Geographic variations in utilization rates in Veterans Affairs hospitals and clinics

N Engl J Med. 1999 Jan 7;340(1):32-9. doi: 10.1056/NEJM199901073400106.


Background: In the United States, geographic variation in hospital use is common. It is uncertain whether there are similar geographic variations in the health care system of the Department of Veterans Affairs (VA), which differs from the private sector because it predominantly serves men with annual incomes below $20,000, has a central system of administration, and uses salaried physicians. Thus, it might be less likely to have geographic variations.

Methods: We used VA data bases to obtain information on patients treated for eight diseases (chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, and major depression). We analyzed their use of hospital and outpatient services by assessing the risk-adjusted numbers of hospital days (the average number of days a patient spent in the hospital per 12 months of follow-up, regardless of the number of hospital stays), hospital-discharge rates, and clinic-visit rates from 1991 through 1995 for the entire system and within the 22 geographically based health care networks.

Results: We found substantial geographic variation in hospital use for all eight cohorts of patients and all the years studied. Variations in the numbers of hospital days per person-year among the networks were greatest among patients with chronic obstructive pulmonary disease (ranging from a factor of 2.7 to a factor of 3.1) during a given year and smallest among patients with angina (ranging from a factor of 1.5 to a factor of 2.1). Levels of hospital use were highest in the Northeast and lowest in the West. The variation in the rates of clinic visits for principal medical care among the networks ranged from a factor of approximately 1.6 to a factor of 4.0; variations in the rates were greatest among patients with chronic renal failure and smallest among patients with chronic obstructive pulmonary disease. There was no clear geographic pattern in the rates of outpatient-clinic use.

Conclusions: There are significant geographic variations in the use of hospital and outpatient services in the VA health care system. Because VA physicians are unable to increase their income by changing their patterns of practice, our findings suggest that their practice styles are similar to those of other physicians in their geographic regions.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Chronic Disease / therapy*
  • Cohort Studies
  • Hospital Bed Capacity
  • Hospitals, Veterans / statistics & numerical data*
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Multivariate Analysis
  • Outpatient Clinics, Hospital / statistics & numerical data*
  • Patient Discharge / statistics & numerical data
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Risk Adjustment
  • Statistics, Nonparametric
  • United States
  • Utilization Review