, however, was sicker than those from MAP. After adjusting for case-mix, the HR for mortality in the MAP was significantly higher than that in the VHA (HR, 1.404; 95% CI = 1.383-1.426). We obtained similar results when we compared the mortality rates of females for VHA and MAP.


CONCLUSIONS
After adjusting for their higher prevalence of chronic disease and worse self-reported health, mortality rates were lower for patients cared for in the VHA compared with those in the MAP. Further studies should examine what differences in care structures and processes contribute to lower mortality in the VHA.
Center for Health Quality, Outcomes, and Economic Research, A Health Services Research and Development Field Program, VA Medical Center, Bedford, Massachusetts 01730, USA. Selim.Alfredo_J@Boston.Med.VA.gov
Alfredo J
AJ
Selim
Lewis E
LE
Kazis
William
W
Rogers
Shirley
S
Qian
James A
JA
Rothendler
Austin
A
Lee
Xinhua S
XS
Ren
Samuel C
SC
Haffer
Russ
R
Mardon
Donald
D
Miller
Avron
A
Spiro
Bernardo J
BJ
Selim
Benjamin G
BG
Fincke
D000368:Aged; D000369:Aged, 80 and over; D016001:Confidence Intervals; D005260:Female; D006302:Health Services Research; D006304:Health Status; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data*; D006278:Medicare / Q000458:organization & administration* / Q000706:statistics & numerical data; D009026:Mortality; D016017:Odds Ratio; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D020379:Risk Adjustment; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*; D014728:Veterans / Q000706:statistics & numerical data*