Impact of New Technologies on Chronic Heart Failure Outcomes and Costs in the VHA

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DESCRIPTION (provided by applicant): Background Chronic heart failure is an extremely common, high-mortality and high-cost disease among older veterans. Several technologies, including devices such as implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy-defibrillators (CRT-Ds), as well as pharmacotherapies such as the beta-blockers carvedilol and extended-release metoprolol, have been demonstrated to reduce mortality among patients with CHF. While some technologies such as ACE- inhibitors currently are used in almost all veterans with CHF, devices and beta-blockers are not yet used in all clinically eligible patients. The costs of these technologies are substantial, and thus it is important to quantify the benefits that these technologies have yielded among veterans with CHF during the past ten years relative to their costs, and it is also critical to identify existing opportunities to improve CHF health care quality at reasonable cost. Objectives The goals of this project are: (1) to examine national trends across VA from 2001-2010 in the use of ICDs/CRTs and carvedilol/metoprolol and to determine if changes in technology use at the VAMC/VISN level were correlated with changes in CHF outcomes; (2) to measure the changes in costs of care for veterans with CHF resulting from the increased use of devices and carvedilol/metoprolol; (3) to identify opportunities for improvement in VA CHF care through greater use of these therapies, estimate the magnitude of the veteran CHF population health benefit that would result from greater technology use, and compare this benefit to the increase in costs to VA that would be necessary for full dissemination of these technologies. Methods This study will use multiple sources of data describing health care utilization and costs among veterans with CHF, including the VA's Medical SAS datasets at the Austin Information Technology Center, VA Decision Support System data, the VA Vital Status File, and linked VA- Centers for Medicare and Medicaid Services datasets that provide information on veterans dually enrolled in both VA and Medicare. We will identify annual cohorts of CHF patients within each VAMC and VISN. We will then examine longitudinal trends in technology use rates, outcomes, and costs among cohorts of heart failure patients across VISNs and VAMCs via hierarchical linear regression models using a "difference-in-difference" approach. These models will then be used to predict costs and benefits of future increases in technology use among VAMCs and VISNs that show evidence of below-target use of newer CHF technologies. Impact This project will investigate how increasing use of evidence-based pharmaceutical and device therapies from 2001-2010 among veterans with chronic heart failure (CHF) has affected clinical outcomes for veterans with this high-mortality disease. As many of the new technologies introduced in the past ten years to treat heart failure are costly, this project will also quantify the rise in VA costs associated with the increasing use of these therapies. The project will illuminate potential opportunities for improvement in CHF outcomes in the VHA by increasing the use of evidence-based therapies. The additional costs to VA of implementing this care also will be forecast. The overarching goal is to provide VA policymakers with information on how technology has impacted the outcomes and costs of CHF care in the recent past, and to predict how technology might influence VA's CHF outcomes and costs in the immediate future.