Groeneveld PW, et al. - Authors ascertained whether or not there are substantial differences in cardiovascular outcomes across Veterans Affairs medical centers (VAMCs). Findings suggested a wide variation in the risk-standardized mortality rates for ischemic heart disease (IHD) and chronic heart failure (CHF) across the VA health system, and a good explanation of this variation was not given by differences in demographics or comorbidities. Substantial differences in the quality of cardiovascular care between VAMCs could be indicated by this variation.

Methods

• Experts conducted a retrospective cohort study comprising 138 VA hospitals and each hospital’s affiliated outpatient clinics.
• They identified the patients who received VA inpatient or outpatient care between 2010 and 2014.
• They constructed separate cohorts for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF).
• They evaluated the data between June 24, 2015 and November 21, 2017.
• In order to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs, hierarchical linear models with VAMC-level random effects were estimated.
• Risk standardization of mortality estimates using a wide array of patient-level covariates derived from both VA and Medicare health care encounters was done.
• Main outcomes and measures included all-cause mortality.

Results

• Findings suggested that the cohorts comprised 930,079 veterans with IHD and 348,015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n=822,665 [89%] and CHF, n=287,871 [83%]) and male (IHD, n=916,684 [99%] and CHF n=341,352 [98%]).
• As per data, for IHD, the VA-wide crude annual mortality rate was 7.4% and for CHF it was 14.5%.
• Results demonstrated that for IHD, VAMCs’ risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference).
• VAMCs’ risk-standardized mortality for CHF, varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference).
• IHD mortality rates that significantly exceeded the national mean were seen in 29 VAMCs, while CHF mortality rates that significantly exceeded the national mean were seen in 35 VAMCs.
• Authors did not note any association of VAMCs’ mortality rates among their IHD and CHF populations with 30-day mortality rates for myocardial infarction (R2=0.01; P=.35) and weakly associated with hospitalized heart failure 30-day mortality (R2=0.16; P < .001) and the VA’s star rating system (R2=0.06; P=.005).