摘要：Objectives. 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. Since its reorganization in 1996, the Veterans Health Administration (VHA) has made a major institutional commitment to improve the quality of the care provided to veterans. 1 As part of this effort, VHA has built a nationwide electronic medical record that includes physician order entry (an electronic prescribing system). This electronic record has facilitated the development of a performance measurement and feedback system that evaluates a variety of quality-of-care indicators: access to care (e.g., wait times to appointments), adherence to evidence-based guidelines (e.g., diabetic foot and retinal examinations), and both medical 2 (e.g., hypertension or glycemic control) and surgical (e.g., risk-adjusted general 3 and cardiothoracic surgery 4 ) outcomes. Although these efforts focus on the care that veterans obtain within the VHA system, many VHA patients also receive care in the private sector. Most VHA patients who are 65 years and older are concurrently enrolled in Medicare 5 , 6 and are known to obtain much of their routine outpatient care, 6 , 7 acute cardiac care, 8 , 9 and elective coronary revascularizations 10 – 12 in the private sector. Surveys of younger VHA patients also report frequent use of private-sector care. 13 – 15 Frequent use of private-sector care raises the possibility that outcomes could also be improved by influencing the care that VHA patients receive outside of the VHA. Directing patients to higher-quality care would seem particularly important for common, high-risk procedures that show substantial variation in outcomes across hospitals, 16 , 17 and it has been proposed as a mechanism to improve outcomes among the Medicare population. 18 , 19 To determine the magnitude of the opportunity to improve outcomes for VHA patients who undergo high-risk procedures, we linked VHA and Medicare databases to determine how frequently VHA patients obtain these procedures in the private sector and to assess the potential impact of directing their care to high-performance hospitals (based on historical performance and determined 2 years in advance of the service year).
