Study: Shorter stays don’t reduce quality

Quality indicators show significant improvement

According to a study published in the Oct. 23, 2003, New England Journal of Medicine, the Department of Veterans Affairs (VA) health care system has slashed the time veterans spend in the hospital by half without sacrificing quality of patient care.

Starting in 1994, the VA began an effort to significantly reduce unnecessary hospital stays and encourage veterans to get routine care for chronic conditions. This initiative was part of the reorganization of the VA medical care system undertaken in the mid-1990s.

"When we embarked on those changes, we asked one of our research centers to track the most vulnerable cohorts of patients while we were embarking on a massive change of system, to see what the effect would be," explains Kenneth W. Kizer, MD, MPH, one of the study’s lead authors and formerly the head of the VA health care system. Currently, he is president and CEO of the Washington, DC-based National Quality Forum.

In fact, the researchers noted that these patients were picked because they were the sickest and most vulnerable veterans and would best indicate the VA reforms’ impact on quality.

Kizer says that several papers have been written about the VA experience; this particular paper addressed one- and five-year survival rates.

Many of the reforms, noted the authors, "Were aimed at reducing the historically high levels of use of VA hospitals."1 Clearly, such a reduction had to be offset by many other system changes, including improvements in ambulatory care, to keep urgent care visits from increasing or survival rates from falling.

The transformation of the VA system included reconfiguring its four regions into 22 service delivery networks; the institution of a primary care model; and a change in the eligibility laws to allow the VA to provide a full range of services. In addition, starting in 1997, VA networks were financed by a capitation system. "We also put in place an electronic health information system, which was a key element, in addition to shifting to an integrated service delivery network model, a new performance management system, and the new payment policy," Kizer explains.

The implementation of universal primary care resulted in much better coordination and continuity of care, which may have been the most significant change of all, he points out. "We put in place more community-based clinics, which made care more accessible."

In addition, veterans were encouraged to get routine care for chronic conditions. "We removed the barriers for them to get the care. Most patients want to do it, but we make it difficult for them to get the care they need," Kizer explains.

The nine patient cohorts were: chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, major depressive disorder, and schizophrenia. The results of the study were very impressive.

"Not only did reduced hospital utilization not result in adverse outcome, but in five of the nine cohorts [pneumonia, congestive heart failure, angina, bipolar disorder, and major depressive disorder], it actually resulted in improvement; this is not trivial," Kizer asserts. "We closed 55% of the acute care hospital beds, reduced cost per patient by 25.1%, while dramatically improving quality of care indicators." The study also found that urgent care visits dropped by 37%.

"Something else we should not overlook is the fact that VA patients are much more difficult to treat than the average patient," Kizer observes. "So many of them are homeless, less well educated, or poor; the VA is a safety net system. To get that type of improved outcomes with that patient population makes you wonder what you would do with a middle-class population."

Does that suggest what was accomplished in the VA system could serve as a legitimate benchmark for other systems around the country?

"I think it can," Kizer asserts. "Of course, we’re not truly looking at apples to apples — perhaps MacIntosh to Delicious — but an awful lot of the rest of the systems could learn from the VA."

Ironically, he says, most of what he did in the VA was based on experiences in the private sector. "In our case, however, we could actually put in place what people in the private sector were just talking about," he notes.

What’s more, Kizer says, the reforms he instituted were not really that costly. "They were actually done within the context of taking budget reductions every year." For example, one year, he had a $400 million increase, which sounds like a lot, but the budget included a 3% pay increase. "So to make it work, I needed $800 million." The VA, Kizer says, instituted initiatives such as a national formulary to save money.


1. Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med 349; 17:1,637-1,646.

Need More Information?

For more information, contact:

Kenneth W. Kizer, MD, MPH, President and CEO, National Quality Forum, 601 13th St., N.W., Suite 500 N., Washington, DC 20005. Phone: (202) 783-1300. Fax: (202) 783-3434. Web: