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Regionalization of invasive cardiac procedures may explain seeming underuse of coronary angiography at VA hospitals

Regionalization policies that refer patients needing invasive cardiac procedures to high-volume centers that perform many such procedures each year are being implemented by some payers, since research has shown that cardiac patients usually fare better at high- versus low-volume centers. Due to this regionalization, the Department of Veterans Affairs (VA) health care system performs invasive cardiac procedures in only a few centers in each of its 22 networks. The lack of availability of cardiac services at other VA centers may be an important factor in the underuse of needed coronary angiography at VA hospitals, according to a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS08071).

The researchers compared the use of angiography and 1-year mortality among 1,665 elderly male veterans from 81 VA hospitals and 19,305 elderly male Medicare beneficiaries treated at 1,530 non-VA hospitals. In contrast to the VA system, fee-for-service Medicare is a nonregionalized, dispersed system. Rates of angiography needed by eligible patients, for example, those with persistent reduced cardiac blood flow after heart attack, were significantly lower in VA than non-VA hospitals. However, when the researchers controlled for the on-site availability of cardiac procedures, VA patients were no less likely than Medicare patients to undergo needed angiography.

This finding suggests that a key factor in the underuse of angiography in the VA system is the lack of availability of invasive services at every VA hospital, partly a byproduct of regionalization. Since regionalization can improve the efficiency and quality of care, the solution to the problem of underuse is not to provide such services in more hospitals, but to improve the efficiency of the referral and transfer process for patients with heart disease, conclude the researchers.

More details are in "Regionalization and the underuse of angiography in the Veterans Affairs health care system as compared with a fee-for-service system," by Laura A. Petersen, M.D., M.P.H., Sharon-Lise T. Normand, Ph.D., Lucian L. Leape, M.D., and Barbara J. McNeil, M.D., Ph.D., in the May 29, 2003, New England Journal of Medicine 348, pp. 2209-2217.

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