WASHINGTON, DC — The Veterans Affairs (VA) healthcare program that allows patients to undergo elective percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) at non-VA centers indeed cuts the cost of travel to the hospital, one of the program’s goals, but showed “mixed” results in terms of 30-day clinical outcomes and costs of health services, according to a new report.[1]
Mean 30-day PCI mortality at the non-VA community care centers was more than twice as high as that for PCI at VA centers (1.54% vs 0.65%). The difference was significant in adjusted analysis, but observers think unmeasured confounders are responsible.
Mean total PCI costs were also higher at community care centers: $22,025 vs $15,683.
For CABG, mortality rates were similar at both kinds of centers, but total costs were lower at community care centers than VA centers at $55,526 vs $63,144.
The report, appearing January 3 in JAMA Cardiology, covers elective coronary revascularization procedures for US veterans younger than age 65 years performed as part of the VA’s Patient-Centered Community Care program from 2008 to 2011, before it expanded to include the controversial Choice program.
The analysis sought to learn “how the VA can be a good purchaser and arranger of care,” lead author, Dr Paul G Barnett (VA Palo Alto Health Care System, Menlo Park, CA), told theheart.org | Medscape Cardiology. “We can see that there’s room for improvement.”
The researchers looked at publically available outcomes data, “and it wasn’t useful,” said Barnett, in that the available data didn’t identify community care centers clearly providing higher-value care to veterans.
“What we learned is there may be some strategies for being a better purchaser. We can’t just assume that the care that we buy is as good or better than VA care,” Barnett said.
Actually, he said, one of the study’s takeaway messages is that “for those who get care at the VA, the quality is pretty good.” Still, however, “there are some people who are clearly advantaged getting care in the community because they live a long way from the VA.”
The report states that during the study period, 21% of elective PCIs and about 16% of elective CABGs sponsored by the VA system were outsourced to community centers.
Of note, the analysis suggested that “even if you compensated the veteran for the cost of traveling to the VA, and their time for going to the VA, it was still less costly to get their PCI from the VA. That wasn’t true for CABG—it was more expensive” at VA centers, Barnett noted.
The study has limitations and can’t really say whether it’s best to arrange for PCI or CABG at one kind of center or the other, he emphasized, “but think it does say that, as a purchaser, the VA should ask for the quality information of the hospitals that we’re buying from.”
PCI Mortality Difference Was “Not Subtle”
The increased PCI mortality at community centers shouldn’t be overlooked, according to an accompanying editorial from Dr Frederic S. Resnic (Lahey Hospital and Medical Center, Burlington, MA) and Dr Gautam Gadey (Tufts School of Medicine, Boston, MA).[2]
“The mortality difference observed for PCI was not subtle, nor was it expected based on the conventional quality measures available for cardiac care at hospitals,” they write. “The rigor of the risk adjustment and the consistency of the findings across multiple sensitivity analyses indicate that the findings are robust and deserve thoughtful consideration.”
The editorialists and the study authors agree that the increased mortality at community care PCI centers probably didn’t come directly from the care they provided. Also, the analysis couldn’t control for every relevant variable.
The magnitude of the difference “makes me wonder whether or not there may be some unmeasured confounders,” Dr Frederick A Masoudi (University of Colorado Denver, Aurora), who was not associated with the study, said in an interview with theheart.org | Medscape Cardiology.
“In some cases, even for elective cases, there may be some VA hospitals that are not as comfortable taking on cases that may require temporary hemodynamic support, for instance. Those are particularly high-morbidity cases.”
But if nothing else, Masoudi said, the analysis supports “an approach to active surveillance in terms of understanding the costs and the quality of care, as well as the burden to veterans in terms of access to care.”
Certainly, he said, “having a comprehensive understanding of the burden to the patients of the care they receive is an important one and is something we probably don’t spend a lot of time thinking about. It’s particularly germane in the VA, where there are a limited number of hospitals, particularly for folks who live in rural settings or in small states.”
Adjusted 30-Day Outcomes
The study looked at a cohort of veterans younger than 65 years undergoing 13,237 elective PCIs and 5818 elective CABG surgeries (at VA centers in 79% and 84% of cases, respectively) during 3 years ending in September 2011.
The 30-day mortality hazard ratios (HRs) with 95% confidence intervals for community-care centers vs VA centers were as follows:
The corresponding HR for readmission at 30 days were as follows:
Mean total adjusted costs, covering the procedures, readmissions, and patient travel, were higher for PCI but lower for CABG at community care centers than at VA centers, respectively:
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$23,059 vs $16,771 (P<0.001) for PCI
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$56,749 vs $65,264 (P<0.01) for CABG
Interestingly, despite greater total costs for PCI at community care centers overall, mean total PCI costs at such centers considered low-volume for the procedure (<200 procedures per year) came in significantly lower than at standard-volume VA centers: $17,015 vs $20,777 (P<0.001). The difference was seemingly driven by significantly lower cost of the index procedure at low-volume community care centers.
Barnett called that finding “surprising because it’s thought that the volume standards matter. But I think what we learned was that the low-volume hospitals seem to be doing a good job of managing their quality.”
Given how much remains to be learned about the subject, the editorialists point out, “Perhaps a future requirement for participation in the CC [community care] program should be an explicit commitment to engage in quality monitoring and improvement efforts in conjunction with the VA to identify opportunities to improve the care at all centers.”
They continue: “We believe the VA should actively monitor the clinical outcomes and costs at CC hospitals and provide this information to veterans and their VA clinicians to help them choose the most appropriate setting for their individual needs for coronary revascularization.”
Masoudi seemed to agree. The study, he said, “highlights the kind of analysis that would be wonderful to be able to do continuously, and to have mechanisms to do that in a relatively timely way, so we can better understand the most effective and efficient ways to ensure highest quality care. And that includes timely care, for our veterans.”
The study authors and editorialists have disclosed no relevant financial relationships.
Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org, follow us on Twitter and Facebook.
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