A program designed to supplement U.S. Department of Veterans Affairs (VA) medical services with community-based care led to reduced travel distances for coronary revascularizations but also mixed results in clinical outcomes, according to a study published Jan. 3 in JAMA Cardiology.
Specifically, percutaneous coronary interventions (PCIs) at Community Care (CC) Program hospitals were associated with a 1.54 percent risk of 30-day mortality compared to a 0.65 percent risk at VA hospitals—a 2.4-fold relative increase. Thirty-day mortality following coronary artery bypass graft (CABG) surgery was 1.33 percent at CC centers and 1.51 at VA centers.
In addition, cost was higher for PCI in CC hospitals ($22,025 vs. $15,683 for VA) but lower for CABG ($55,526 vs. $64,144 for VA).
“The VA hospitals had lower mortality and lower costs than CC hospitals for PCI and had similar mortality but higher costs for CABG surgery,” wrote lead researcher Paul G. Barnett, PhD, with the VA Health Economics Resource Center, and colleagues. “To ensure that veterans receive care that is timely, accessible, and of the highest quality, policymakers should consider providing information to help veterans seek care from the highest-value hospitals and health care professionals regardless of whether the hospitals are VA or CC.”
Barnett and coauthors studied 13,237 elective PCIs and 5,818 elective CABG procedures from October 2008 through September 2011. All veterans undergoing revascularization were younger than 65 years old.
Twenty-one percent of the PCIs and 16.4 percent of the CABGs were performed at CC facilities. These community-based hospitals sell their services to the VA, a program that cost $5.6 billion in 2014. Elective coronary revascularizations accounted for $170 million of the CC costs that same year, according to Barnett et al.
The researchers showed the program increased access to care based on travel distance and cost; patients having PCI at CC hospitals traveled an average of 53.6 miles less and saved $153 in travel expenses. Patients undergoing CABG at CC hospitals traveled an average of 73.3 miles less and saved $690 in travel expenses.
Barnett and colleagues said patient access—like clinical outcomes and procedural costs—are necessary to consider as the VA mulls adding more CC hospitals to its program. All those factors tie into the value of the program, they wrote, but more work is necessary to determine the centers worthy of inclusion.
“The VA currently requires CC providers to have an active license and a lack of sanctions but does not set minimum quality thresholds or choose hospitals based on cost,” the researchers wrote. “Better information on the characteristics of CC patients and the hospitals that care for them could improve VA decision making. For this reason, we recommend that the VA seek information needed to assess the quality of care, including performance measures based on submission to the national registries of PCI and CABG surgery. This process could allow the VA to selectively contract with hospitals that meet standards of both quality and transparency.”
With death being so rare in the study, the power to detect differences in quality based on mortality could have been limited, the authors noted. In addition, because the analysis only included patients younger than 65, the findings may not be generalizable to older veterans.