BACKGROUND/RATIONALE:
Ischemic heart disease (IHD) affects a large proportion of the U.S. population, accounting for hundreds of thousands of hospital admissions each year, nearly 500,000 deaths among women, and over 430,000 deaths among men annually. It is one of the most prevalent health problems of veterans. The most dramatic manifestation of IHD is acute coronary syndrome, comprised of both acute myocardial infarction (heart attack or AMI) and unstable angina which are responsible for over 25,000 admissions to VA hospitals annually. Although studies in the 1990's showed equivalent survival for patients admitted with AMI to VA facilities compared with patients with AMI whose care was covered by Medicare, a more recent investigation reported a disparity favoring Medicare. That study and others also showed lower use of invasive cardiac procedures after AMI among VA patients, suggesting clinically indicated cardiac catheterization might be underused within VHA.

OBJECTIVE(S):
The objective of the study, a collaboration between IHD QuERI, the Office of Quality and Performance and the Office of Patient Care Services, was to create a database to follow all patients discharged from VHA inpatient acute care facilities with a diagnosis of AMI or UA; and to use this database to identify gaps in performance for which implemention of evidence-based best practices would be most beneficial to patient care.

METHODS:
Data from OQP's External Peer Review Program (EPRP) for FY04 through FY07, the Survey of Health Experiences of Patients (SHEP), Pharmacy Benefits Management (PBM), the National Patient Care Databases (NPCD) and SAS Medical Inpatient files at the Austin Automation Center, and the VHA Decision Support System National Data Extracts (DSS NDE) Laboratory Results and Pharmacy Datasets were merged and updated on a periodic basis. To evaluate outcomes and processes of care for all patients admitted to VHA hospitals with AMI and UA, we constructed risk-adjusted models that evaluated 30-day, 60-day and one-year mortality; cardiac catheterization; revascularization; and transfer. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. In addition, data from the 2004 and 2006 VHA All-Employee survey were used to evaluate the influence of organizational factors on the adoption of innovation and technology in cardiac care.

FINDINGS/RESULTS:
Using EPRP data from 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p=.011). Similar declines were found for in-hospital and 90-day mortality. Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Between FY04 and FY06, the percent of patients receiving ECG within 10 minutes increased from 51.1 to 61.6 percent, and the percent with troponin report within 60 minutes increased from 71.3 to 76.3.
CONCLUSION: Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals. Improvements in process of care for patients with ACS over the past three years have paralleled national efforts in process improvement and performance measurement.

IMPACT:
The results of collaborative efforts involving OQP, PCS, OI and VA Research and Development demonstrate that a multifaceted and sustained program has the potential to improve care and produce new knowledge.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Maynard C, Lowy E, McDonell M, Fihn SD. Cause of death in Washington state veterans hospitalized with acute coronary syndromes in the veterans health administration. Population Health Metrics [Electronic Resource]. 2008 Jul 23; 6:3. [view]
2. Fihn SD, Bucher JB, McDonell M, Diehr P, Rumsfeld JS, Doak M, Dougherty C, Gerrity M, Heidenreich P, Larsen G, Lee PI, Lucas L, McBryde C, Nelson K, Plomondon ME, Stadius M, Bryson C. Collaborative care intervention for stable ischemic heart disease. Archives of internal medicine. 2011 Sep 12; 171(16):1471-9. [view]
3. Fihn SD, Vaughan-Sarrazin M, Lowy E, Popescu I, Maynard C, Rosenthal GE, Sales AE, Rumsfeld J, Piñeros S, McDonell MB, Helfrich CD, Rusch R, Jesse R, Almenoff P, Fleming B, Kussman M. Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System. BMC cardiovascular disorders. 2009 Aug 31; 9:44. [view]
4. Ho PM, Peterson ED, Wang L, Magid DJ, Fihn SD, Larsen GC, Jesse RA, Rumsfeld JS. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA : the journal of the American Medical Association. 2008 Feb 6; 299(5):532-9. [view]
5. Bradley SM, Bryson CL, Maynard C, Maddox TM, Fihn SD. Recent hospitalization for non-coronary events and use of preventive medications for coronary artery disease: an observational cohort study. BMC cardiovascular disorders. 2011 Jul 9; 11:42. [view]
6. Ho PM, Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED, Rumsfeld JS. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA : the journal of the American Medical Association. 2009 Mar 4; 301(9):937-44. [view]
7. Plomondon ME, Ho PM, Wang L, Greiner GT, Shore JH, Sakai JT, Fihn SD, Rumsfeld JS. Severe mental illness and mortality of hospitalized ACS patients in the VHA. BMC health services research. 2007 Sep 18; 7:146. [view]
8. Ho PM, Prochazka AV, Magid DJ, Sales AE, Grunwald GK, Hammermeister KE, Rumsfeld JS. The association between processes, structures and outcomes of secondary prevention care among VA ischemic heart disease patients. BMC cardiovascular disorders. 2006 Feb 9; 6:6. [view]
9. Maynard C, Lowy E, Rumsfeld J, Sales AE, Sun H, Kopjar B, Fleming B, Jesse RL, Rusch R, Fihn SD. The prevalence and outcomes of in-hospital acute myocardial infarction in the Department of Veterans Affairs Health System. Archives of internal medicine. 2006 Jul 10; 166(13):1410-6. [view]
10. Maynard C, Sun H, Lowy E, Sales AE, Fihn SD. The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction. BMC health services research. 2006 Aug 21; 6:107. [view]
11. Wheeler S, Bowen JD, Maynard C, Lowy E, Sun H, Sales AE, Smith NL, Fihn SD. Women veterans and outcomes after acute myocardial infarction. Journal of women's health. 2009 May 1; 18(5):613-8. [view]

Journal Other

1. Helfrich CD, Hekman D, Li YF, Fihn SD. Exploratory factor analysis of quality of care indicators for acute coronary syndrome. [Abstract]. Circulation. 2008 May 27; 117(21):e445. [view]

Conference Presentations

1. Greiner G, Lowy E, Maynard C, Sales A, Fihn S. A Comparison of Four AMI Mortality Risk Adjustment Models. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
2. Pineros S, Sales AE, Pineros V, McDonell M, Maynard C, Lehmann K, Fihn SD. An Evaluation of a Patient Education Initiative in VHA: Time is Life for Heart Attack. Poster session presented at: American Heart Association Annual Scientific Forum; 2006 May 8; Washington, DC. [view]
3. Greiner GT, Lowy E, Maynard C, Sales A, Fihn S. Comparison of Six Mortality Risk Adjustment Models for Acute Myocardial Infarction. Poster session presented at: American Heart Association Annual Scientific Forum; 2006 May 8; Washington, DC. [view]
4. McDermott K, Sales A, Lowy E, Helfrich CD, Fihn S. Factors Associated with Reperfusion for ST Segment Elevation MI Patients in VHA Facilities. Paper presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
5. Sales A, McDermott K, Helfrich CD, Lowy E, Greiner GT, Lehmann K, Fihn S. Factors Associated with Reperfusion for ST Segment Elevation Myocardial Infarction Patients in VHA Facilities. Poster session presented at: American Heart Association Annual Scientific Forum; 2006 May 8; Washington, DC. [view]
6. Sales A, Maynard C, Sun H, Fihn S. Race and the Use of Percutaneous Coronary Intervention in Veterans with Acute Mycardial Infarction. Poster session presented at: American Heart Association Annual Scientific Forum; 2006 May 8; Washington, DC. [view]
7. Sun H, Maynard C, Sales A, Fihn S. Race and the Use of Percutaneous Coronary Intervention in Veterans with Acute Myocardial Infarction. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
8. Lowy E, Greiner G, Sales A, Maynard C, Fihn S. Race or Region? Examining Race Disparities in AMI Mortality in VHA. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
9. Lowy E, Greiner GT, Sales A, Maynard C, Fihn S. Race, Race, and Mortality Among Veterans with Acute Myocardial Infarction. Paper presented at: American Heart Association Annual Scientific Forum; 2006 May 8; Washington, DC. [view]
10. Wang L, Sun H, Lowy E, McDonell M, Bryson CL, Frisbee K, Loftus S, Nielson C, Maynard CC, Fihn SD. Risk of hospitalization among patients with heart failure within Veterans Health Administration. Poster session presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2011 May 10; Atlanta, GA. [view]
11. Helfrich CD, Sun H, Sales AE, Li YF, Fihn S. The Association of VHA Facilities' Organizational Culture to Time-to-EKG for Acute Coronary Syndrome Patients. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
12. Maynard C, Lowy E, Rumsfeld J, Sales A, Sun H, Kopjar B, Fleming B, Jesse R, Fihn S. The Prevalence and Outcomes of In-Hospital Acute Myocardial Infarction in the VHA. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
13. Fihn SD, Vaughan-Sarrazan M, Lowy E, Popescu I, Maynard C, Rosenthal GE, Sales AE, Rumsfeld J, Jesse R, Almenoff P, Fleming B, Kussman M. Trends in Mortality Following Acute Myocardial Infarction in the Veterans Health Administration and Medicare Funded Hospitals. Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2008 May 1; Baltimore, MD. [view]
14. Vaughn-Sarrazin M, Lowy E, Popescu I, Maynard C, Rosenthal G, Sales A, Jesse J, Almenoff P, Fleming B, Kussman M. Trends in Mortality following Acute Myocardial Infarction in the Veterans Health Administration and Medicare-Funded Hospitals. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]

DRA: none
DRE: none
Keywords: none
MeSH Terms: none