title: Outcomes of acute myocardial infarction in the Department of Veterans Affairs: does regionalization of health care work?
abstract: OBJECTIVE
  This study examines the association between the regional availability of cardiac technology and outcomes of care for patients admitted to Department of Veterans Affairs (VA) hospitals. Patients using the VA regional medical system initially are admitted to a hospital with or without the on-site availability of technology-intensive cardiac services.
  
  
  METHODS
  The authors identified male veterans (n = 24,229) discharged from VA hospitals with a primary diagnosis of acute myocardial infarction (AMI) from January 1, 1988 through December 31, 1990. Analyses of mortality up to 2 years after AMI and the use of cardiac procedures were stratified by the type of VA hospitals to which patients initially were admitted. Logistic regression models adjusted for age, race, marital status, hospitalization in previous year, comorbidities, cardiac complications coded, and year of AMI.
  
  
  RESULTS
  Adjusted mortality was significantly higher for patients initially admitted to hospitals without on-site cardiac technology at: 2 days (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.62-0.81), 90 days (OR 0.78; 95% CI 0.73-0.85); 1 year (OR 0.87, 95% CI 0.81-0.93); and 2 years (OR 0.86, 95% CI 0.81-0.92) compared with hospitals with on-site cardiac technology (ie, coronary angioplasty and cardiac surgery facilities). Patients initially admitted to hospitals without on-site cardiac technology also were less likely to undergo cardiac procedures than patients admitted to hospitals with on-site cardiac technology.
  
  
  CONCLUSIONS
  The regional distribution of cardiac technology may restrict patient access to technology-intensive services and to "equally good medical care." Policies that promote regionalization of medical services should consider carefully the distribution of benefits and burdens to patients.
authors.affiliation: Health Services Research and Development, Department of Medicine, Brockton/West Roxbury Veterans Affairs Medical Center, MA 02132, USA.
authors.forename: S M
authors.initials: SM
authors.lastname: Wright
authors.forename: J
authors.initials: J
authors.lastname: Daley
authors.forename: E D
authors.initials: ED
authors.lastname: Peterson
authors.forename: G E
authors.initials: GE
authors.lastname: Thibault
mesh_terms: D016507:Cardiology Service, Hospital / Q000592:standards*; D017052:Hospital Mortality; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality*; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012041:Regional Medical Programs / Q000592:standards*; D013675:Technology, High-Cost; D014481:United States