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IIR 04-236 – HSR&D Study

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IIR 04-236
Reducing Avoidable Deaths by Directing Veterans' Surgical Care in the Private Sector
William B. Weeks MD MBA
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: July 2005 - June 2007

BACKGROUND/RATIONALE:
Using two interventional cardiac procedures (Coronary Artery Bypass Grafting (CABG) surgery and Percutaneous Coronary Interventions (PCI) as examples of regionalized high technology services, we have studied the impact of regionalizing care on the volume of services that New York veterans obtain through the private sector. Our results suggest that the large majority of enrolled veterans' interventional cardiac procedures take place in the private sector. However, we discovered that veterans are more likely to obtain this care in lower quality private sector hospitals, i.e.., those with higher risk-adjusted mortality. We found that directing enrolled veterans' private sector coronary interventions to high quality hospitals has the potential to reduce risk-adjusted mortality rates for CABG and PCI by 50%. These findings suggest a new role for VHA - similar to that recently adopted by large employers to improve the outcomes of their employees - that of directing enrolled veterans to high quality private sector care.

OBJECTIVE(S):
We propose to explore the broader efficacy of this new role by examining the potential benefits of directing enrolled veterans to high quality private sector care for fourteen high-risk surgical procedures (coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, carotid endarterectomy, lower-extremity bypass, elective repair of abdominal aortic aneurysm, colectomy, gastrectomy, esophagectomy, pancreatic resection, nephrectomy, cystectomy, pulmonary lobectomy, or pneumonectomy). We chose to study these procedures for five reasons:
1. Cardiovascular disease and cancer are common in the veteran population.
2. Veterans are likely to obtain these services in the private sector.
3. These procedures are largely elective and present a non-trivial mortality risk.
4. There procedures demonstrate variation in outcomes in the private sector.
5. Established methods for analysis and comparison exist.

METHODS:
We conducted a retrospective study of veterans aged 65 and older who a) were patients in
the VA health care system during 2000 and 2001 and b) obtained, in either a VA or a Medicare-
funded private sector hospitalization, any of fourteen procedures which have non-trivial mortality
rates and show hospital-specific variation in 30-day risk-adjusted mortality among Medicare
beneficiaries. These procedures included six cardiovascular procedures (coronary artery
bypass grafting (CABG) surgery, carotid endarterectomy, lower extremity bypass surgery, aortic
valve replacement, elective abdominal aortic aneurysm repair, and mitral valve replacement) and
eight cancer resection procedures (colectomy, lobectomy, nephrectomy, gastrectomy, cystectomy,
pancreatectomy, pneumonectomy, or esophagectomy). Emergent cardiovascular cases and non-
cancer related resection procedures were eliminated from the analysis.

FINDINGS/RESULTS:
Over the two year study period, older veterans who were enrolled in the VA obtained a
total of 139,217 procedures: 119,245 (85.6%) were obtained in the private sector,funded by Medicare, and 20,072 (14.4%) were obtained in the VA. The VA provided only about
1/8 of the cardiovascular procedures that these older veterans received, and a little more than 1/5 of their cancer resections. Reliance on the VA was greatest for cystectomies and esophagectomies, in particular, as the VA provided more than ¼ of these procedures.

Ninety-seven percent of these high-risk procedures were obtained in hospitals that we
were able to rank by performance quintile. By definition, the expected distribution of patients, assuming older VA enrollees used the private sector similarly to the overall Medicare population, was 20% in each quintile. With only a few exceptions among the less common surgeries and regardless of procedure and regardless of whether performance was defined by historical volume or historical risk-adjusted mortality rates, we found that VA patients used lower and higher performance hospitals at close to expected rates.

If VA patients who were already using the private sector had obtained their private sector
care in only the best two performance quintiles, between 376 and 584 lives could have been saved, depending on the method used to define performance. If these patients had been directed to historically high volume centers for their procedures, expected mortality rates would have decreased by 6.6% (from 4.76% to 4.44%) potentially saving 376 lives during the two years. Directing private sector care to historically low risk-adjusted mortality centers would have decreased expected mortality rates by 9.9% (from 4.93% to 4.43%), potentially saving 584 lives. Under either scenario, about half of the potential lives saved would come from directing private sector CABG surgery and aortic valve replacement to high performance hospitals.

With performance based on historical volumes, a substantial travel time burden would be
associated with directing patients to better private sector care. Directing patients to high
performance CABG surgery and aortic valve replacement hospitals would have led to mean additional travel times of 61 and 54 minutes, respectively, but would have saved 188 lives. Alternatively, with performance based on historical risk-adjusted mortality, a much more modest travel time burden would be associated with directing private sector care. Under that scenario, directing patients to high performance CABG surgery and aortic valve replacement hospitals would have led to a mean additional travel time associated of 20 and 15 minutes, respectively, and would have saved 318 lives.

IMPACT:
In our analysis of older VA patients, we found that the large majority of their
cardiovascular procedures and cancer resections are provided in the private sector. These patients and their doctors did not appear to select high performance private sector hospitals; instead, VA patients were equally likely to obtain care in low and high performance surgical centers. We found that directing VA patients’ private sector care to high performance hospitals might save a substantial number of lives. When high performance in the private sector is defined by historical risk-adjusted mortality rates, directing care would save more lives and minimize additional travel burden.

Our findings are important for several reasons. First, they confirm that VA patients are
distributed evenly across private sector hospitals of varying performance. To be sure, the influence of publicly released outcomes data does not appear to influence hospital choice for most private sector patients. However, our study suggests a potential new role for the VA – that of taking an active role in coordinating private sector care for VA enrollees. Indeed, through cooperative efforts between VA and CMS, VA may be able to influence the quality of care received by veterans treated outside of VA facilities by providing incentives for VA patients to obtain private sector care in high performance hospitals.

Second, our analysis suggests that efforts at directing private sector care could be focused on a limited number of procedures, if necessary. While every potential life saved is important, our findings suggest that prioritizing CABG surgery and aortic valve surgery would be the most productive and efficient approach to saving lives. Further, our results indicate that veterans should not bear an undue travel burden if such a program is implemented.

Finally, our findings suggest that a focus on improving the quality of VA enrollees’
private sector care is likely to have a greater payoff than a focus on improving care provided within the VA for three reasons. First, directing private sector care is feasible. The Leapfrog Group and other health care purchasers, including CMS, have examined the benefits of restricting care to high performance hospitals. Particularly if coordinated with Medicare, VA could adopt a combined HMO/insurer approach to managing the outcomes of its overall service population. Second, due to the much greater volume of private sector care, smaller outcomes improvements can have a greater impact on VA’s service population than additional efforts to improve VA care. Given the volumes and crude mortality rates for VA care for these procedures, an overall reduction in VA’s crude mortality rates for all procedures of 52% would be required to save the same number of lives that could be saved through directing private sector care to high performance hospitals. VA crude mortality rates would then be approximately ½ the rates of top
private sector performers, an unrealistic goal for improvement for any healthcare provider, particularly because patients who obtain these procedures within the VA are more likely to be sicker, poorer, and uninsured, rendering risk-adjusted mortality rate reduction much harder to achieve . Third, while some might argue that an alternative to directing private sector care would be to direct care into the VA system, this strategy might not be as effective or efficient as directing private sector: because relatively few VA sites provide these services, restricted access to care might render the strategy practically infeasible; in addition, the costs of absorbing dramatic volume increases might render the strategy fiscally infeasible.

PUBLICATIONS:

Journal Articles

  1. Payette M, Chatterjee A, Weeks WB. Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions. American journal of surgery. 2009 Jun 1; 197(6):820-5; discussion 826-7.
  2. Weeks WB, Lee RE, Wallace AE, West AN, Bagian JP. Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals? The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2009 Jan 1; 25(1):62-9.
  3. Weeks WB, West AN, Wallace AE, Fisher ES. Comparing the characteristics, utilization, efficiency, and outcomes of VA and non-VA inpatient care provided to VA enrollees: a case study in New York. Medical care. 2008 Aug 1; 46(8):863-71.
  4. West AN, Weeks WB, Wright SM, Wallace AE, Fisher ES. When VA patients have non-VA hospitalizations, who pays for what services, and what are the research implications? A New York case study. Medical care. 2008 Aug 1; 46(8):872-7.
  5. Muffly TM, Weeks WB. Income differentials required to make fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral. International urogynecology journal and pelvic floor dysfunction. 2008 Jan 1; 19(1):151-6.
  6. Weeks WB, Wallace AE. Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2008 Jan 1; 24(2):161-70.
  7. Weeks WB, Fisher ES. Characteristics of VA patients who use low-quality private-sector CABG centers in New York. Medical care research and review : MCRR. 2007 Dec 1; 64(6):691-705.
  8. Weeks WB, Wallace AE. Gender differences in ophthalmologists' annual incomes. Ophthalmology. 2007 Sep 1; 114(9):1696-701.
  9. Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JP. Awareness and use of a cognitive aid for anesthesiology. Joint Commission Journal on Quality and Patient Safety. 2007 Aug 1; 33(8):502-11.
  10. Wallace AE, West AN, Booth BM, Weeks WB. Unintended consequences of regionalizing specialized VA addiction services. Psychiatric services (Washington, D.C.). 2007 May 1; 58(5):668-74.
  11. Weeks WB, Wallace AE. Differences in the annual incomes of emergency physicians related to gender. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2007 May 1; 14(5):434-40.
  12. Weeks WB, Wallace AE. Gender differences in the annual income of psychiatrists. Psychiatric services (Washington, D.C.). 2007 Apr 1; 58(4):515-20.
  13. Weeks WB, Wallace AE, Mackenzie TA. Gender differences in anesthesiologists' annual incomes. Anesthesiology. 2007 Apr 1; 106(4):806-11.
  14. Weeks WB, Wallace AE. Race and gender differences in pediatricians' annual incomes. Ambulatory Pediatrics : The Official Journal of The Ambulatory Pediatric Association. 2007 Mar 1; 7(2):196-200.
  15. Weeks WB, Wallace AE. The influence of provider sex on neurologists' annual incomes. Clinical Neurology and Neurosurgery. 2007 Jan 1; 109(1):38-44.
  16. Weeks WB, Wallace A. The influence of race and gender on family physicians' annual incomes. Journal of the American Board of Family Medicine. 2006 Nov 1; 19(6):548-56.
  17. Weeks WB, Wallace AE. Race and gender differences in general internists' annual incomes. Journal of general internal medicine. 2006 Nov 1; 21(11):1167-71.
  18. Weeks WB, Wallace AE. Association of race and gender with general surgeons' annual incomes. Journal of the American College of Surgeons. 2006 Oct 1; 203(4):558-67.
  19. Weeks WB, Wallace AE. Gender differences in diagnostic radiologists' annual incomes. Academic Radiology. 2006 Oct 1; 13(10):1266-73.
Conference Presentations

  1. Weeks B. Implications of a single payer for veterans in the US: CABG in New York as an example. Poster session presented at: Associazone Italiana di Economia Sanitaria Annual Conference; 2007 Nov 16; Venice, Italy.
  2. Wallace E, Lee, West N, Weeks B. Longitudinal differences in health status and utilization when comparing rural and urban veterans. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 3; Washington, DC.
  3. Weeks B, Schmidek, Wallace E, Dimick. Do JCAHO accredited hospitals perform better on quality measures? An analysis of process-of-care measures and surgical indicators. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 3; Washington, DC.
  4. Weeks B, West N, Lee, Wallace E. VA Can improve older enrollees' outcomes by directing public health sector care to high performance hospitals. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 3; Washington, DC.
  5. West N, Weeks B. Comparing three datasets on payers for the private sector inpatient care of VA patients. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 3; Washington, DC.
  6. Muffly , Weeks B. Income differentials required to make fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral. Poster session presented at: American Urogynecologic Society Annual Scientific Meeting; 2007 Sep 27; Hollywood, FL.
  7. Weeks B, Schmidek M, Wallace E, Dimick B. JCAHO accreditation associated with improved surgical outcomes: use of the accreditation process to improve patient safety. Paper presented at: Patient Safety Research Annual Conference; 2007 Sep 24; Porto, Portugal.
  8. Nyweide J, Anthony L, West N, Weeks B, Fisher S. How large are primary care medical groups in the United States? A descriptive analysis. Poster session presented at: National Research Service Award Trainees Research Annual Conference; 2007 Jun 2; Orlando, FL.
  9. Wallace AE, Booth BM, Weeks WB, West AN. Distance as a barrier to addiction treatment for rural and urban veterans in the regionalized VA system. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 17; Anchorage, AK.
  10. West N, Wallace E, Weeks B. Urban-rural inequities in access to inpatient PTSD treatment in the VA healthcare system. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 17; Anchorage, AK.
  11. West N, Weeks B. Urban-rural inequities in the quality of hospitals where older veterans receive high-risk surgeries. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 17; Anchorage, AK.
  12. Schmidek, Weeks B, Nelson A, Wallace E. How does hospital performance among rural hospitals compare to suburban or urban hospitals? An analysis of process-of-care measures and surgical indicators. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 16; Anchorage, AK.
  13. Weeks B, Wallace E. Differences in practice characteristics and physician incomes associated with practicing primary care in a rural, as opposed to urban, setting. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 16; Anchorage, AK.
  14. Neily, Mills D, Watts V, Dunn J, Williams, Bagian P, Weeks B. Development of an interprofessional fellowship program for patient safety. Poster session presented at: National Patient Safety Foundation Patient Safety Annual Congress; 2007 May 3; Washington, DC.
  15. Mooney E, Weeks B. Where do women veterans get their inpatient care? Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  16. West N, Weeks B, Bagian P. AHRQ's patient safety indicators in nine years of VA inpatient data: Low reliability limits their use as performance measures. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  17. Wallace E, West N, Booth M, Weeks B. Distance as a barrier to addiction treatment for rural and urban veterans. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  18. Weeks B, Wallace B, Wallace E. Gender and race differences in the incomes of US primary care physicians. Paper presented at: Associazone Italiana di Economia Sanitaria Annual Conference; 2006 Nov 16; Venice, Italy.
  19. Wallace AE, Weeks WB. Alcohol use disorder and drinking age on US military bases. Paper presented at: Addiction Health Services Research Conference; 2006 Oct 23; Little Rock, AR.


DRA: Health Systems
DRE: none
Keywords: Adverse events, Safety, VA/non-VA comparisons
MeSH Terms: none

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