title: Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.
abstract: OBJECTIVE
  We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals.
  
  
  METHODS
  Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals.
  
  
  RESULTS
  VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal.
  
  
  CONCLUSIONS
  For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.
authors.affiliation: VA Outcomes Group, Veterans Health Administration, White River Junction, Vermont 05009, USA. William.B.Weeks@Dartmouth.edu
authors.forename: William B
authors.initials: WB
authors.lastname: Weeks
authors.forename: David M
authors.initials: DM
authors.lastname: Bott
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Bazos
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Campbell
authors.forename: Rosemary
authors.initials: R
authors.lastname: Lombardo
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Racz
authors.forename: Edward L
authors.initials: EL
authors.lastname: Hannan
authors.forename: Steven M
authors.initials: SM
authors.lastname: Wright
authors.forename: Elliott S
authors.initials: ES
authors.lastname: Fisher
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D015331:Cohort Studies; D001026:Coronary Artery Bypass; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009518:New York; D017149:Private Sector / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs