1052 — Declines in VHA Mortality in Association with Organizational Efforts to Improve Care of Patients with Acute Coronary Syndromes
Popescu I (Iowa City VA CRIISP) , Vaughan-Sarrazin MS
(Iowa City VA CRIISP), Rosenthal GE
(Iowa City VA CRIISP)
Following a 2003 report that raised concerns about quality of care for patients with acute myocardial infarction (AMI), VHA undertook a number of efforts to standardize care for patients with acute coronary syndromes. The goal of this study was to evaluate the impact of these organizational changes on AMI outcomes in VHA hospitals nationally.
The Patient Treatment File was used to identify consecutive patients admitted with a principle diagnosis of AMI (ICD-9 code 410) during 2000-2005 (n=43,691) to all VHA acute care facilities. Patients who died within 30 days of admission were identified using the Beneficiary Identifier Record Locator System. Primary endpoints included in-hospital and 30-day mortality. Hierarchical logistic regression models adjusted mortality for admission source, socio-demographics, comorbidity, and AMI location, and treated individual VAMCs as random effects.
Unadjusted 30-day mortality decreased from 12.3% in 2000 to 8.6% in 2005 (p<.001), while in-hospital mortality decreased from 10.8% to 8.2% (p<.001). Rates of coronary revascularization during the index hospitalization increased from 22.2% to 27.4% (p<.001), largely due to increases in use of coronary angioplasty (18.4% to 23.7%). In hierarchical models, the adjusted odds of 30-day mortality exhibited modest but not statistically significant declines in 2001 (OR, 0.97, p=.47), 2002 (OR, 0.95, p=.34), and 2003 (OR, 0.91, p=.053), compared to 2000, but did exhibit more marked declines in 2004 (OR 0.79, 95%CI 0.68-0.90,p<.001) and 2005 (OR 0.66, 95%CI 0.54-0.78, p<.001). Similarly, the adjusted odds of in-hospital death were comparable in 2000-03 (OR, 0.94, p=.25, OR, 0.97, p=.52, and OR, 0.96, p=.45, respectively), but were significantly lower in 2004 (OR 0.85, 95%CI 0.73-0.97, p=.006) and 2005 (OR 0.78, 95%CI 0.66-0.90, p<.001).
VHA experienced significant declines in 30-day and in-hospital mortality for AMI in 2004 and 2005, in association with major organizational efforts to improve quality for patients with acute coronary syndromes. The declines in mortality over time were much less marked prior to these efforts during 2000-2003.
The findings highlight the potential impact of a system wide effort, involving collaborations between VHA research teams and central and local operational leaders, to improve health care delivery for a defined patient population.