That's the message of two studies appearing in the May 29 issue of the New England Journal of Medicine.
Both reports frame their research within structural changes that have been taking place within the VA. The system has recently undergone an overhaul that included implementing accountability, electronic medical records and other changes. Regionalization means that cardiac procedures are not available at all VA facilities, and this seems to be responsible for the underuse of angiographies.
The authors of the first study compared the quality of preventive, acute and chronic care in the VA health-care system before and after the system-wide re-engineering took place. They also compared VA health care with the Medicare fee-for-service program.
For 1994 and 1995 (the period before the overhaul), the VA lagged behind Medicare fee-for-service in nearly all areas, with a 27 percent rate for pneumococcal vaccines and a 64 percent rate for breast cancer screening among females. The rates of aspirin and beta blocker use in heart attack patients were higher, with 89 percent of heart attack patients admitted receiving aspirin at the time of discharge.
By 1997, however, improvements were clearly evident. Pneumococcal and influenza vaccination rates more than doubled, and there were increases in the rates of appropriate diabetes management and the inpatient care of heart attack patients. There were also moderate improvements in the rates of hypertension control, eye examinations in patients with diabetes, and colorectal cancer screening.
In 2000, 90 percent or more of patients were receiving appropriate care for nine out of 17 indicators. More than 70 percent of patients were receiving appropriate care for 13 out of 17 indicators.
The VA performed significantly better than Medicare fee-for-service on all 11 similar quality indicators for the period 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators.
The second study looked at diagnostic angiographies in two groups of men 65 years and older who had had at least one heart attack in the previous eight weeks. One group was comprised of a national random sample of 1,665 veterans discharged from 81 VA facilities. The other was composed of 19,305 fee-for-service Medicare beneficiaries.
An angiography uses a catheter and special dye to do an X-ray examination of the blood vessels or heart chambers.
Two-thirds of the VA patients and half of the Medicare patients met the criteria for needing angiography. Underuse was evident in both groups, but VA patients were even less likely than Medicare patients to have the procedure (43.9 percent versus 51 percent). Angiography was performed in 38 percent of VA patients and 48.8 percent of Medicare patients.
When the authors included the availability of on-site technology in the admitting hospital, the differences were no longer significant. In other words, when the technology was available on site, patients were more likely to get the procedure.
"I was primarily interested in whether regionalization policies could explain this difference between underuse," says study author Dr. Laura Petersen, a staff physician at the Houston VA Medical Center. "Regionalization means they don't put as many high-tech-procedure facilities in a VA network as you might see in fee-for-service. They try to concentrate high tech in one site."
The VA offers invasive cardiac procedures at only a few locations in each of its 22 national networks. "This makes sense from the point of view of duplication of services," Petersen says. "Under fee-for-service, the more procedures you do, the more money you get."
It appears that regionalization can explain the difference in use. "It looks like when you concentrate these procedures at one site, what happens is that patients have to travel a lot farther, these little hospitals that don't have procedures on site have to then refer patients to a different site, and there are many hoops to jump through to do that," Petersen says.
The solution, though, may not be to provide extra services in more hospitals but to improve the efficiency of the referral and transfer process. "Perhaps using guidelines for the use of procedures, having better protocols for when to refer to high-tech facilities," Petersen suggests. As the system stands, underuse of this particular procedure did not contribute to mortality, at least not in this study.