title: Reducing avoidable deaths among veterans: directing private-sector surgical care to high-performance hospitals.
abstract: OBJECTIVE
  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.
authors.affiliation: Veterans Administration (VA) Outcomes Group Research Enhancement Award Program, VA Medical Center, White River Junction, Vt 05009, USA. wbw@dartmouth.edu
authors.forename: William B
authors.initials: WB
authors.lastname: Weeks
authors.forename: Alan N
authors.initials: AN
authors.lastname: West
authors.forename: Amy E
authors.initials: AE
authors.lastname: Wallace
authors.forename: Richard E
authors.initials: RE
authors.lastname: Lee
authors.forename: David C
authors.initials: DC
authors.lastname: Goodman
authors.forename: Justin B
authors.initials: JB
authors.lastname: Dimick
authors.forename: James P
authors.initials: JP
authors.lastname: Bagian
mesh_terms: D000368:Aged; D019985:Benchmarking; D013504:Cardiovascular Surgical Procedures / Q000401:mortality / Q000592:standards; D017052:Hospital Mortality; D016304:Hospitals, Private / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D006278:Medicare; D009369:Neoplasms / Q000601:surgery; D017063:Outcome Assessment, Health Care; D012017:Referral and Consultation; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000401:mortality / Q000592:standards; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans