BACKGROUND/RATIONALE:
The goal of this project is to evaluate the quality of cardiac care delivered within VHA and compare it to non-VHA health care. This evaluation will be based on detailed, prospective assessment of the clinical characteristics of patients, their disease burden, and processes of care, and will assess mortality and other important clinical outcomes such as symptom relief and physical function.
OBJECTIVE(S):
To meet the continuing need for appropriately risk-adjusted evaluations of VHA cardiac care, we propose a study with the following objectives:
1.Compare patient characteristics, processes of care (e.g., provision of medications, and procedures) and risk-adjusted in-hospital mortality for acute coronary syndromes (ACS) between patients treated in VHA and those treated in other systems;
2.Compare adjusted, patient-reported health status outcomes (angina frequency, physical function, and health-related quality of life) among VHA patients and similar non-VHA patients enrolled in the The PRospective Evaluation of Myocardial Infarction (PREMIER) registry;
3.Ascertain the sensitivity of case-finding methods for ACS being applied by VHA External Peer Review Program (EPRP).
4.Evaluate structural and process components of change in cardiac care within VHA from October 2003 through September 2005.
METHODS:
For Objectives 1-3, we will recruit all patients admitted with suspected ACS during a 16-month period to a total of 9 medical centers (Portland, OR; Roseburg, OR; Minneapolis, MN; Fargo, ND; Durham and Salisbury, NC; Denver, CO and Sheridan, WY; Tampa, Fla). Prospective clinical data will be collected at each medical center. Enrolled patients will be asked to complete a set of health status questionnaires at baseline, and again at 6 and 12 months after discharge. We will assess mortality, re-hospitalization for cardiac events, revascularization procedures both within and outside VHA, and medication prescriptions. We will compare VA patients with those in national registries of ACS. We will validate EPRP using the data collected in this study. A series of multivariable regression analyses will be performed to identify the key patient risk factors associated with in-hospital and one-year mortality, re-hospitalization, and both 6-month and 12-month health status outcomes. For Objective 4, VHA Directive 2003-017 requires all VISNs to coordinate plans for ACS care for each hospital in their network. We will be monitoring these changes over time through qualitative interviews with Key Players in each VISN and documenting the relationship of system changes to changes in patient outcomes of care. We will assess the amount of change achieved in each VISN over the study period by Goal Attainment Scaling.
FINDINGS/RESULTS:
We have screened 3543 patients with suspected ACS and enrolled 837 patients admitted with suspected ACS during a 16-month period to 9 VA medical centers (Portland, OR; Roseburg, OR; Minneapolis, MN; Fargo, ND; Durham and Salisbury, NC; Denver, CO; Sheridan, WY; and Tampa, FL). Enrolled patients have been asked to complete a set of health status questionnaires at entry, and again at 6 and 12 months after discharge. Outcomes being evaluated include mortality, re-hospitalization for cardiac events, revascularization procedures both within and outside VHA, and medication prescriptions. Preliminary results confirm that VA patients with ACS typically have an extensive history of past cardiac disease and risk factors. The results also indicate that previous concerns regarding underuse of invasive cardiac procedures within VHA are unsupported. In comparison with the PREMIER registry, VA patients have undergone more procedures such as PCI and bypass surgery.
IMPACT:
Our study will provide both important new findings and methods for conducting quality improvement in the VHA. The end product of this study will be a working data collection and risk stratification system for the evaluation of ACS care in VHA hospitals. In addition, the evaluation of the process components of change in cardiac care in VHA can help further understand the impact of organizational variables on the quality of care ACS patients receive.
PUBLICATIONS:
Journal Articles
- Helfrich CD, Sharp ND, Pineros SL, Lowey E, McDermott KA, Sales AE, Larsen GC, Fihn SD. How Veterans Health Administration facilities have changed practices to improve care for patients with acute coronary syndromes. Circulation. 2007; 115(21): e591.
- McFalls EO, Ward HB, Moritz TE, Littooy F, Santilli S, Rapp J, Larsen G, Reda DJ. Clinical factors associated with long-term mortality following vascular surgery: outcomes from the Coronary Artery Revascularization Prophylaxis (CARP) Trial. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2007; 46(4): 694-700.
