William B. Weeks ^1*, Alan N. West ², Amy E. Wallace ³, Richard E. Lee ², David C. Goodman ⁴, Justin B. Dimick ⁵, James P. Bagian ⁶

¹ VA, Dartmouth Medical School
² VA Outcomes Group REAP, VA National Center for Patient Safety
³ VA Outcomes Group REAP, Dartmouth Medical School
⁴ Dartmouth Medical School
⁵ VA Outcomes Group REAP, University of Michigan
⁶ VA National Center for Patient Safety

^* To whom correspondence should be addressed. E-mail: wbw{at}dartmouth.edu.

	Abstract

Objectives. We quantified older (65 years and older) Veterans Health Administration (VHA) patients’ use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals.

Methods. Using a merged VHA–Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals.

Results. Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time.

Conclusions. Policy that directs older VHA enrollees’ private-sector care to high-performance hospitals promises to reduce mortality for VHA’s service population and warrants further exploration.

Key Words: Cancer, Cardiovascular Disease, Quality of Care, Health Service Delivery, Mortality