Title: WinsLosses and ErrorsTies: Quality of Care for Acute Myocardial Infarction in the VA Health Care Sys
1Wins/Losses and Errors/TiesQuality of Care for
Acute Myocardial Infarction in the VA Health Care
System
- Laura A. Petersen, M.D., M.P.H.1
- Sharon-Lise T. Normand, PhD2
- Barbara J. McNeil, MD, PhD2
- 1 Houston Center for Quality of Care and
Utilization Studies, - an HSRD Center of Excellence
- 2Harvard Department of Health Care Policy
- Supported by VA HSRD IIR 94-054
- VA HSRD Career Development Award Program RCD
95-306 RWJ Foundation Generalist Physician
Faculty Scholar Award Program - AHRQ RO1-HS08071
2Background
- Acute myocardial infarction (AMI) is a common,
costly, and clinically significant condition, and
represents a signal event in the natural history
of ischemic heart disease - Appropriate quality of care for AMI improves
survival - Quality of care for AMI may indicate a hospitals
or systems ability to deliver highly skilled,
specialized acute medical care
3Goals
- To compare process of care and outcomes after
acute myocardial infarction in VA and non-VA
hospitals, controlling for differing patient
characteristics
4Methods - Patient Samples
- Age gt 65
- Male
- Clinically confirmed discharge diagnosis of acute
myocardial infarction - 29,249 FFS Medicare patients from 1,530 non-VA
acute care hospitals in CA, FL, MA, NY, OH, PA,
and TX - Random sample of 2,486 patients from 81 VA
hospitals nationwide
5Wins
- Petersen LA, Normand SL, Leape LL, McNeil BJ.
Comparison of use medications after acute
myocardial infarction in the Veterans Health
Administration and Medicare. Circulation,
2001104(24)2898-2904.
6Use of Thrombolytic Therapy at Arrival or Aspirin
at Discharge in VA Relative to Medicare
All comparisons significant at plt0.05
7Use of ACE Inhibitors or Beta-Blockers at
Discharge in VA Relative to Medicare
plt0.05 comparison NS
8Losses and Errors
- Petersen LA, Normand SL, Leape LL, McNeil BJ.
Regionalization and the underuse of angiography
in the Veterans Affairs Health Care System as
compared with a fee-for-service system. N Engl J
Med 2003 3482209-17.
9Age-Adjusted Rates of Cardiac Procedures Among
ACC Class I Patients
RR 0.72 95 CI (0.67-0.78)
RR 0.82 95 CI (0.78-0.87)
Diagnostic angiography within 90 days after
index admission. Procedures within 90 days among
patients who underwent angiography within 90 days
after index admission.
10Summary
- Differences in underuse not eliminated by
adjustment for patient characteristics and
clustering - Differences eliminated by adjustment for
procedure availability in the regionalized system
11Ties
- Petersen LA, Normand SL, Daley J, McNeil BJ.
Outcome of myocardial infarction in Veterans
Health Administration patients as compared with
Medicare patients. N Engl J Med
20003431934-41.
12Adjusted Odds of Mortality Medicare Relative to
VA(Using full sample 29,249 Medicare and 2,486
VA)
-
- Logistic Regression OR 95CI
- 30-day 0.93 (0.81-1.07) c0.800
- 1-year 0.93 (0.83-1.05) c0.799
- Adjusting for 30 sociodemographic, clinical and
hospital variables cArea under ROC curve - Results confirmed with propensity score adjustment
13Summary
- Wins VA patients were equally likely (in the
case of beta-blockers) or more likely (in the
case of thrombolytic therapy, ACE inhibitors, or
aspirin) than Medicare patients to receive
medications of known benefit after AMI - Losses/Errors Rates of use of angiography and
cardiac revascularization procedures were
significantly lower in the VA than in Medicare,
even among groups where angiography was deemed
clinically needed
14Summary and Conclusions (2)
- However, once admitting hospital procedure
availability was controlled for, there was no
difference in angiography use between patients
cared for in VA and Medicare - The findings suggest that underuse of angiography
could be remedied by changes in policy regarding
availability of angiography services and
regionalization of cardiac technology
15Summary and Conclusions (3)
- Ties VA patients were somewhat sicker than
Medicare patients. Yet, we found no significant
differences in 30-day or 1-year mortality between
Medicare and VA AMI patients