Higher Mortality for Veterans Choosing Community Hospitals Rather than VA for Percutaneous Coronary Intervention
BACKGROUND:
Due to concerns about timely access within the VA healthcare system, VA expanded care options with the development of a community care program that enables Veterans to receive care from non-federal facilities, with the expenses covered by the federal government. Moreover, recent changes in policy also will expand the use of healthcare in the community for Veterans. Concurrent with these policy changes, the cases of Veterans afflicted with cardiovascular disease have increased in complexity over the last decade. Therefore, this study compared the clinical outcomes of Veterans undergoing elective percutaneous coronary revascularization (PCI) at VA and community hospitals after the significant expansion of the community care program. Investigators identified 8,913 Veterans who were actively enrolled in VA healthcare and underwent elective PCI for stable angina between October 2015 and December 2018. Data for those treated within VA were obtained from the electronic medical record; the Fee-Basis Claim System and the Program Integrity Tool were used to collect data for non-VA care. Using this information, investigators analyzed all-cause mortality between the two groups.
FINDINGS:
- Veterans receiving elective PCI in the community were at higher risk of dying—especially within the first month—than those treated at a VA medical center.
- There was a 33% increase in death risk for Veterans treated at community hospitals versus within VA, with an absolute risk difference of 1.4%. Restricting the analysis to just the first month after the procedure showed an even sharper increase in relative risk—143%, with an absolute difference of 0.7%—for the community-hospital setting.
- Two-thirds (67%) of Veterans received elective PCI within VA, while 33% received PCI in community facilities. However, over the period of 2015 to 2018, the probability of having PCI performed at a non-VA hospital rose from 39% to 52%.
IMPLICATIONS:
- Further investigations should focus on the most effective means to improve Veterans' access to cardiovascular care while also maintaining quality.
LIMITATIONS:
- Limited data were available on the procedural characteristics for patients treated in the community, thus it is possible that more anatomically complex procedures were performed in that setting.
AUTHOR/FUNDING INFORMATION:
Dr. Waldo is National Director of the VA Clinical Assessment, Reporting and Tracking (CART) Program. Dr. Ho is co-Director of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care in Denver, CO. Drs. Waldo, Barón, Valle, Plomondon, and Mr. Glorioso are part of the Rocky Mountain Regional VA Medical Center in Aurora, CO.
Waldo S, Glorioso T, Barón A, Plomondon M, Valle J, Schofield R, and Ho PM. Outcomes among Patients Undergoing Elective Percutaneous Coronary Intervention at Veterans Affairs and Community Care Hospitals. Journal of the American College of Cardiology. September 2020;(76)9.
