Remarkable advances during the past 50 years in the technology to prevent, diagnose, and treat cardiovascular disease have contributed to marked declines in cardiovascular mortality. However, these gains have been accompanied by substantial growth in healthcare costs. The VA faces pressure like never before to more fully optimize the value of its cardiovascular care.
This mixed-methods study compares the outcomes and costs of care for two widely prevalent and high-cost cardiovascular conditions - ischemic heart disease (IHD) and chronic heart failure (CHF) - across VA medical centers from fiscal years 2010 to 2014. The specific aims of the research project are: (1) to identify the VAMCs that consistently produced excellent risk-adjusted health outcomes for veterans with IHD and CHF during this five-year period and quantify the costs of care associated with producing these outcomes; (2) to identify and quantify the structural aspects of CHF/IHD care at these VAMCs that are most conducive to optimal outcomes and economic efficiency.
This is a "mixed-methods" study involving (Phase 1) a retrospective cohort analysis of existing VA national health care data to assess health care costs and outcomes among Veterans with IHD and CHF using multivariable statistical analyses. Hierarchical generalized linear models were conducted to investigate hospital-level outcomes and costs of cardiovascular care while controlling for key differences across VAMCs in their CHF and IHD patient populations. Phase 2 involved a prospective series of targeted interviews with healthcare providers at VAMCs to identify factors that contribute to high value cardiovascular care.
Investigators completed their analyses of cardiovascular outcomes for CHF (n=348,015) and IHD (n=930,079) at 138 VA hospitals and their affiliated outpatient clinics. Statistically significant variation in the mortality rates for Veterans with these diseases was observed across VA medical centers. For IHD, VA hospitals' risk-standardized mortality varied from 5.6% to 8.9%, p<0.001 for the difference. For CHF, VA hospitals' risk-standardized mortality varied from 11.8% to 18.0%, p<0.001 for the difference. Hospitals' mortality rates among their IHD/CHF populations were only loosely correlated to hospitals' 30-day mortality rates for myocardial infarction (R2=0.04, p=0.06) or hospitalized heart failure (R2=0.13, p<0.001) and to the VA's star rating system (R2=0.07, p=0.003).
Analysis of healthcare cost data across 138 VAMCs revealed that mean annual expenditures for veterans with heart failure varied from $21,300 to $52,800 per patient, while annual survival varied between 81.4% and 88.9%. There was a modest U-shaped association between spending and survival such that adjusted survival was statistically significantly higher at the minimum (p<0.001) and maximum levels (p<0.001) of spending by an average of 2 percentage points.
Qualitative analysis from Phase 2 revealed that most providers were aware of process-of-care measurements at their facilities, received regular feedback generated from those data, and used that feedback to change their practices. Fewer respondents reported clinical outcomes measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care. Providers also expressed general enthusiasm for the VA's quality measurement/improvement efforts, with relatively few criticisms about the workload or opportunity costs inherent in clinical performance data collection.
Results indicate that risk-standardized mortality rates for IHD and CHF varied widely across the VA's hospitals, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care across the VA's hospitals. Additionally, despite marked differences in mean annual expenditures per Veteran with CHF, we observed only a modest relationship between spending amounts and survival, with slightly higher survival observed at the extremes of the spending range. Interviews with providers at high- and low-performing hospitals revealed that most VA cardiovascular providers used feedback from process-of-care data to inform their practice. However, the limited use of outcomes data to inform health care practice raises concern that health care outcomes may have insufficient influence, while the lack of value data influencing cardiovascular care practices may perpetuate inefficiencies in resource use. These data provide a critical blueprint to VA clinical and operations leaders seeking to improve cardiovascular care throughout the VA healthcare system. Via the Center for Health Equity Research and Promotion's dissemination program, our findings will be communicated to key policy and clinical leaders in VA cardiology, who have partnered with the project's research team as co-investigators in the design and conduct of the study.
- Groeneveld PW, Medvedeva EL, Walker L, Segal AG, Richardson DM, Epstein AJ. Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration. JAMA cardiology. 2018 Jul 1; 3(7):563-571.