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Regional Variations of Aggressive Medicare Treatments in VA and Medicare Hospitals

Yu W, Hill A, Richardson S, Garber A. Regional Variations of Aggressive Medicare Treatments in VA and Medicare Hospitals. Poster session presented at: AcademyHealth Annual Research Meeting; 2005 Jun 1; Boston, MA.


Objectives Researchers have observed a positive relation between healthcare utilization and medical capacity, suggesting that demand is induced by supply. However, we know little about how much of the variation is explained by other factors such as practice pattern. This study analyzes the variation in aggressive medical treatments near the end of life in the Department of Veterans Affairs (VA) and Medicare hospitals. Because the VA budget is allocated based on the number of patients, VA hospitals have little financial incentive to induce demand for aggressive treatments. Thus, variations within the VA and the difference between VA and Medicare hospitals could reveal the impact of other factors on medical treatments. Study designWe retrospectively extracted healthcare utilization provided by the VA or Medicare hospitals during the final 2 years of life and analyzed variations between 21 VA integrated service networks (VISNs) in the utilization of five aggressive medical treatments: intensive care unit (ICU), mechanical ventilator, pulmonary artery monitor, cardiac catheterization, and dialysis. We grouped Medicare hospitals into the 21 VISNs by their location. We compared treatment variations among acute hospital stays during the final 30 days, the final year, and the second year before death with bivariate and multivariate methods. We examined the regional effects using a Probit regression model, controlling for demographics, principal diagnosis, and severity of comorbid conditions measured by the Charlson Comorbidity Index. Population studied Veterans who died between October 1, 1999 and September 30, 2001, were over age 67 at death, and used the VA system during their final 2 years of life (N = 169,314). We excluded people under 67 at death so that all subjects were eligible for both VA and Medicare during the study period. Results Use of aggressive treatments varied considerably among the 21 VISNs in both VA and Medicare hospitals. During hospital stays within the final 30 days of life, ICU use varied from 23.3% to 47.5% in VA and from 31.9% to 50.5% in Medicare, ventilator use varied from 9.0% to 20.1% in VA and from 14.3% to 24.5% in Medicare, pulmonary artery monitor use varied from 1.4% to 6.5% in VA and from 1.5% to 2.9% in Medicare, cardiac catheterization use varied from 0.7% to 3.4% in VA and from 1.9% to 3.8% in Medicare, and dialysis use varied from 2.5% to 5.6% in the VA and from 2.6% to 7.0% in Medicare. These variations persisted after controlling for other factors and in all the three time periods in regression analysis. The aggressiveness of care was not consistent between Medicare and VA facilities in the same region. Conclusions Regional practice patterns could significantly affect the intensity of medical treatments and could be a significant factor for the variation observed in the private sector. The difference in practice patterns between VA and Medicare hospitals suggests that financial incentives is also involved in medical decisions. Policy implicationsReducing variation in medical treatments could enhance the quality of care near the end of life. As practice pattern is also a significant factor in medical decisions, evidence-based guidelines may improve the quality of care.

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