Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.
Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.
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DOI：
10.1001/jamacardio.2017.4843
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发表时间：
2018-02-01
期刊：
影响因子：
24
通讯作者：
Maddox TM
中科院分区：
文献类型：
--
作者：
Barnett PG;Hong JS;Carey E;Grunwald GK;Joynt Maddox K;Maddox TM
退伍军人事务部社区护理计划允许退伍军人在非退伍军人事务部网站接受护理，是否增加了他们选择性冠状动脉血运重建手术的可及性和价值？在这项退伍军人队列研究的13237例择期经皮冠状动脉介入治疗和5818例择期冠状动脉旁路移植术中，社区护理计划的使用减少了退伍军人进行血运重建的总旅行距离。社区护理计划医院的经皮冠状动脉介入治疗的死亡率和费用较高，而冠状动脉旁路移植术的死亡率和费用相当。在我们的退伍军人队列中，社区护理计划医院的使用改善了血运重建的总体可及性;社区护理计划医院提供了价值较低的经皮冠状动脉介入治疗手术，但价值较高的冠状动脉旁路移植术。退伍军人事务部（VA）社区护理（CC）计划通过社区医疗服务补充VA护理。然而，CC提供的访问增益和价值尚未得到很好的描述。比较VA和CC医院之间择期冠状动脉血运重建术的入路、成本和质量，并评价手术量或公开报告的质量数据是否可用于识别高价值护理。对接受选择性冠状动脉血运重建的65岁以下退伍军人进行的观察性队列研究，使用倾向调整控制风险因素的差异。地点是VA和CC医院。参与者是在2008年10月1日至2011年9月30日期间接受择期经皮冠状动脉介入治疗（PCI）的退伍军人和接受冠状动脉旁路移植术（CABG）手术的退伍军人。该分析在2014年7月至2017年7月期间进行。在VA vs CC机构接受择期冠状动脉血运重建。通过旅行距离、30天死亡率和费用衡量的获得护理的机会。在截至2011年9月30日的3年内，在VA或CC医院中，在符合研究入选标准的退伍军人中，共进行了13237例择期PCI（VA为79.1%）和5818例择期CABG手术（VA为83.6%）。平均而言，与仅VA治疗相比，使用CC与PCI的净旅行减少53.6英里和CABG手术的净旅行减少73.3英里相关。经皮冠状动脉介入治疗后30天校正死亡率CC组高于VA组（CC组1.54% vs VA组0.65%，P <0.001），但CABG术后相似（CC组1.33% vs VA组1.51%，P = 0.74）。PCI（CC组7.04% vs VA组7.73%，P = 0.66）或CABG手术（CC组8.13% vs VA组7.00%，P = 0.28）的校正后30天再入院率无差异。CC组的平均调整后PCI费用较高（CC组为22025美元，VA组为15683美元，P <0.001）。CC组的平均调整后CABG费用较低（CC组为55526美元，VA组为63144美元，P <0.01）。无论是手术量还是公开报道的死亡率数据，都没有确定提供更高价值护理的医院，只有小容量CC医院的CABG死亡率较低。在这个退伍军人队列中，与VA医院相比，在CC医院进行PCI的旅行距离较短，但死亡率较高，费用较高，旅行节省很少。在CC医院进行的CABG手术与较短的旅行距离、相似的死亡率和较低的费用相关。随着退伍军人事务部考虑扩大CC计划，对价值和访问收益的持续评估对于优化退伍军人成果和退伍军人事务部支出至关重要。这项退伍军人队列研究比较了退伍军人事务部和社区护理计划医院之间选择性冠状动脉血运重建手术的访问，成本和质量，并评估手术量或公开报道的质量数据是否可用于预测高价值的护理。
Does the Veterans Affairs Community Care Program, which allows veterans to receive care at non–Veterans Affairs sites, increase the accessibility and value of their elective coronary revascularization procedures? Among 13 237 elective percutaneous coronary interventions and 5818 elective coronary artery bypass graft procedures in this veteran cohort study, use of the Community Care Program reduced aggregate veteran travel distance for revascularization. Community Care Program hospitals had higher mortality and costs for percutaneous coronary intervention and had equivalent mortality and lower costs for coronary artery bypass graft surgery. In our veteran cohort, use of Community Care Program hospitals improved overall access for revascularization; Community Care Program hospitals provided lower-value percutaneous coronary intervention procedures but higher-value coronary artery bypass graft procedures. The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Receipt of an elective coronary revascularization at a VA vs CC facility. Access to care as measured by travel distance, 30-day mortality, and costs. In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending. This veteran cohort study compares the access, cost, and quality of elective coronary revascularization procedures between Veterans Affairs and Community Care Program hospitals and evaluates if procedural volume or publicly reported quality data can be used to predict high-value care.
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影响因子：
3
作者：
Barnett, PG;Rodgers, JH
通讯作者：
Rodgers, JH
影响因子：
39.2
作者：
Asch, SM;McGlynn, EA;Kerr, EA
通讯作者：
Kerr, EA
影响因子：
2.2
作者：
Choi, Justin C.;Bakaeen, Faisal G.;Chu, Danny
通讯作者：
Chu, Danny
影响因子：
3.5
作者：
Manning, WG;Mullahy, J
通讯作者：
Mullahy, J
DOI：
10.1016/s0735-1097(01)01372-9
发表时间：
2001-06-15
影响因子：
24
作者：
Brindis, R G;Fitzgerald, S;Williams, J F
通讯作者：
Williams, J F