Waldo Stephen W, Glorioso Thomas J, Butala Neel, Varosy Paul, Duvernoy Claire S, Plomondon Mary E, Francis Joseph
CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA.
Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO USA.
J Am Heart Assoc. 2025 Aug 5;14(15):e041930. doi: 10.1161/JAHA.125.041930. Epub 2025 Jul 17.
The Veterans Affairs (VA) Healthcare System maintains the largest integrated health system in the United States but also supports fee-for-service insurance for veterans receiving care in community facilities outside the VA. We sought to evaluate the management and outcomes of patients referred for consultation in either venue, using cardiovascular evaluation as a model.
We conducted a retrospective cohort study identifying patients enrolled in the VA Healthcare System referred for cardiovascular evaluation from October 2020 through September 2024 and stratified the population based on the venue in which evaluation was completed. The primary outcome was major adverse cardiovascular events (acute coronary syndromes/stroke/mortality) in a matched population.
Among 235 197 consultations for cardiovascular evaluation, 201 453 were completed in the chosen venue within 6 months. The time between consultation and evaluation was similar across venues (community, 35 days [95% CI, 17-65] versus VA, 33 days [95% CI, 19-53]), with comparable delays to diagnostic testing or therapeutic interventions. Patients receiving care in the community were more likely to undergo stress testing (43.2% versus 36.4%, =1.5×10) and coronary angiography (23.1% versus 17.4%, =2.1×10) within 2 years compared with those treated in the VA Healthcare System. Despite this, patients treated in the community had a significantly higher rate of major adverse events at 2 years (17.6% versus 15.3%, =5.9×10) compared with those treated in the VA Healthcare System.
Patients undergoing cardiovascular evaluation in community practices were not evaluated more rapidly than those seen in the VA, though they were more likely to receive initial and repeat diagnostic testing. Adverse events were more common among community-treated patients than those in the VA, suggesting an opportunity to optimize access to care while improving clinical outcomes.
退伍军人事务部（VA）医疗保健系统是美国最大的综合医疗系统，但也为在VA以外的社区设施接受治疗的退伍军人提供按服务收费的保险。我们试图以心血管评估为模型，评估在这两种场所接受会诊的患者的管理情况和治疗结果。
我们进行了一项回顾性队列研究，确定2020年10月至2024年9月期间在VA医疗保健系统登记接受心血管评估的患者，并根据评估完成的场所对人群进行分层。主要结局是匹配人群中的主要不良心血管事件（急性冠状动脉综合征/中风/死亡率）。
在235197次心血管评估会诊中，201453次在选定场所于6个月内完成。不同场所从会诊到评估的时间相似（社区，35天[95%CI，17 - 65]；VA，33天[95%CI，19 - 53]），诊断测试或治疗干预的延迟相当。与在VA医疗保健系统接受治疗的患者相比，在社区接受治疗的患者在2年内更有可能接受压力测试（43.2%对36.4%，=1.5×10）和冠状动脉造影（23.1%对17.4%，=2.1×10）。尽管如此，与在VA医疗保健系统接受治疗的患者相比，在社区接受治疗的患者在2年时主要不良事件的发生率显著更高（17.6%对15.3%，=5.9×10）。
在社区医疗机构接受心血管评估的患者，其评估速度并不比在VA接受评估的患者快，但他们更有可能接受初次和重复诊断测试。社区治疗的患者不良事件比VA治疗的患者更常见，这表明有机会在改善临床结局的同时优化医疗服务的可及性。
