Department of Veterans Affairs Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
JAMA Netw Open. 2019 Jul 3;2(7):e197238. doi: 10.1001/jamanetworkopen.2019.7238.
The US Department of Veterans Affairs (VA) provides health care to more than 2 000 000 veterans with chronic cardiovascular disease, yet little is known about how expenditures vary across VA Medical Centers (VAMCs), or whether VAMCs with greater health expenditures are associated with better health outcomes.
To compare expenditures for patients with chronic heart failure (CHF) across the nation's VAMCs and examine the association between health care spending and survival.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using existing administrative data sets from the VA's Corporate Data Warehouse and each veteran's Medicare enrollment information and claims history for fee-for-service clinicians outside of the VA from 265 714 patients diagnosed with CHF between April 1, 2010, and December 31, 2013, who received care at any of 138 VAMCs or affiliated outpatient clinics nationwide. Patients were followed up through September 30, 2014. Data were analyzed from April 1, 2010, through September 30, 2014.
Main outcomes were patient deaths per calendar quarter and aggregate VA costs per calendar quarter. Hierarchical generalized linear models with hospital-level random effects were estimated to calculate both risk-standardized annual health care expenditures and risk-standardized annual survival rates for veterans with CHF at each VAMC. The association between VAMC-level expenditures and survival was then modeled using local and linear regression.
Of the 265 714 patients included, 261 132 (98.7%) were male; 224 353 (84.4%) were white; 41 110 (15.5%) were black, Asian, Pacific Islander, American Indian, or Alaskan Native; and 251 (0.1%) did not report race. Mean (SD) age of the patients included was 74 (10) years. Across 138 VAMCs, mean (95% CI) annual expenditures for veterans with CHF varied from $21 300 ($20 300-$22 400) to $52 800 ($49 400-$54 300) per patient, whereas annual survival varied between 81.4% to 88.9%. There was a modest V-shaped association between spending and survival such that adjusted survival was 1.7 percentage points higher at the minimum level of spending compared with the inflection point of $34 100 per year (P = .001) and 1.9 percentage points higher at the maximum level of spending compared with the inflection point (P = .006).
Despite marked differences in mean annual expenditures per veteran, only a modest association was found between CHF spending and survival at the VAMC level, with slightly higher survival observed at the extremes of the spending range. Hospitals with high expenditures may be less efficient than their peer institutions in producing optimal health outcomes.
重要性：美国退伍军人事务部（VA）为超过 200 万患有慢性心血管疾病的退伍军人提供医疗服务，但人们对 VA 医疗中心（VAMC）之间的支出差异知之甚少，也不知道医疗支出较高的 VAMC 是否与更好的健康结果相关。
目的：比较全国 VAMC 中慢性心力衰竭（CHF）患者的支出，并研究医疗保健支出与生存率之间的关系。
设计、地点和参与者：这是一项使用 VA 企业数据仓库中现有的行政数据集以及每位退伍军人的医疗保险登记信息和退伍军人事务部以外的服务费临床医生的索赔历史进行的回顾性队列研究，共纳入 265714 名在 2010 年 4 月 1 日至 2013 年 12 月 31 日期间被诊断为 CHF 的患者，他们在全国范围内的 138 家 VAMC 或附属门诊诊所接受了治疗。患者随访至 2014 年 9 月 30 日。数据分析时间为 2010 年 4 月 1 日至 2014 年 9 月 30 日。
主要结局和措施：主要结局是每个日历季度的患者死亡人数和每个日历季度的 VA 总费用。使用具有医院水平随机效应的分层广义线性模型，为每个 VAMC 中的 CHF 退伍军人计算风险标准化的年度医疗保健支出和风险标准化的年度生存率。然后使用局部和线性回归来模拟 VAMC 级别支出与生存率之间的关系。
结果：在纳入的 265714 名患者中，261132 名（98.7%）为男性；224353 名（84.4%）为白人；41110 名（15.5%）为黑人、亚洲人、太平洋岛民、美洲印第安人或阿拉斯加原住民；251 名（0.1%）未报告种族。包括的患者的平均（SD）年龄为 74（10）岁。在 138 家 VAMC 中，CHF 患者的年平均支出从每位患者 21300 美元（20300 美元至 22400 美元）到 52800 美元（49400 美元至 54300 美元）不等，而年生存率在 81.4%至 88.9%之间。支出与生存之间存在适度的 V 形关联，与拐点 34100 美元/年相比，调整后的生存率在支出最低水平时提高了 1.7 个百分点（P=0.001），与拐点相比，调整后的生存率在支出最高水平时提高了 1.9 个百分点（P=0.006）。
结论和相关性：尽管每位退伍军人的平均年度支出差异显著，但在 VAMC 级别仅发现 CHF 支出与生存之间存在适度关联，在支出范围的极端水平观察到稍高的生存。支出较高的医院在产生最佳健康结果方面可能不如其同行机构有效。
