1. Wins/Losses and Errors/Ties: Quality of Care for Acute Myocardial Infarction in the VA Health Care System Laura A. Petersen, M.D., M.P.H. 1 Sharon-Lise T. Normand, PhD 2 Barbara J. McNeil, MD, PhD 2 1 Houston Center for Quality of Care and Utilization Studies, an HSR&D Center of Excellence; 2 Harvard Department of Health Care Policy Supported by: VA HSR&D IIR 94-054; VA HSR&D Career Development Award Program RCD 95-306; RWJ Foundation Generalist Physician Faculty Scholar Award Program; AHRQ RO1-HS08071

2. Background Acute myocardial infarction (AMI) is a common, costly, and clinically significant condition, and represents a signal event in the natural history of ischemic heart disease Appropriate quality of care for AMI improves survival Quality of care for AMI may indicate a hospital’s or system’s ability to deliver highly skilled, specialized acute medical care

3. Goals To compare process of care and outcomes after acute myocardial infarction in VA and non-VA hospitals, controlling for differing patient characteristics

4. Methods - Patient Samples Age > 65 Male Clinically confirmed discharge diagnosis of acute myocardial infarction –29,249 FFS Medicare patients from 1,530 non-VA acute care hospitals in CA, FL, MA, NY, OH, PA, and TX –Random sample of 2,486 patients from 81 VA hospitals nationwide

5. “Wins” Petersen LA, Normand SL, Leape LL, McNeil BJ. Comparison of use medications after acute myocardial infarction in the Veterans Health Administration and Medicare. Circulation, 2001;104(24):2898-2904.

6. Use of Thrombolytic Therapy at Arrival or Aspirin at Discharge in VA Relative to Medicare All comparisons significant at p<0.05

7. Use of ACE Inhibitors or Beta- Blockers at Discharge in VA Relative to Medicare * p<0.05 ** comparison NS

8. “Losses and Errors” Petersen LA, Normand SL, Leape LL, McNeil BJ. Regionalization and the underuse of angiography in the Veterans Affairs Health Care System as compared with a fee-for-service system. N Engl J Med 2003; 348:2209-17.

9. Age-Adjusted Rates of Cardiac Procedures Among ACC Class I Patients RR = 0.82; 95% CI (0.78-0.87) RR = 0.72; 95% CI (0.67-0.78) *† *Diagnostic angiography within 90 days after index admission. †Procedures within 90 days among patients who underwent angiography within 90 days after index admission.

10. Summary Differences in underuse not eliminated by adjustment for patient characteristics and clustering Differences eliminated by adjustment for procedure availability in the regionalized system

11. “Ties” Petersen LA, Normand SL, Daley J, McNeil BJ. Outcome of myocardial infarction in Veterans Health Administration patients as compared with Medicare patients. N Engl J Med 2000;343:1934-41.

12. Adjusted Odds of Mortality: Medicare Relative to VA (Using full sample = 29,249 Medicare and 2,486 VA) Logistic Regression OR [95%CI]* 30-day0.93(0.81-1.07) c=0.800 1-year0.93(0.83-1.05) c=0.799 Adjusting for 30 sociodemographic, clinical and hospital variables; c=Area under ROC curve Results confirmed with propensity score adjustment

13. Summary Wins: VA patients were equally likely (in the case of beta-blockers) or more likely (in the case of thrombolytic therapy, ACE inhibitors, or aspirin) than Medicare patients to receive medications of known benefit after AMI Losses/Errors: Rates of use of angiography and cardiac revascularization procedures were significantly lower in the VA than in Medicare, even among groups where angiography was deemed clinically needed

14. Summary and Conclusions (2) However, once admitting hospital procedure availability was controlled for, there was no difference in angiography use between patients cared for in VA and Medicare The findings suggest that underuse of angiography could be remedied by changes in policy regarding availability of angiography services and regionalization of cardiac technology

15. Summary and Conclusions (3) Ties: VA patients were somewhat sicker than Medicare patients. Yet, we found no significant differences in 30-day or 1-year mortality between Medicare and VA AMI patients