Veterans who underwent elective percutaneous coronary intervention (PCI) for stable angina at a community facility were at a 33% increased hazard, or chance, of death compared to patients treated within the Veterans Affairs (VA) Healthcare System, according to an analysis of nearly 9,000 veterans published today in the Journal of the American College of Cardiology.
Due to patient access concerns, the VA Healthcare System has expanded clinical care outside of the integrated system through a community care program that enables veterans to receive care from non-federal facilities. Facilities in the community care program range from academic medical centers to rural safety net hospitals, and since the community care program does not restrict access based on procedural volumes or quality, patients may choose facilities with differing levels of expertise.
According to the analysis, the utilization of community facilities for elective PCI has increased over 50% in the last three years. Overall, treatment in the community was associated with worse outcomes, including a 33% increased hazard of death within the first year after intervention and a 143% increased hazard of death within the first month.
"A larger proportion of Veterans are undergoing elective coronary intervention for stable angina in community facilities, a trend that will likely continue with the recent adoption of the MISSION ACT. The community facilities that provide care to these patients are heterogeneous, and the data available for quality assessment is largely limited to billing records," said Stephen W. Waldo, MD, National Director of the VA Clinical Assessment, Reporting and Tracking (CART) Program and lead author of the study. "While these data may be limited, this analysis suggests that clinical outcomes for Veterans undergoing percutaneous coronary intervention in the community may diverge from those treated within the VA Healthcare System. Because of this, we must ensure that increased access to medical care in the community is accompanied by mechanisms to ensure similar levels of quality."
Limitations include data for the VA Healthcare System was derived from clinical documentation whereas administrative billing data was used for care provided in community facilities. The limited data available on patients treated in community facilities means it is possible that more complex procedures were performed in that setting.
The researchers concluded that further study is needed to determine the most effective means to improves veterans' access to medical care while also maintaining quality.
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Journal of the American College of Cardiology