HSR&D Home » Research » SDR 03-289 – QUERI Project
Evaluating Quality of Care for Acute Coronary Syndromes in VHA
Stephan D. Fihn, MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Greg Larsen MD
VA Portland Health Care System, Portland, OR
Funding Period: October 2004 - June 2008
A VA-commissioned audit suggested that VA patients had higher one-year mortality and fewer cardiac procedures following acute myocardial infarction (AMI) compared with patients admitted to Medicare facilities. In response, we prospectively collected data to further evaluate quality of care and outcomes for patients with acute coronary syndromes (ACS) admitted to VA facilities.
Objectives were to: compare patient characteristics, processes of care, and clinical and patient-reported outcomes for ACS between patients treated in VA and other systems; validate sensitivity of case-finding methods employed by VA's external peer review program (EPRP); and evaluate structural and process components of change in cardiac care within VA. Subsequently, we added an objective to examine care and outcomes of patients presenting with ACS symptoms who were deemed not to have ACS by their physician but who ultimately had laboratory results suggesting AMI, specifically, elevated troponins.
We prospectively collected data from nine VA facilities. Four were tertiary care centers capable of performing percutaneous coronary intervention (PCI), including Portland, OR, Denver, CO, Minneapolis, MI, and Durham, NC. Four others were the closest, most frequently referring non-tertiary facilities, including Roseburg, OR, Sheridan, WY, Fargo, MN, and Salisbury, NC, respectively. A ninth site added to increase recruitment was a PCI-capable tertiary facility in Tampa, FL. Patients were screened based on admitting symptoms of ACS or suspicion of ACS for other reasons. Detailed information was collected from patients and VISTA.
We screened 3352 patients admitted with suspected ACS and enrolled 832. Eighty were diagnosed with ST-segment-elevated AMI (STEMI), 425 were diagnosed as having non-ST elevation MI (NSTEMI), and 327 were diagnosed with unstable angina. To compare patients with elevated troponin levels but not ACS to those with AMI, we collected limited data on 564 patients not initially enrolled. Relative to data published from other prospective registries, VA patients had more coexisting chronic illnesses such as diabetes and kidney disease and higher prevalence of prior CABG (coronary artery bypass grafting). VA patients also underwent more cardiac procedures and were more frequently prescribed discharge medications. Compared with results from other studies, a larger percentage of VA patients with AMI arrived more than 12 hours after symptom onset. A high proportion of patients had positive troponin levels but were considered by attending cardiologist not to have ACS, although proportion varied dramatically by site. Compared to patients with ACS, patients with troponin-positive non-ACS had more coexisting chronic illnesses and worse in-hospital mortality.
Largely descriptive findings suggest that VA patients with ACS differ in important ways from those included in non-VA registries. In particular, the proportion with STEMI was considerably smaller, most likely due to characteristics of patients (e.g., greater burden of chronic illness) as well as system-level factors (e.g., proximity to VA facility) that have been associated with delays in seeking care. Patients with elevated troponins and no diagnosis of ACS were also very common, again likely reflecting high level of comorbidities. These findings provide important information for policies for clinical magement of ACS in VHA.
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DRA: Health Systems
Keywords: Acute illness, Cardiovasc’r disease
MeSH Terms: Acute Disease, Quality