Quality of Cardiovascular Care May Vary Substantially Across the VA System

In a paper published today in JAMA Cardiology, Peter W. Groeneveld, MD, MS, of the Veterans Affairs Medical Center, Philadelphia, and colleagues report that death rates for patients with ischemic heart disease (IHD) and chronic heart failure (CHF) vary widely across the Veterans Affairs (VA) system.¹ Those variations, they say, may point to important differences in care provided at VA medical centers.

Although the VA is a highly integrated system, some prior research has suggested that variation in health outcomes occurs across the VA; in order to assess whether there are substantial differences in the outcomes of patients with IHD and CHF, which are prevalent in the VA healthcare system, the research team conducted a cohort study among 930,079 patients with IHD and 348,015 patients with CHF who received treatment at 138 medical centers between 2010 to 2014. The patients were predominantly white males.

They found that the overall annual mortality rate in the IHD cohort was 7.4% and that the risk-standardized mortality rate for this group ranged from 5.5% (95% CI, 5.2%-5.7%) at the medical center with the lowest mortality to 9.4% (95% CI, 9.0%-9.9%) at the facility with the highest mortality.

In the CHF cohort, the overall annual mortality rate was 14.5%, which also varied across centers, with the lowest-mortality facility having a rate of 11.1% (95% CI, 10.3%-12.1%) and the highest-mortality center having a rate of 18.9% (95% CI, 18.3%-19.5%).

Mean composite IHD and CHF standardized survival scores were slightly higher in the East and Midwest than in the West and South of the country. The researchers observed a weak (R² = .06) but statistically significant (P = .005) association between the composite cardiovascular outcome measure and the VA’s Strategic Analytics for Improvement and Learning star system for quality measurement, but mortality rates for these cohorts were not associated with 30-day mortality rates and were only weakly associated with hospitalized heart failure 30-day mortality rates (R² =.16; P <.001).

The authors write that these differences among VA populations could reflect variability across the medical centers in terms of quality of care, adherence to evidence-based treatment and screening guidelines, access to urgent care, posthospitalization care protocols, chronic disease management, and access to specialty care, social work services, and behavioral health care.

In a linked editorial,² Paul A. Heidenreich, MD, MS, called the findings “provocative” and said that “the demand for quality has outpaced our ability to measure it.” According to Heidenreich, pay-for-performance programs for IHD and CHF that focus on hospitalization and the following 30 days may be part of the problem, because hospital-centric views of quality do not adequately address most patients with chronic diseases who spend more time outside the hospital than in it.

According to Heidenreich, the next steps for improvement include better data sharing to track patients across health systems, additional health services research, and increased analytical expertise among staff in health systems.

References

1. 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 [published online May 16, 2018]. JAMA Cardiol. doi: 10.1001/jamacardio.2018.1115.

2. Heidenreich PA. In pursuit of better measures of quality of care [published online May 16, 2018]. JAMA Cardiol. doi: 10.1001/jamacardio.2018.1204.