Evidence map›Paper›PMID 41004336›Full record

Observational studyHealth services research2026

Risk of Hospital Readmissions and Association With Receipt of Post-Hospitalization Care Coordination Services Among High-Risk Veterans.

Diana J Govier, Meike Niederhausen, Alex Hickok, Mazhgan Rowneki, Holly McCready, Abby Moss, Kristina M Cordasco, Kathryn M McDonald, Matthew L Maciejewski, Kathleen C Thomas and 1 more

Abstract readObservational Study
In one paragraph

Observational study in Health services research, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

2 citing papers in PubMed.

  1. Five Milestones to Addressing Rural Veteran Care Coordination, Care Management, and Case Management Needs: An Integrated Case Management Practice Framework.The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association · 2026
    Article
  2. Observational
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

11 authors.

Diana J GovierVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.ORCID https://orcid.org/0000-0002-3643-3540
Meike NiederhausenVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.
Alex HickokVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.
Mazhgan RownekiVA Office of Geriatrics and Extended Care, Veterans Health Administration, Washington DC, USA.
Holly McCreadyVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.
Abby MossVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.
Kristina M CordascoVA HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.ORCID https://orcid.org/0000-0002-5866-1763
Kathryn M McDonaldCenter for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Nursing, Baltimore, Maryland, USA.
Matthew L MaciejewskiVA HSR Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.
Kathleen C ThomasDivision of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
Denise M HynesVA HSR Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.

Funding

HSRD VA I01 HX003261HSRD VA IK6 HX003395HSRD VA SDR 02-237U.S. Department of Veterans Affairs IIR 20-165U.S. Department of Veterans Affairs RCS 21-136U.S. Department of Veterans Affairs SDR 98-004U.S. Department of Veterans Affairs VRHRC-IC 04246VA RCS 10-391
6 · The paper itself

Abstract

objectiveTo examine associations between receipt of post-hospitalization care coordination and VA-delivered, VA-purchased, and Medicare fee-for-service hospital readmissions among Veterans at high risk for hospitalization and/or mortality. STUDY SETTING AND

designIn this observational retrospective cohort study, we compared high-risk Veterans who received care coordination within one day after hospital discharge ("treated") with up to five matched high-risk Veterans who did not receive care coordination during this time ("comparators"). Competing risk models estimated adjusted sub-hazard ratios (aSHR) for 30-day all-cause and ambulatory care sensitive condition (ACSC) readmissions between treated and comparators, with death as a competing risk. In sensitivity analyses, we implemented inverse probability of censoring weights to account for censoring due to cross-over to treatment among comparators during follow-up. DATA SOURCES AND ANALYTIC SAMPLE: Data sources included the VA Vital Status File, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services administrative files. Participants included 31,614 treated and 99,634 comparator high-risk Veterans initially hospitalized in fiscal year 2021. PRINCIPAL

findingsParticipants were primarily male sex, ≥ 65 years of age, and had initial hospitalizations in VA facilities; 15.9% and 2.3% of treated Veterans had 30-day all-cause and ACSC readmissions, respectively, compared with 13.5% and 2.1% of comparators. After accounting for the competing risk of death and covariates that remained imbalanced across groups after matching, post-hospitalization care coordination was associated with no difference in the risk of 30-day all-cause (aSHR 1.03, 95% CI 1.00, 1.07) and ACSC (aSHR 0.97, 95% CI 0.89, 1.05) readmission among high-risk Veterans. The risk of ACSC readmission was similar after including censoring weights (aSHR 1.00, 95% CI 0.92, 1.09); the increased risk of all-cause readmission was small in magnitude but statistically significant (aSHR 1.09, 95% CI 1.05, 1.13).

conclusionsReceipt of post-hospitalization care coordination was largely associated with no difference in 30-day readmission risk, suggesting that alternative or additional services may be needed to address readmissions among high-risk Veterans.

Indexed as

Continuity of Patient CarePatient ReadmissionVeteransAgedAged, 80 and overFee-for-Service PlansFemaleHumansMaleMedicareMiddle AgedRetrospective StudiesRisk FactorsUnited StatesUnited States Department of Veterans Affairsambulatory care sensitive conditioncare coordinationcare managementcompeting riskhospital readmissionveterans

Identifiers

PMID41004336
PMCPMC12857460

What OpenQuestion holds

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LicenceCC BY
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Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.