Differences in Quality, Cost, and Access between VA and Fee Basis CABG and PCI

描述(由申请人提供)： 对退伍军人医疗保健的预期影响。购买护理计划的变化可能会影响VHA赞助的选择性冠状动脉血运重建术的成本、质量和可获得性。在农村和高度农村的退伍军人中，影响可能最大，因为他们更依赖购买的护理。背景资料。VHA购买了其为65岁以下退伍军人赞助的选择性冠状动脉旁路移植(CABG)的19%和选择性经皮冠状动脉介入治疗(PCI)的22%。这些护理的一半提供给农村退伍军人。VA选择性收缩试验计划对心脏护理的影响尚未被研究。VHA正在实施一项国家选择性承包计划，以控制购买的护理费用。选择性承包可以提高质量和降低成本，但并不是所有的管理型护理组织都成功地选择了高质量的提供者。当一项计划完全依赖其成员的经验时，质量衡量是困难的，因为统计可信度的观察值可能太少。以前的研究得出了相互矛盾的结论，即选择性签约导致供应商数量减少所带来的额外旅行的重要性。目标。政策的成本效益 将根据易于观察的标准选择提供商进行评估。政策包括：使用位于合理旅行距离内的VA提供者，使用满足最小容量标准的VA提供者，使用满足最低年容量标准的非VA提供者，以及使用报告的30天风险调整死亡率高于医院比较平均水平的非VA提供者。补充项目的目的是了解政策对成本组成部分(程序、随访和患者产生的旅行成本，包括患者时间的价值)、结果(存活率、重复手术的可能性)和可获得性(冠状动脉疾病患者的旅行距离和获得选择性手术的比率)的影响。为了估计可能与供应商谈判的折扣，将研究根据试点VHA合同计划HERO项目提供的心脏血运重建服务的成本。将预测具有成本效益的政策对预算的影响。方法：研究方法。将利用向65岁以下患者提供非紧急心脏血管重建术的地区差异来估计这些政策对成本和生存的影响。多元成本和生存回归将被用来估计符合每项政策的护理与不符合政策的护理之间的差异。这些回归将根据从退伍军人管理局数据、退伍军人管理局数据仓库和退伍军人管理局心导管实验室登记处获得的患者特征进行风险调整。费用将包括全部旅行费用，包括退伍军人发生的旅行费用和病人在过境时花费的时间价值(即从社会角度来看)。仪器变量将被用来校正选择偏差。将通过将估计的危险比应用于年龄调整后的预期寿命来估计长期结果。旅行距离对冠心病VHA患者获得心脏血管重建术的概率的影响将被估计，以了解选择性收缩导致的额外旅行是否可能阻止一些患者接受手术。

DESCRIPTION (provided by applicant): Anticipated Impacts on Veterans Health Care. Changes in the purchased care program might affect the cost, quality, and accessibility of elective coronary revascularization procedures sponsored by VHA. The impact may be greatest among rural and highly rural Veterans as they are more reliant on purchased care. Background. VHA purchases 19% of the elective Coronary Artery Bypass Graft (CABG) and 22% of the elective Percutaneous Coronary Intervention (PCI) that it sponsors for veterans under age 65. Half of this care is provided to rural veterans. The effect of the VA pilot program of selective contracting on cardiac care has not been studied. VHA is undertaking a national program of selective contracting to contain purchased care cost. Selective contracting can improve quality and lower costs, but not all managed care organizations have succeeded in selecting high quality providers. Quality measurement is difficult when a plan relies exclusively on its own members' experience, as there may be too few observations for statistical confidence. Previous research has generated conflicting findings about the significance of the additional travel that is imposed by the reduction in the number of providers that results from selective contracting. Objectives. The cost-effectiveness of polices to select providers based on easily observed criteria will be evaluated. Policies include: use of a VA provider located within a reasonable travel distance, use of a VA provider that meets a minimum volume criterion, use of a non-VA provider that meets a minimum annual volume criterion, and use of a non-VA provider that reported a better than average 30-day risk-adjusted mortality in Hospital Compare. Supplementary project aims are to understand the effect of policy on components of cost (procedure, follow-up and patient incurred travel cost, including the value of patient time), outcomes (survival, probability of repeated procedure), and access (distance traveled and the rate of obtaining an elective procedure in patients with coronary artery disease). To estimate the discounts that might be negotiated with providers, cost of cardiac revascularization services provided under the pilot VHA contracting program, Project HERO, will be studied. The budget impact of cost-effective policies will be projected. Methods. Regional differences in the provision of non-emergency cardiac revascularization procedures to patients under age 65 will be used to estimate the impact of the policies on cost and survival. Multivariate cost and survival regressions will be used to estimate the difference between care that was consistent with each policy and care that was not policy concordant. These regressions will be risk adjusted for patient characteristics obtained from VA administrative data, the VA Corporate Date Warehouse, and the VA cardiac catheterization lab registry. Cost will include the full cost of travel, including veteran incurred travel cost and the value of patient time spentin transit (i.e., the societal perspective). Instrumental variables will be used to correct for selecton bias. Long-term outcomes will be estimated by applying the estimated hazard ratio to age-adjusted life-expectancy. The effect of travel distance on the probability that VHA patients with coronary artery disease obtain cardiac revascularization will be estimated to learn if the extra travel caused by selective contracting might prevent some patients from getting a procedure.