Does VA health care measure up?

Characteristics and outcomes of very elderly patients after first hospitalization for heart failure

BACKGROUND

The very elderly (age 80 years and older) with heart failure (HF) is a growing population that is rarely included in clinical trials. The aim of this investigation was to describe the characteristics and outcomes of very elderly patients after a first HF hospitalization.

METHODS AND RESULTS

We identified very elderly patients (age 80 years and older) discharged with HF from the Veteran's Administration National Patient Care Database from 1999 to 2008. Outcomes of interest were death during index admission, 30-day and 1-year mortality, and 30-day all-cause and HF readmissions. We used generalized estimating equations to evaluate outcome differences between age groups within the very elderly cohort (ages 80 to 84, 85 to 89, and 90 and older), adjusting for comorbidities, demographics, and clustering by treatment facility. We identified 21 397 very elderly veterans with a first HF hospitalization during the study period. Thirty-day mortality decreased from 14% to 7% (both P<0.001) and 1-year mortality decreased from 49% to 27% (P<0.001). Although these improvements were most notable for patients age 90 and older (1-year mortality improved by 25.9%), the adjusted odds of death within 1 year were highest for the oldest veterans (odds ratio, 1.85; 95% confidence interval, 1.64 to 2.09, using the 80- to 85-year age group as reference). For all patients, 30-day all-cause readmissions remained largely unchanged and did not differ between age groups.

CONCLUSIONS

Mortality for very elderly HF patients has improved over time, but 30-day readmissions remain frequent. Future studies should identify interventions to reduce cardiac and noncardiac rehospitalization of very elderly HF patients.

The academic hematology-oncology firm:a model for postgraduate cancer education

OBJECTIVE

To examine whether the introduction of a subspecialty firm system results in improving fellowship training in hematology and oncology.

METHODS

A subspecialty firm in Hematology-Oncology was created to provide ambulatory and inpatient, primary, and subspecialty care. A survey was conducted of all fellows who trained in this firm while enrolled in an affiliated University subspecialty fellowship program.

RESULTS

The survey showed a positive impact of the firm in improving trainee-patient relationships, achievement of educational goals, and clinical competency.

CONCLUSIONS

Larger observational studies are needed to evaluate the full impact of this model on educational outcomes in cancer patients.

Estimating private sector values for VA health care: an overview

OBJECTIVES

To provide an overview of methods used to establish what taxpayer costs would be if all Veterans Health Administration (VA) patient care were paid for by the federal government but provided in the private sector.

METHODS

Study assumptions included (1) that there would be a hypothetical policy change to pay for VA care through a Medicare-based fee-for-service program, (2) that the VA coverage benefit would not change, (3) that practice styles would remain the same, and (4) that there would be no impact on market values. To achieve the objective, project staff adapted Medicare payment schedules and guidelines, where available, with oversight of an advisory committee with VA and non-VA expertise in costs and data. For six sites, detailed payments were estimated using VA utilization databases and software and Medicare rate schedules available in the private sector. Overhead, interest on capital, and malpractice costs were added to VA-reported operating costs. Patient severity was examined, and patient-level costs were explored.

FINDINGS

Detailed methods for pricing seven types of health services are presented. Three methods articles focus on process issues.

DISCUSSION

Because VA care is not directly comparable with private sector health care as a result in part of differences in benefits covered and the scope of services provided, estimating costs for this care based on a private sector model requires careful consideration of market valuation approaches. The articles in this supplement describe the methods used to estimate market values for VA care so that other researchers can use them in future studies.

Article Commentary: Improving the US Health Care System: Action Plan to Enhance Efficiency, Reduce Errors, and Improve Quality

The decisions made by stakeholders in the nation's health care system that affect the quality of care experienced by patients are too often made without the benefit of scientific evidence. A multidisciplinary set of investigators conducting health services research have traditionally filled this gap between research findings and clinical decision making, but several barriers are hindering this work. This article offers several recommendations—restructuring organizations, ensuring funding, developing infrastructure, strengthening the community of researchers, and forging new links among stakeholders—to promote high-quality information for health decision makers.