More Quality Assurance Needed as Care Increases Outside VA System

AURORA, CO — Veterans who received a common cardiovascular procedure at VA facilities had a significantly lower risk of death than those being treated at a community hospital.

A report in the Journal of the American College of Cardiology discussed results of a study of nearly 9,000 veterans, comparing results of elective percutaneous coronary intervention (PCI) for stable angina at community facilities vs. the VA Healthcare System. Researchers determined that patients having the procedure outside of the VA system had a 33% increased hazard of death in the first year.

That is especially concerning when, because of concerns about patient access concerns, the VA has expanded clinical care outside of the integrated system through a community care program that makes it easier for veterans to receive care from non-federal facilities. Facilities in the community care program vary greatly—ranging from academic medical centers to rural safety net hospitals—and veterans are free to choose facilities with a variety of levels of expertise.

Assess to hospitals is not restricted based on procedural volumes or quality, the article pointed out. Patients may choose facilities with differing levels of expertise.

Use of non-VA facilities for PCI has increased more than 50% in the last three years. Researchers from VAMCs in Aurora, CO, and Gainesville, FL, as well as the University of Colorado and the University of Florida emphasize that, not only was the hazard of death greater in the first year, but patients receiving PCI in the community had a 143% increased hazard of death within the first month.

“A larger proportion of veterans are undergoing elective coronary intervention for stable angina in community facilities, a trend that will likely continue with the recent adoption of the MISSION ACT. The community facilities that provide care to these patients are heterogeneous, and the data available for quality assessment is largely limited to billing records,” explained lead author Stephen W. Waldo, MD, national director of the VA Clinical Assessment, Reporting and Tracking (CART) Program. “While these data may be limited, this analysis suggests that clinical outcomes for veterans undergoing percutaneous coronary intervention in the community may diverge from those treated within the VA Healthcare System. Because of this, we must ensure that increased access to medical care in the community is accompanied by mechanisms to ensure similar levels of quality.”

The authors advise that study data for the VA Healthcare System was derived from clinical documentation, but administrative billing data was used for care provided in community facilities. It also is unknown whether more-complex procedures were performed in the community setting.

Researchers called for further study to determine the most effective ways to improves veterans’ access to medical care while also maintaining quality.

Background information in the article explained that the community care services, with expenses covered by the federal government, are primarily offered if the VA integrated healthcare system cannot provide access to specialist care in a timely manner in close enough proximity to a veteran’s home. The authors cautioned, however, that recent changes in policy will expand the use of healthcare in the community for veterans, even though concerns have been raised about community providers’ ability to meet the need for increased capacity.

Making the situation potentially more fraught is that veterans with cardiovascular disease have increasingly complex cases in the last 10 years or so, according to the report.

Constant or Improved at VA

“Despite this, the clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) have remained constant or improved over the same time,” the authors wrote. “Similar data regarding the quality of cardiovascular care for veterans treated outside the integrated health care system is more challenging to obtain. With this in mind, the present analysis compared the clinical outcomes of veterans undergoing elective percutaneous revascularization at VA and community hospitals after the significant expansion of the community care program.”

Included in the study were patients actively enrolled in the VA Healthcare System who underwent elective percutaneous revascularization for stable angina between Oct.1, 2015, and Dec. 31, 2018.

Overall, researchers identified 30,310 patients who underwent percutaneous intervention for stable angina, although only 8,913 were evaluated in the study because of the restriction to include only those who received the dominant form of care in a given location. Of those, 5,942 (67%) received PCI in the VA Healthcare System and 2,971 (33%) in the community facilities.

The authors pointed out that the largest number of exclusions occurred in geographic regions where there was not an equal opportunity to be seen at a community or VA facility, adding that the use of community care for PCI has been increasing with the probability of an elective intervention being performed in the community increasing from 38.9% to 51.8% over the study period.

“Treatment in the community is associated with worse clinical outcomes, with a 33% increased hazard of death in a propensity weighted sample,” the authors advised. “The discrepancy in clinical outcomes is even more pronounced when the analysis is limited to the first month after the procedure, with a 143% increased hazard of death.”

They added, “Although residual confounding could be present, it would take a factor with a sizeable difference in prevalence between treatment groups (approximately 7%) associated with a significant increase in risk (approximately 164%) to completely nullify these findings.”

A key issue, according to researchers, is that VA doesn’t require high quality standards for facilities providing community care to veterans.

“The current community care program does not restrict access to facilities based on procedural volumes or quality, because patients have the liberty to choose a facility based on their own personal preferences,” they pointed out. “Because of this, the community facilities used under this program may constitute a heterogeneous collection of hospitals ranging from academic quaternary care medical centers to rural safety net facilities with differing levels of expertise.”

On the other hand, the study noted, the Clinical Assessment, Reporting, and Tracking Program monitors the quality and safety of invasive cardiac procedures for those treated within the VA Healthcare System, where clinical outcomes have remained constant or improved despite treatment of a more comorbid population. Yet, the authors explained, “A similar organization to monitor the same quality of care for veterans treated in the community does not currently exist on a national scale. Because the VA Healthcare System serves as an unrecognized national safety net, we must ensure that increased access to medical care is accompanied by mechanisms to ensure similar levels of quality regardless of treatment venue.”


  1. Waldo SW, Glorioso TJ, Barón AE, et al. Outcomes Among Patients Undergoing Elective Percutaneous Coronary Intervention at Veterans Affairs and Community Care Hospitals. J Am Coll Cardiol. 2020;76(9):1112-1116. doi:10.1016/j.jacc.2020.05.086