VA Out-of-System Access to PCI Linked to Higher Mortality

Debra L Beck

August 24, 2020

In an effort to expand access and decrease wait times, veterans can now have their elective percutaneous coronary intervention (PCI) done at nonfederal facilities, with the government footing the bill.

This policy has led to an increase of over 50% in the use of non-Veterans Administration (VA) facilities in the past 3 years, but also an apparent increase in mortality with these out-of-system procedures.

A study published online August 24 in the Journal of the American College of Cardiology reveals a 33% increased hazard in mortality among patients treated in the community, compared with those treated within the VA Healthcare System, with an absolute risk difference of 1.4%.

In a censored analysis looking at mortality over just the first month, a 143% increased hazard for mortality was seen (hazard ratio, 2.43; 95% CI, 1.50 - 3.94), with a 0.7% absolute risk difference.

In comments to theheart.org | Medscape Cardiology, lead author Stephen W. Waldo, MD, national director of the VA Clinical Assessment, Reporting, and Tracking (CART) Program, said the unclear provenance of these "clearly impressive" mortality differences highlight the need for continual assessment of care quality.

"Whether it's within the VA or outside the VA, the assessment of interventional quality is paramount to ensure that patients receive the best possible care, veterans or nonveterans," said Waldo, who is affiliated with both the University of Colorado School of Medicine and the Rocky Mountain Regional VA Medical Center, both in Aurora.

Looking specifically at this group of veterans undergoing PCI, he said that the data the VA receives back from the community hospitals are primarily limited to administrative billing records.

"We don't know if guidelines-recommended therapies or medications were given. We don't know if procedural-based recommendations were followed. For example, is there a high use of radial access and intravascular imaging at these non-VA facilities, which we hold to be the standard of care and indicative of high-quality procedural care?" said Waldo.

"It is also possible that the patients treated in the community are significantly more anatomically complex, and because of that, their procedural complication rate could also be significantly higher," he noted.

He acknowledged, however, that a significant difference in anatomical complexity between the two groups is unlikely. In fact, in data not included in the publication because of space restrictions, he noted that the clinical comorbidities were similar between the two groups.

Another possibility is that the VA just does PCI better.

There are no direct comparisons of PCI outcomes in VA and non-VA centers, said Waldo. But in a report he coauthored in 2018 that looked at temporal trends and PCI outcomes among patients treated within the VA, outcomes for the VA are comparable to, if not slightly better than, National Cardiovascular Data Registry CathPCI Registry outcomes, despite increasing and greater medical complexity in the VA cohort.

"Those are indirect comparisons, with no matching, and there's certainly room for residual confounding," he stressed.

In this current study, even when the researchers created a model using a hypothetical confounder, the difference in mortality persisted.

The researchers made up a hypothetical confounder that was similar in prevalence to a myocardial infarction, so approximately 20%, and had a significant association with death, similar to heart failure with a hazard of about 2.6.

"What we saw was that even if we missed that residual confounder and we didn't measure it, but subsequently found out about it and included it in the models, the risk of death would still be higher in the community by 22%," reported Waldo.

Of 8913 patients studied, 67% received PCI for stable angina in the VA Healthcare System, compared with 33% in community facilities. The researchers excluded from their analysis patients treated in geographic regions where there was not an equal opportunity to be seen at a community or VA facility.

More Care Isn't Always Better

In comments to theheart.org | Medscape Cardiology, Tyler J. Gluckman, MD, medical director of the Center for Cardiovascular Analytics, Research, and Data Science (CARDS) at Providence Heart Institute in Portland, Oregon, said the study "highlights the ongoing tension that exists in healthcare between expanded access and maintenance of quality."

He suggested that the heterogeneity of the expanded access facilities might have contributed to the observed findings, given what is known about the differences in outcomes at higher volume compared to lower volume facilities, and with higher vs lower-volume operators.

Poor care integration might also be to blame. "The finding that most of the observed increase in mortality occurred in the first 2 months following the procedure underscores the importance of early care coordination following procedures such as PCI," said Gluckman.

"To this end, it's possible that utilization of known risk-reducing interventions (eg, guideline-directed medical therapy, phase 2 cardiac rehabilitation) in the examined population posed a greater challenge for the expanded access (community) facilities," he added.

Veterans Choice Act and VA Mission Act

To reduce wait times, the VA developed a system whereby patients can receive care from nonfederal facilities, with the expenses covered by the federal government. For patients needing PCI, this means getting care at non-VA community hospitals instead of only at VA facilities.

The Veterans' Access to Care Through Choice, Accountability, and Transparency Act of 2014, also known as the Veterans Choice Act, was passed in response to the VA waitlist scandal of 2014.

The 2018 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, known as the VA Mission Act, was designed to improve access to care by, among other things, relaxing the criteria by which veterans are eligible to access nonurgent care outside the VA.

Veterans can currently receive non-VA care if their wait time in the system exceeds 30 days or if they live more than 60 minutes from a VA facility that performs the procedure needed.

According to Waldo, the majority of patients in this study who sought care outside the VA Healthcare System did so because they lived more than 60 minutes away from a tertiary-care VA facility that provided those services.

In this case, that freedom to "go anywhere" might be part of the problem. Once a patient is approved to go out of system, "they can essentially choose from among a defined list which hospital they would like to go to as long as that center contracts with the organization…. So, it's not limited, for example, based on hospitals that are deemed those that provide superior quality," said Waldo.

Waldo has received unrelated investigator-initiated research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated, Janssen Pharmaceuticals, and the National Institutes of Health. Gluckman has disclosed no relevant financial relationships.

J Am Coll Cardiol. 2020;76:1112-1116. Abstract

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