Weeks WB (VA Outcomes Group, Dartmouth)
Bott DM (Dartmouth)
Bazos DA (Dartmouth)
Racz MJ (New York Department of Health)
Hannan EL (New York Department of Health)
Wright SM (VA OQP)
Fisher ES (VA Outcomes Group, Dartmout)
VA is focusing on improving the quality of cardiac care provided within the VA system. Because many VA patients also obtain care in the private sector, it may be equally important to focus on improving the quality of care they receive outside the VHA system. We sought to assess the potential impact of directing VA patients’ private sector revascularizations to high quality hospitals.
We performed a retrospective study of 280,180 male New York State residents who were enrolled in VHA between 1999 and 2000. Using New York Department of Health datasets, we identified the private sector hospitals in which they obtained coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCIs). We then determined potential changes in mortality and travel burden associated with directing that care to low mortality and/or high volume hospitals.
Over two years, VA patients obtained 83% of their CABG surgeries (2341/2829) and 87% of their PCIs (4054/4665) in the private sector. VA patients were just as likely to obtain private sector revascularizations at high and low mortality hospitals. Directing private sector care to low mortality hospitals would have decreased expected mortality rates by 16% (from 2.29% to 1.92%) and reduced median travel burden from 21 to 18 minutes. Directing care to high volume, low mortality centers would have reduced expected mortality by 26% (to 1.74%) and would have increased the median travel time by 7 minutes. Directing private sector PCIs to low mortality centers would have had no mortality or travel time impact. Directing private sector care to high volume, low mortality centers would have reduced expected mortality by 17% (from 0.78% to 0.65%) but would have increased median travel time from 21 to 29 minutes.
VA patients living in New York State obtained the large majority of coronary revascularizations through the private sector. Nontrivial mortality reduction could have been achieved at a minimal travel cost by directing private sector care for CABG, less so for PCI.
For high mortality procedures that veterans obtain in the private sector in high volumes, like CABG, directing private sector care to low mortality hospitals may be an effective way to improve outcomes.