Health Services Research & Development

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2006 HSR&D National Meeting Abstract


3017 — Regional Variations of Aggressive Medicare Treatments in VA and Medicare Hospitals

Author List:
Yu W (VA Health Economics Resource Center)
Chow A (VA Health Economics Resource Center)
Hill A (VA Health Economics Resource Center)
Richardson S (VA Health Economics Resource Center)
Garber A (VA Palo Alto Health Care System)

Objectives:
This study analyzes the geographic variation in aggressive medical treatments near the end of life in the Department of Veterans Affairs (VA) and Medicare hospitals.

Methods:
We retrospectively analyzed geographic variation of five aggressive medical treatments (intensive care unit (ICU), mechanical ventilator, pulmonary artery monitor, cardiac catheterization, and dialysis) provided by either VA or Medicare hospitals during the final 2 years of life of veterans who died between October 1, 1999 and September 30, 2001, and were over age 67 at death (N=169,314). 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.

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.

Implications:
Regional practice pattern is a significant factor in the observed variation of medical treatments although financial incentive is also involved in medical decisions.

Impacts:
Although the VA system does not have financial incentive to induce demand, variation in aggressive treatments indicates inconsistency in quality of care near the end of life. Reducing this variation could improve the quality of care in the VA.