BACKGROUND/RATIONALE:
Health care systems frequently regionalize high-technology, high cost health care services. Regionalizing care allows for increased volume and, thereby, better outcomes and lower costs. However, the extended times and distances that many patients must travel to obtain regionalized high-technology services through VHA may create implicit access restrictions. Although veterans frequently have a choice of where to obtain health care services, little is known about enrolled veterans' frequency of use of private sector services (across the age spectrum), enrolled veterans' outcomes of private sector care, and which characteristics influence veterans' choice of system of care for regionalized high-technology services.

OBJECTIVE(S):
Using two interventional cardiac procedures (Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Interventions (PCI)) as examples of regionalized high-technology services, this research will answer the following questions: 1) How many private sector interventional cardiac procedures do veterans use? 2) Why do veterans use the private sector instead of VHA for interventional cardiac procedures? 3) Is veteran status an independent risk factor for private sector in-hospital CABG mortality?

METHODS:
Retrospective cohort study of annual cohorts of veterans enrolled in the VHA system who were residents of New York in 1997-2000. We matched enrollment and utilization data from VHA to utilization data from New York’s Cardiac Surgery Reporting System (CSRS), in order comprehensively enumerate CABG and PCI utilization by New York veterans and to determine whether veteran status is an independent risk factor for private sector in-hospital CABG mortality. Using data from the merged VHA/Medicare database, New York’s CSRS, the Dartmouth Atlas of Health Care, the Department of Agriculture, and the US Census, we determined whether demographics, proximity to care, socioeconomic variables and insurance coverage status are associated with using the private sector instead of VHA for CABG and PCI.

FINDINGS/RESULTS:
Enrolled veterans who are residents of New York obtain the large majority of their coronary revascularizations through the private sector, even in younger age groups. In 1999 and 2000, 6,558 enrolled veterans obtained 7,494 coronary revascularizations; 85% were performed in the private sector. Veterans who used the VHA system for their revascularizations were younger, more likely to be black, more likely to have a VHA service connected disability, and had more recently used the VHA for other services. Distance to care was not associated with using VHA for CABG, but is associated with using VHA for PCI. Enrolled veterans who used the VHA were more likely to live in lower income areas than those who used the private sector for revascularization. Enrolled veteran status is not an independent risk factor for private sector in-hospital CABG mortality.

We also found that enrolled veterans’ private sector revascularizations were equally distributed across higher and lower mortality cardiac centers. Selective referral to lower mortality hospitals within the private sector care had the potential to reduce mortality at modest additional travel burden.

IMPACT:
Our findings suggest a new role for VHA: for procedures that veterans obtain in the private sector in high volumes, selective referral to high quality settings may be an effective way to improve veterans’ outcomes.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Weeks WB, Bazos DA, Bott DM, Lombardo R, Racz MJ, Hannan EL, Fisher ES. New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG. Health services research. 2005 Aug 1; 40(4):1186-96. [view]
2. Weeks WB, Bott DM, Bazos DA, Campbell SL, Lombardo R, Racz MJ, Hannan EL, Wright SM, Fisher ES. Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals. Medical care. 2006 Jun 1; 44(6):519-26. [view]

Conference Presentations

1. Weeks WB, Bott DM, Bazos DA, Racz MJ, Hannan EL, Wright SM, Fisher ES. Directing Private Sector Revascularization to Improve VA Patients' Outcomes. Poster session presented at: VA HSR&D National Meeting; 2005 Feb 17; Baltimore, MD. [view]
2. Weeks WB, Bott DM, Bazos DA, Campbell SLLR, Racz MJ, Wright SM, Fisher ES. Most Veterans Obtain Cardiac Care Revascularization Outside VHA. Presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]
3. Weeks WB, Bott DM, Bazos DA, Racz MJ, Hannan EL, Wright SM, Fisher ES. Travel costs and mortality benefits of directing VA patients' private sector revascularizations. Poster session presented at: International Health Economics Association Biennial World Congress on Health Economics; 2005 Jul 10; Barcelona, Spain. [view]
4. Weeks WB, Bazos DA, Bott DM, Campbell SL, Hanan EL, Racz MJ, Wright SM, Fisher ES. Veteran Status is not an independent risk factor for CABG mortality. Presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]

DRA: Health Systems Science
DRE: none
Keywords: Cardiac procedures, Utilization patterns
MeSH Terms: none