In the Journals

Diverse mortality rates seen in VA medical centers for HF, heart disease

Peter W. Groeneveld

Mortality rates for patients with ischemic heart disease and chronic HF varied across the Veterans Affairs health system, according to a study published in JAMA Cardiology.

“Our findings may be placed in the context of increasing emphasis on the importance of hospital/health system quality performance in the care of populations of patients with chronic disease,” Peter W. Groeneveld, MD, MS, associate professor of medicine at University of Pennsylvania Perelman School of Medicine and attending physician and vice chair of the research and development committee of Philadelphia VA Medical Center, and colleagues wrote. “While hospital outcomes for the treatment of acute medical episodes, such as myocardial infarction, remains an important quality measure, mortality rates among the broader population of patients receiving care by a hospital and/or its outpatient clinics provides important insight into the effectiveness of the hospital/health system in optimizing the health of its patient population.”

VA medical center data

Researchers analyzed administrative data from 930,079 patients with ischemic heart disease (mean age, 72 years; 1% women; 89% white) and 348,015 patients with chronic HF (mean age, 72 years; 2% women; 83% white) who received care from 138 VA medical centers between 2010 and 2014. Both cohorts were constructed so that same patients could appear in both groups.

The overall annual mortality rate was 14.5% for patients with chronic HF and 7.4% for patients with ischemic heart disease. VA medical centers’ risk-stratified mortality for patients with ischemic heart disease varied from 5.5% (95% CI, 5.2-5.7) to 9.4% (95% CI, 9-9.9; P for difference < .001). This was also seen in patients with chronic HF, which ranged from 11.1% (95% CI, 10.3-12.1) to 18.9% (95% CI, 95% CI, 18.3-19.5; P for difference < .001).

Comparisons with national rates

Of the 138 VA medical centers included in the study, mortality rates for patients with ischemic heart disease exceeded the national mean in 29 centers, and mortality rates for patients with chronic HF exceeded the national mean in 35 centers.

Risk-standardized mortality for both cohorts was not associated with 30-day mortality rates for MI (R2 = 0.01; P = .35). Weak associations were also seen for risk-standardized mortality and both 30-day chronic HF posthospitalization mortality (R2 = 0.16; P < .001) and the VA star-rating system for quality measurement (R2 = 0.06; P = .005).

Paul A. Heidenreich

“While process measures are undeniably important in the assessment of quality of care, these are only important to the extent that they are associated with the clinical outcomes that matter to patients,” Groeneveld and colleagues wrote. “Measurement of risk-adjusted mortality among chronic disease populations, therefore, presents an important dimension of quality measurement that might be missed if process measures or acute-care outcomes were the sole metrics.”

In a related editorial, Paul A. Heidenreich, MD, MS, professor of medicine and health research and policy and vice chair for clinical, quality and analytics at Stanford University School of Medicine, wrote: “Perhaps the most important question is how hospitals can use these data to improve. Are the mortality differences because of differences in guideline compliance? Without measures of process of care known to improve mortality, it is not clear how hospital leaders can intervene to lower the mortality rate.” – by Darlene Dobkowski

Disclosures: The authors and Heidenreich report no relevant financial disclosures.

Peter W. Groeneveld

Mortality rates for patients with ischemic heart disease and chronic HF varied across the Veterans Affairs health system, according to a study published in JAMA Cardiology.

“Our findings may be placed in the context of increasing emphasis on the importance of hospital/health system quality performance in the care of populations of patients with chronic disease,” Peter W. Groeneveld, MD, MS, associate professor of medicine at University of Pennsylvania Perelman School of Medicine and attending physician and vice chair of the research and development committee of Philadelphia VA Medical Center, and colleagues wrote. “While hospital outcomes for the treatment of acute medical episodes, such as myocardial infarction, remains an important quality measure, mortality rates among the broader population of patients receiving care by a hospital and/or its outpatient clinics provides important insight into the effectiveness of the hospital/health system in optimizing the health of its patient population.”

VA medical center data

Researchers analyzed administrative data from 930,079 patients with ischemic heart disease (mean age, 72 years; 1% women; 89% white) and 348,015 patients with chronic HF (mean age, 72 years; 2% women; 83% white) who received care from 138 VA medical centers between 2010 and 2014. Both cohorts were constructed so that same patients could appear in both groups.

The overall annual mortality rate was 14.5% for patients with chronic HF and 7.4% for patients with ischemic heart disease. VA medical centers’ risk-stratified mortality for patients with ischemic heart disease varied from 5.5% (95% CI, 5.2-5.7) to 9.4% (95% CI, 9-9.9; P for difference < .001). This was also seen in patients with chronic HF, which ranged from 11.1% (95% CI, 10.3-12.1) to 18.9% (95% CI, 95% CI, 18.3-19.5; P for difference < .001).

Comparisons with national rates

Of the 138 VA medical centers included in the study, mortality rates for patients with ischemic heart disease exceeded the national mean in 29 centers, and mortality rates for patients with chronic HF exceeded the national mean in 35 centers.

Risk-standardized mortality for both cohorts was not associated with 30-day mortality rates for MI (R2 = 0.01; P = .35). Weak associations were also seen for risk-standardized mortality and both 30-day chronic HF posthospitalization mortality (R2 = 0.16; P < .001) and the VA star-rating system for quality measurement (R2 = 0.06; P = .005).

Paul A. Heidenreich

“While process measures are undeniably important in the assessment of quality of care, these are only important to the extent that they are associated with the clinical outcomes that matter to patients,” Groeneveld and colleagues wrote. “Measurement of risk-adjusted mortality among chronic disease populations, therefore, presents an important dimension of quality measurement that might be missed if process measures or acute-care outcomes were the sole metrics.”

In a related editorial, Paul A. Heidenreich, MD, MS, professor of medicine and health research and policy and vice chair for clinical, quality and analytics at Stanford University School of Medicine, wrote: “Perhaps the most important question is how hospitals can use these data to improve. Are the mortality differences because of differences in guideline compliance? Without measures of process of care known to improve mortality, it is not clear how hospital leaders can intervene to lower the mortality rate.” – by Darlene Dobkowski

Disclosures: The authors and Heidenreich report no relevant financial disclosures.