Study Suggests Little Correlation between VA Spending and Survival among Veterans with Chronic Heart Failure
Studies of private sector care have demonstrated that healthcare spending varies widely across different regions in the US and that increased spending does not lead to better health outcomes. Although comparisons of VA costs and outcomes in highly selected VA clinical populations have been previously reported, relatively little is known about whether and how the variation in healthcare spending among large patient populations with chronic disease across the VA healthcare system is related to the substantial variation in cardiovascular outcomes. This retrospective cohort study sought to determine the association between healthcare spending and survival in VA patients with chronic heart failure (CHF). Using VA administrative data, investigators identified 265,714 Veterans who had been diagnosed with CHF between April 1, 2010 and December 31, 2013, and who had received care at any of 138 VAMCs or affiliated outpatient clinics. Patients were followed through September 2014. The study included patients with new onset CHF (diagnosed during the study period), as well as patients with existing CHF to more fully capture the entirety of VAMC-level spending. Investigators also assessed patient demographics, comorbidities, and previous major medical/surgical events (i.e., acute myocardial infarction, acute coronary syndrome, pneumonia, and stroke). Hospital-level factors (i.e., organizational environment and capabilities) were included in regression model analyses.
- There was a modest but statistically significant association between VA spending and survival among patients with CHF; however, the general relationship indicated little correlation.
- Mean annual expenditures varied from $21,300 to $52,800 per patient (annual expenditures at the highest-cost VAMC were about 2.5 times greater than expenditures at the lowest-cost VAMC)—and annual survival varied between 81% and 89%.
- 13 VAMCs in the lowest quartile for cost were also in the highest quartile for survival, whereas 10 VAMCs in the highest quartile for cost were also in the lowest quartile for survival.
- The addition of hospital-level factors to the regression model confirmed that the relationship between VA spending and outcomes was minimally affected by differences in VAMCs’ local labor costs, structural capacity, or the fraction of healthcare provided by non-VA sources.
- VA medical centers with high expenditures for patients with CHF may have opportunities to improve efficiencies and reduce costs while still aiming for optimal health outcomes.
- Comorbidity and disease severity are imperfectly measured using administrative data, thus the variations in survival and costs could have been the result of unobserved differences across VAMCs in comorbidities and/or disease severity.
This study was funded by HSR&D (IIR 14-077). Dr. Groeneveld, Ms. Medvedeva, and Ms. Walker are part of HSR&D’s Center for Health Equity Research & Promotion (CHERP), in Philadelphia, PA.
Groeneveld P, Medvedeva E, Walker L, et al. Association between Spending and Survival of Chronic Heart Failure Care in the Veterans Health Administration. JAMA Network Open. Epub: July 19, 2019.