Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals

被引:35
作者
Barnett, Paul G. [1 ,2 ,3 ]
Hong, Juliette S. [1 ]
Carey, Evan [4 ,5 ]
Grunwald, Gary K. [4 ,5 ]
Maddox, Karen Joynt [6 ]
Maddox, Thomas M. [6 ]
机构
[1] VA Palo Alto Hlth Care Syst, Vet Affairs Hlth Econ Resource Ctr, 795 Willow Rd,Mail Code 152, Menlo Pk, CA 94025 USA
[2] Vet Affairs Ctr Innovat Implementat, Menlo Pk, CA USA
[3] Stanford Univ, Ctr Primary Care & Outcomes Res, Stanford, CA 94305 USA
[4] Univ Colorado, Colorado Sch Publ Hlth, Dept Biostat & Informat, Anschutz Med Campus, Aurora, CO USA
[5] Vet Affairs Eastern Colorado Hlth Care Syst, Denver, CO USA
[6] Washington Univ, Sch Med St Louis, John T Milliken Dept Internal Med, Cardiol Div, St Louis, MO USA
关键词
ACUTE MYOCARDIAL-INFARCTION; ASSOCIATION TASK-FORCE; BYPASS GRAFT-SURGERY; PRIVATE-SECTOR; CLINICAL-ASSESSMENT; PRACTICE GUIDELINES; THORACIC SURGEONS; RISK PREDICTION; SURGICAL CARE; OF-CARE;
D O I
10.1001/jamacardio.2017.4843
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
IMPORTANCE The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. OBJECTIVES To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. EXPOSURES Receipt of an elective coronary revascularization at a VA vs CC facility. MAIN OUTCOMES AND MEASURES Access to care as measured by travel distance, 30-day mortality, and costs. RESULTS In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. CONCLUSIONS AND RELEVANCE In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.
引用
收藏
页码:133 / 141
页数:9
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