Heart failure is a common problem with many different approaches to delivering care. The variation in care within the VA and the association with process of care and outcome is unclear.
We sought to understand the current variation in heart failure care in the VA health care system, and determine if certain care practices are associated with recommended care and better survival and rehospitalization.
We surveyed 130 VA facilities to determine types of presence of heart failure specialists, use of heart failure clinics, reminders, and order sets. We determined the association of different care practice and guideline recommended interventions, diagnostic tests (using External Peer Review Program data), 30-day rehospitalization for heart failure and 30-day mortality following discharge from 2005-2007 in the VA Health Care System. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and for clustering of patients within hospitals.
Staff cardiologists were used in the vast majority of facilities and these facilities had better use of certain recommended treatments but more readmission for heart failure compared to facilities without staff cardiologists after adjustment for patient characteristics. Having a heart failure clinic was associated with better process of care. Use of any type of reminder related to heart failure was associated with worse process of care and survival. It should be noted that we could not determine changes in process of care and outcome relative to institution of any heart failure care program. Thus, cause and effect cannot be determined.
In summary, we found substantial variation in programs and personnel used to treat heart failure. Use of cardiologists and heart failure clinics were associated with better process of care for some but not all measures. The next step in this research should be determining when such interventions were put in place, and whether care changed in response to these interventions.
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