Post-ICU care trajectories and outcomes among Veterans: Comparing Veterans Affairs and community hospital discharges

Abstract: Background: Survivors of critical illness face fragmented care transitions, leading to readmissions, emergency care use, and death. The Veterans Affairs (VA) Patient Aligned Care Team model emphasizes coordinated outpatient follow-up, yet many veterans now receive VA-purchased intensive care at community hospitals, potentially disrupting continuity. Research Question: How do outcomes after ICU care differ for veterans discharged from VA medical centers vs community hospitals, and what recovery trajectories emerge after discharge? Study Design and Methods: We conducted a retrospective cohort study of 311,224 veterans discharged home after medical ICU admission (2016-2023) using VA Corporate Data Warehouse and VA-purchased care claims. Outcomes included primary care visits, emergency department (ED) use, readmissions, mortality, and hospital-free days. Fine-Gray subdistribution hazard models estimated 30-day and 90-day risks, accounting for competing risks and adjusting for demographics, comorbidities, and facility clustering. Marginal standardization yielded adjusted risks, risk differences, and hazard ratios. A Bayesian mediation analysis tested whether 30-day primary care follow-up mediated readmission risk. Weekly transitions across 5 states—home, primary care visit, ED visit, readmission, and death—were analyzed with state sequence clustering. Results: Of 311,224 survivors of ICU stays, 36.9% were discharged from VA hospitals and 63.1% were discharged from community hospitals. At 30 days, patients from VA hospitals showed higher primary care follow-up rates (20.2% vs 15.3%), but higher 90-day readmission rates (27.0% vs 24.4%) and mortality rates (8.4% vs 7.3%). Patients discharged from community hospitals relied more on ED visits (32.1% vs 25.7%). Mediation analysis showed early primary care was protective, but explained little of the VA-community difference. Trajectory clustering revealed diverse recovery patterns, ranging from high primary care with low readmission to recurrent acute care use or early death. Interpretation: Our results showed that patients discharged from VA hospitals received earlier primary care, but showed higher readmission and mortality, whereas patients discharged from community hospitals made fewer visits but more ED use, highlighting the need for structured, risk-stratified transitional care.