VA can improve older enrollees' outcomes by directing private sector care to high performance hospitals

Background: Most veterans 65 or older who use VA care are concurrently enrolled in the government funded Medicare system; they can obtain care through the VA or in the private sector. In the private sector, 30-day mortality rates for 14 high-risk elective surgical procedures have been shown to vary dramatically. We wanted to determine whether veterans who obtained these procedures in the private sector did so in high or low performance hospitals and to model whether directing VA patients' private sector care to high performance hospitals might reduce overall mortality without unduly increasing travel burden.

Methods: Using a merged dataset of VA and private sector Medicare-funded hospitalizations during 2000-2001, we determined where VA enrollees ages 65 or older obtained any of 14 high-risk elective cardiovascular surgeries or cancer resections. We considered whether private sector services were provided in high or low performance hospitals (defined by surgical volumes or mortality rates calculated two years in advance of the service year). We then modeled the effect of redirecting all patients to high performance hospitals on mortality and travel burden.

Results: Depending on the procedure, older veterans obtained between 70-89% of these services in the private sector; they were equally likely to use high and low performance hospitals. Redirecting care to high performance hospitals would have resulted in a relative reduction in risk-adjusted mortality rates of 1% (pneumonectomy) to 42% (pancreatectomy). During the two years examined, between 376 and 385 deaths could have been avoided; most by redirecting cardiovascular care. Generally, patients would have to travel 15-30 minutes further if high performance was defined by historically low mortality, but 60-120 minutes further if by historically high volumes.

Discussion: Redirecting VA enrollees' private sector care to high performance hospitals could save a substantial number of lives, though there would be a modest additional travel burden. A focus on cardiovascular care would have the greatest impact on mortality reduction; using historical mortality to define high performance would minimize travel burden. To save the same number of lives, VA would need to reduce already low mortality rates for each procedure examined by almost 40%. VA has made great strides in improving the quality and safety of care provided within its hospitals. To ensure the safety of its service population, VA now needs to develop systems that direct patients who choose to use the private sector to the safest, highest performance private sector care available.