Study Compares VA Care to Community Care for Veterans Receiving Elective Coronary Revascularization
BACKGROUND:
VA supplements its hospitals and clinics with care purchased from community providers. This program, known as Community Care (CC), cost $5.6 billion in 2014 and represents 10% of VA's healthcare budget. Elective coronary revascularization procedures, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), accounted for $170 million of CC program costs in 2014. Currently, Veterans are eligible to use CC services if VA cannot provide necessary services due to a lack of available specialists, long wait times, or extraordinary distance from a Veteran's home. This observational study compared access, quality, and cost of elective coronary revascularization procedures between VA and CC hospitals. Access to care was measured as the distance traveled to the hospital that provided the procedure – less the distance to the nearest hospital offering the procedure (VA or CC). Other outcomes measured included 30-day readmission for a cardiac-related diagnosis, 30-day mortality, and costs (for both VA and CC care). Procedures, demographics, and medical comorbidities also were assessed for 13,237 Veterans (younger than age 65) who underwent PCI (79% at VA) and 5,818 Veterans who underwent CABG (84% at VA) between FY2009 and 2011.
FINDINGS:
- Compared to CC hospitals, Veterans who underwent PCI in VA hospitals had lower mortality (1.5% vs. 0.65%), lower costs ($22,025 vs. $15,683), and similar readmission rates. Compared to CC hospitals, Veterans who underwent CABG in VA hospitals had similar mortality, similar readmission rates, but higher cost ($55,526 vs. $63,144).
- Compared to VA-only care, Community Care reduced net travel distance for PCI by 54 miles, and CABG by 73 miles, on average. CC care also was associated with significantly lower travel costs – an average of $156 less for PCI and $690 less for CABG.
- One in five coronary revascularizations for VA patients was performed at CC sites.
IMPLICATIONS:
- Findings demonstrate that, on average, Veterans seeking high-quality care with low mortality and readmission rates are well-served by VA. As VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimizing outcomes and costs.
LIMITATIONS:
- Mortality in the study sample was a sufficiently rare event that the power to detect differences in the quality of VA and CC care may have been limited.
- Data only included procedures between 2008 and 2011, and patterns may have changed over time.
- It is possible that there was undetected referral bias, and that Veterans referred to CC hospitals had elevated risk beyond that represented by the available covariates.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 11-049 and CDP 09-415). Dr. Barnett and Ms. Hong are with HSR&D's Health Economics Resource Center (HERC).
Barnett P, Hong J, Carey E, Grunwald G, Maddox K, and Maddox T. Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization between Veterans Affairs and Community Care Hospitals. JAMA Cardiology. January 3, 2018;e-pub ahead of print.
