Ischemic heart disease (IHD) affects a large proportion of the U.S. population, accounting for hundreds of thousands of hospital admissions each year, nearly 500,000 deaths among women, and over 430,000 deaths among men annually. It is one of the most prevalent health problems of veterans. The most dramatic manifestation of IHD is acute coronary syndrome, comprised of both acute myocardial infarction (heart attack or AMI) and unstable angina which are responsible for over 25,000 admissions to VA hospitals annually. Although studies in the 1990's showed equivalent survival for patients admitted with AMI to VA facilities compared with patients with AMI whose care was covered by Medicare, a more recent investigation reported a disparity favoring Medicare. That study and others also showed lower use of invasive cardiac procedures after AMI among VA patients, suggesting clinically indicated cardiac catheterization might be underused within VHA.
The objective of the study, a collaboration between IHD QuERI, the Office of Quality and Performance and the Office of Patient Care Services, was to create a database to follow all patients discharged from VHA inpatient acute care facilities with a diagnosis of AMI or UA; and to use this database to identify gaps in performance for which implemention of evidence-based best practices would be most beneficial to patient care.
Data from OQP's External Peer Review Program (EPRP) for FY04 through FY07, the Survey of Health Experiences of Patients (SHEP), Pharmacy Benefits Management (PBM), the National Patient Care Databases (NPCD) and SAS Medical Inpatient files at the Austin Automation Center, and the VHA Decision Support System National Data Extracts (DSS NDE) Laboratory Results and Pharmacy Datasets were merged and updated on a periodic basis. To evaluate outcomes and processes of care for all patients admitted to VHA hospitals with AMI and UA, we constructed risk-adjusted models that evaluated 30-day, 60-day and one-year mortality; cardiac catheterization; revascularization; and transfer. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. In addition, data from the 2004 and 2006 VHA All-Employee survey were used to evaluate the influence of organizational factors on the adoption of innovation and technology in cardiac care.
Using EPRP data from 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p=.011). Similar declines were found for in-hospital and 90-day mortality. Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Between FY04 and FY06, the percent of patients receiving ECG within 10 minutes increased from 51.1 to 61.6 percent, and the percent with troponin report within 60 minutes increased from 71.3 to 76.3.
CONCLUSION: Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals. Improvements in process of care for patients with ACS over the past three years have paralleled national efforts in process improvement and performance measurement.
The results of collaborative efforts involving OQP, PCS, OI and VA Research and Development demonstrate that a multifaceted and sustained program has the potential to improve care and produce new knowledge.
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