Advantages Seen for PCI Performed at VA Hospitals Rather Than in the Community

For US military veterans undergoing elective PCI, receiving treatment at a community hospital rather than a Veterans Affairs (VA) hospital is associated with shorter travel distances but increases in mortality and cost. For those undergoing CABG, however, treatment in the community is tied to reductions in travel distance and cost, with no impact on mortality.

Those findings come from a study published online January 3, 2018, ahead of print in JAMA Cardiology. In the study, researchers led by Paul Barnett, PhD (VA Palo Alto Health Care System, Menlo Park, CA), compared coronary revascularization procedures performed within the VA system with those performed outside of the system as part of the VA Community Care (CC) program, which allows veterans to obtain care at non-VA hospitals if the VA can’t provide the necessary services.

“As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending,” the authors write.

Moreover, they say: “To ensure that veterans receive care that is timely, accessible, and of the highest quality, policymakers should consider providing information to help veterans seek care from the highest-value hospitals and healthcare professionals regardless of whether the hospitals are VA or CC.”

Commenting for TCTMD, Jay Giri, MD (Hospital of the University of Pennsylvania, Philadelphia), said the study adds to other recent research showing that outcomes are at least as good if not better within versus outside of the VA health system, even if there are some issues in terms of access for VA hospitals.

Much of the current debate about improving access for veterans involves expanding opportunities for care at community providers, Giri pointed out, but “what’s not being taken into account with all this is what’s happening objectively when you fragment healthcare for an individual veteran.”

There’s a question about whether it’s better to invest government dollars in expanding access to non-VA services or to put more money toward building systems of care within the integrated VA system. Giri said the latter option—and not sending patients into the more fragmented setting of community care—is the way to go.

“What’s really needed is the ability to expand services in these types of arenas so that access is there for veterans to get care within their integrated health system,” he said, noting that he has successfully advocated for expansion at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, where he is director of the cath lab.

What’s really needed is the ability to expand services in these types of arenas so that access is there for veterans to get care within their integrated health system. Jay Giri

The CC program accounted for 10% of the VA healthcare budget in 2014, according to the authors, and the Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014 expanded the program further.

To explore whether there are differences in coronary revascularization procedures performed at VA versus CC hospitals, Barnett et al examined data on 13,237 elective PCIs and 5,818 elective CABGs performed in veterans younger than 65 between October 2008 and September 2011. Most procedures—79.1% of PCIs and 83.6% of CABGs—were done at VA hospitals.

In terms of access, treatment at CC centers reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG on average. Savings in travel expenses averaged $153 for PCI and $690 for CABG.

That did not translate into better outcomes in either group, however. In fact, propensity-adjusted 30-day mortality after PCI was higher at CC versus VA hospitals (1.54% vs 0.65%; RR 2.40; 95% CI 1.57-3.66). Mortality after CABG, as well as 30-day readmission rates after both PCI and CABG, did not differ based on center type.

Findings on cost were mixed. The mean adjusted cost of the index PCI was higher in CC hospitals ($22,025 vs $15,683; P < 0.001), whereas the cost of the index CABG was lower in the community ($55,526 vs $63,144; P < 0.01). The patterns for total costs—including the index procedure, readmissions, and travel—were similar.

In an additional analysis, trying to select hospitals on the basis of procedure volume or mortality “did not reliably identify centers where veterans had better outcomes,” Barnett et al report.

“Better information on the characteristics of CC patients and the hospitals that care for them could improve VA decision-making,” they write. “For this reason, we recommend that the VA seek information needed to assess the quality of care, including performance measures based on submission to the national registries of PCI and CABG surgery. This process could allow the VA to selectively contract with hospitals that meet standards of both quality and transparency.”

Given the current findings suggesting that veterans receive high-quality care within the VA system, however, they say that “one important way to improve value for veterans may be to increase capacity at high-performing VA facilities rather than seek to increase capacity by outsourcing to the community.”

Why the PCI Mortality Difference?

It remains unclear whether the lower PCI mortality rate seen in VA hospitals is a true difference driven by the advantages offered by an integrated healthcare system or whether other factors could be playing a role.

The authors note that the higher PCI mortality rate seen in the community may not reflect substandard care, but could be due to issues like “delay in making care arrangements, incomplete coordination of care between VA and CC hospitals, or failure to refill medications prescribed by CC clinicians,” all of which are areas that can be addressed with further research and quality improvement efforts.

Giri pointed out that the difference also could be related to referral patterns, in which VA cath labs—which often don’t have surgical back-up—refer more complex cases to community hospitals, or to other factors that are not well captured in administrative databases.

It’s safe to say, however, that given the relatively large gap in mortality between VA and CC centers seen in this study, “the VA is at least as good and . . . potentially better from a 30-day mortality standpoint,” Giri said.

In an accompanying editorial, Frederic Resnic, MD (Lahey Hospital and Medical Center, Burlington, MA), and Gautam Gadey, MD (Tufts School of Medicine, Boston, MA), say this study “is an important contribution to the current debate regarding the strategy of ‘outsourcing’ of care from within the VA to community-based programs in an effort to meet the growing healthcare demands of veterans.”

The results “reinforce the powerful effect on outcomes and costs of the VA integrated healthcare system, and there is much to be learned from the VA regarding the systems of care and coordination around elective PCI,” they write. “Perhaps a future requirement for participation in the CC program should be an explicit commitment to engage in quality monitoring and improvement efforts in conjunction with the VA to identify opportunities to improve the care at all centers. In addition, we believe the VA should actively monitor the clinical outcomes and costs at CC hospitals and provide this information to veterans and their VA clinicians to help them choose the most appropriate setting for their individual needs for coronary revascularization.”