Wins/Losses and Errors/Ties:
Quality 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 HSR&D Center of Excellence;
2Harvard Department of Health Care Policy
Supported by: VA HSR&D IIR 94-054;
VA HSR&D Career Development Award Program RCD 95-306; RWJ Foundation
Generalist Physician Faculty Scholar Award Program;
AHRQ RO1-HS08071
Background
• 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 hospital’s
or system’s ability to deliver highly skilled,
specialized acute medical care
Goals
To compare process of care and
outcomes after acute myocardial
infarction in VA and non-VA
hospitals, controlling for differing
patient characteristics
Methods - Patient Samples
• Age > 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
“Wins”
Petersen LA, Normand SL, Leape LL, McNeil BJ.
Comparison of use medications after acute myocardial
infarction in the Veterans Health Administration and
Medicare. Circulation, 2001;104(24):2898-2904.
Percent
Use of Thrombolytic Therapy at
Arrival or Aspirin at Discharge in
VA
Relative
to
Medicare
100
90
80
70
60
50
40
30
20
10
0
Thrombolytics
Aspirin
All comparisons significant at p<0.05
Use of ACE Inhibitors or BetaBlockers at Discharge in VA
Relative to Medicare
80
70
Percent
60
Medicare
N=29,249
VA
N=2,486
50
40
30
20
* p<0.05
10
** comparison NS
0
ACE Inhibitors*
Beta-Blockers**
“Losses 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 feefor-service system. N Engl J Med 2003; 348:2209-17.
Percent
Age-Adjusted Rates of Cardiac Procedures
Among ACC Class I Patients
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
RR = 0.72; 95% CI (0.67-0.78)
RR = 0.82; 95% CI (0.78-0.87)
Medicare
VA
Angiography *
Any Revas †
*Diagnostic angiography within 90 days after index admission.
†Procedures within 90 days among patients who underwent angiography within 90 days after index admission.
Summary
• Differences in underuse not eliminated by
adjustment for patient characteristics and
clustering
• Differences eliminated by adjustment for
procedure availability in the regionalized
system
“Ties”
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 2000;343:1934-41.
Adjusted Odds of Mortality:
Medicare Relative to VA
(Using full sample = 29,249 Medicare and 2,486 VA)
Logistic Regression OR [95%CI]*
30-day
1-year
0.93 (0.81-1.07) c=0.800
0.93 (0.83-1.05) c=0.799
• Adjusting for 30 sociodemographic, clinical and hospital
variables; c=Area under ROC curve
• Results confirmed with propensity score adjustment
Summary
• 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
Summary 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
Summary 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