Changes in VA hospital use 1980-1990.

During the 1980s several changes occurred within and outside the Veterans Affairs medical system which may have affected levels of Veterans Affairs (VA) hospital use. We performed a secondary analysis of the 1980-1990 national VA hospital discharge database and Veteran Population Files to examine trends in VA hospital use and to assess effects of the aging of the veteran population. Between 1980 and 1990 discharges increased by 7% despite a 6% drop in the number of veterans. Overall the crude discharge rate increased by 13% and the user rate by 1%. Most of the change was attributable to the fact that as the decade progressed, the veteran population was comprised of proportionately older veterans, who are higher users of hospital care than younger veterans. The 11% increase in the multiple stay ratio was not attributable to aging. Examination of age-specific utilization rates showed that veterans younger than age 45 had consistent increases in use, whereas use by older veterans declined. Our findings indicate that change in the age composition of the veteran population is responsible for some but not all of the increase in VA hospital use in the last decade. The increase in use by young veterans may reflect increasing barriers to access to non-VA care. Declines in use by older veterans may indicate that VA has been successful in shifting the locus of care from the hospital to the ambulatory and long-term care settings.

Age-specific death rates with tobacco smoking and occupational activity: sensitivity to sample length, functional form, and unobserved frailty.

In this article, we estimate accelerated time-to-failure and proportional-hazard functions with about 100,000 members of the Dorn sample, finding greater hazards associated with smoking and some dependence on occupational variables that measure risk and physical activity. We answer three questions: (1) How sensitive are the estimates to sample length, using monthly data for the periods 1954-1969 and 1954-1980? The results differ somewhat between these sample periods. (2) How sensitive are the estimates to alternative functions for the hazard? Within a given time period, the estimates are fairly robust to specification changes in the distribution of the hazard in the accelerated time-to-failure models. (3) How sensitive are the estimates to alternative controls for unobserved frailty? Within a given sample period, the estimates are fairly robust to the allowance for parametric or nonparametric heterogeneity in the proportional-hazard models.