Background Policies to concentrate or regionalize invasive proceduresat high-volume medical centers are under active consideration.Such policies could improve outcomes among those who undergoprocedures while increasing their underuse among those who neverreach such centers. We compared the underuse of needed angiographyafter acute myocardial infarction in a traditional Medicarefee-for-service system with underuse in the regionalized Departmentof Veterans Affairs (VA) health care system.
Methods We studied 1665 veterans from 81 VA hospitals and 19,305Medicare patients from 1530 non-VA hospitals, all of whom wereelderly men. We compared adjusted angiography use and one-yearmortality among patients for whom angiography was rated as clinicallyneeded. We compared underuse in models before and after controllingfor the on-site availability of cardiac procedures.
Results After adjustment for the need for angiography, underusewas present in both groups, but VA patients remained significantlyless likely than Medicare patients to undergo angiography (43.9percent vs. 51.0 percent; odds ratio, 0.75; 95 percent confidenceinterval, 0.57 to 0.96). After also controlling for on-siteavailability of cardiac procedures at the admitting hospital,we found no significant difference in the underuse of angiographyamong VA patients as compared with Medicare patients (odds ratio,1.02; 95 percent confidence interval, 0.82 to 1.26) or in one-yearmortality (odds ratio, 1.08; 95 percent confidence interval,0.89 to 1.28).
Conclusions There is underuse of needed angiography after acutemyocardial infarction in both the VA and Medicare systems, butthe rate of underuse is significantly higher in the VA. Thesedifferences appear to be associated with limited on-site availabilityof cardiac procedures in the regionalized VA health care system.Further work should focus on how regionalization policies couldbe improved with effective referral and triage processes.
Source Information
From the Houston Center for Quality of Care and Utilization Studies, Houston Veterans Affairs Medical Center, and the Section for Health Services Research, Baylor College of Medicine, Houston (L.A.P.); the Department of Health Care Policy, Harvard Medical School, Boston (S.-L.T.N., B.J.M.); the Departments of Biostatistics (S.-L.T.N.) and Health Policy and Management (L.L.L.), Harvard School of Public Health, Boston; and the Department of Radiology, Brigham and Women's Hospital, Boston (B.J.M.).
Address reprint requests to Dr. Petersen at Health Services Research and Development (152), Houston Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030.
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