Impact of New Technologies on Chronic Heart Failure Outcomes and Costs in the VHA
Peter W. Groeneveld MD MS
Philadelphia VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: January 2011 - February 2014

BACKGROUND/RATIONALE:
Chronic heart failure is an extremely common, high-mortality and high-cost disease among older veterans. Several technologies, including devices such as implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy-defibrillators (CRT-Ds), as well as pharmacotherapies such as the beta-blockers carvedilol and extended-release metoprolol, have been demonstrated to reduce mortality among patients with CHF. While some technologies such as ACE-inhibitors currently are used in almost all veterans with CHF, devices and beta-blockers are not yet used in all clinically eligible patients. The costs of these technologies are substantial, and thus it is important to quantify the benefits that these technologies have yielded among veterans with CHF during the past ten years relative to their costs, and it is also critical to identify existing opportunities to improve CHF health care quality at reasonable cost.

OBJECTIVE(S):
The goals of this project are: (1) to examine national trends across VA from 2001-2010 in the use of ICDs/CRTs and carvedilol/metoprolol and to determine if changes in technology use at the VAMC/VISN level were correlated with changes in CHF outcomes; (2) to measure the changes in costs of care for veterans with CHF resulting from the increased use of devices and carvedilol/metoprolol; (3) to identify opportunities for improvement in VA CHF care through greater use of these therapies, estimate the magnitude of the veteran CHF population health benefit that would result from greater technology use, and compare this benefit to the increase in costs to VA that would be necessary for full dissemination of these technologies.

METHODS:
This study is using multiple sources of data describing health care utilization and costs among Veterans with CHF, including the VA's Medical SAS datasets at the Austin Information Technology Center, VA Decision Support System data, the VA Vital Status File, and the VA-Centers for Medicare and Medicaid Services datasets (managed by the VA Information Resource Center-VIReC) that provides information on Veterans dually enrolled in VA and Medicare. We have identified annual cohorts of CHF patients within each VAMC and VISN from 2001-2010, and we are using VA's medical procedure, surgery, and pharmacy databases to measure longitudinal trends in technology use rates, outcomes, and costs among these cohorts via hierarchical linear regression models using a "difference-in-difference" approach. In 2013, these models will then be used to predict costs and benefits of future increases in technology use among VAMCs and VISNs that show evidence of below-target use of newer CHF technologies.

FINDINGS/RESULTS:
In late 2012 we finalized our collection of study data when we received Medicare claims from VIReC. We are currently cleaning these data and linking them with VA data obtained from the Austin Information Technology Center. We anticipate using these data for additional project analyses early in 2013.

IMPACT:
This project is investigating how increasing use of evidence-based pharmaceutical and device therapies from 2001-2010 among Veterans with CHF has affected clinical outcomes and will also quantify the rise in VA costs associated with increasing use of these therapies. The project will illuminate potential opportunities for improvement in VHA CHF outcomes by increasing the use of evidence-based therapies. The additional costs to VA of implementing this care also will be forecast. The overarching goal is to provide VA policymakers with information on how technology has impacted the outcomes and costs of CHF care in the recent past, and to predict how technology might influence VA's CHF outcomes and costs in the immediate future.

PUBLICATIONS:

Conference Presentations

1. Groeneveld PW, Richardson DM. Cost consequences of increasing use of implantable cardioverter-defibrillators in the Veterans Health Administration: 2001-2010. Poster session presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2011 May 12; Washington, DC.
2. Groeneveld PW. Cardiovascular devices: comparative effectiveness research and critical economic realities. Paper presented at: Duke University Clinical Research Institute Annual Clinical Medicine Series; 2010 Nov 1; Durham, NC.

Journal Other

1. Groeneveld PW. How drug-eluting stents illustrate our health system's flawed relationship with technology: comment on "use of drug-eluting stents as a function of predicted benefit". Archives of internal medicine. 2012 Aug 13; 172(15):1152-3.

Center Product

1. Groeneveld PW. Implantable cardioverter-defibrillators in VHA and healthcare cost growth: 2001-2010 [HERC Health Economics Seminar]. [Cyberseminar]. 2012 Jun 20.

DRA: Cardiovascular Disease
DRE: Epidemiology
Keywords: Cardiovascular Disease, Comparative Effectiveness, Cost-Effectiveness, Practice Patterns/Trends
MeSH Terms: none