The Quality of Veterans Healthcare Administration Cardiovascular Care

Abstract

A total of 9 million veterans receive care in a unique healthcare system, the Veterans Healthcare Administration (VHA), with nearly 50% reporting at least one cardiovascular disease. Despite evidence for high quality of health care in the VHA, more veteran care is being moved to the non-VHA community. An assumption of this shift in care is that the quality of non-VHA care is at least comparable to VHA care. This paper reviews the quality of cardiovascular care delivered by the VHA in comparison to community care, which is care delivered in non-VHA facilities by non-VHA providers and is authorized and paid for by VHA, examining quality metrics and highlighting novel national care programs. The critical examination of this data is valuable for deriving health care policy, sharing novel and effective quality initiatives throughout the healthcare sector, and will help veterans and their providers make important healthcare decisions.

Central Illustration

Highlights

• •Veteran wait-time for VHA services is generally shorter than for community care services.
• •HF and AMI treatment at VHA hospitals are associated with reduced mortality compared to community.
• •Mortality after elective PCI is lower for veterans treated at VHA than in the community.
• •TAVR outcomes are similar in VHA and non-VHA medical facilities.
• •CART and NCDSP, national programs unique to the VHA, promote quality.

Federal government-provided healthcare for veterans started in 1865, with a law signed by President Abraham Lincoln establishing a national soldiers’ and sailors’ asylum “to care for him who shall have borne the battle.” This evolved into the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States which includes 172 medical centers and 1,138 outpatient clinics and has been recognized as providing high-quality healthcare to 9 million veterans annually.1, 2, 3 Federal legislation continues to shape the care of veterans.² The 2014 Veterans Affairs CHOICE Act (Veterans Access, Choice, and Accountability Act), followed by the 2018 Veterans Affairs MISSION Act (Veterans Affairs Maintaining Systems and Strengthening Integrated Outside Networks Act), were passed to increase veteran use of non-VHA community care, which is services delivered in non-VHA facilities by non-VHA providers and is authorized and paid for by VHA (Figure 1).⁴ The current community care eligibility criteria for specialty care are required service not offered at VHA, wait time is more than 28 days, and drive time is more than 60 minutes. It can be argued that this shift is only beneficial if it improves veterans’ access to care with quality that is comparable or better than that delivered by the VHA. The purpose of our review is to summarize studies with direct comparison of the quality and access to cardiovascular care delivered by VHA vs community that were identified from a PubMed literature search of investigations between 2000 and 2024. In addition, we highlight unique VHA programs that we believe contribute to high-quality cardiovascular care. Finally, based on our findings, we recommend future steps to optimize care for veterans.

Figure 1.

Timeline of VHA Healthcare Legislation

The VA CHOICE and MISSION Acts and funding of community care programs began in 2014 and developed into the veterans community care program by 2019. Created with Biorender.com.

Overview of cardiovascular care in the VHA

Cardiovascular diseases are prevalent in veterans with almost 50% reporting at least one cardiovascular disease, compared to a prevalence of 37% in nonveterans.^4,5 The VHA provides a broad spectrum of cardiovascular care, including prevention, general cardiology, coronary, structural, and electrophysiology interventions, cardiac surgery, advanced heart failure (HF) treatment, and cardiac transplantation. Over 172 medical centers containing 139 cardiology departments, 79 catheterization laboratories, 60 electrophysiology laboratories, and 35 cardiac surgery programs are located throughout the country.⁶ However, since the passage of the CHOICE and MISSION Acts, care of VHA-enrolled veterans has been increasingly transitioning towards the non-VHA community providers (Figure 2), with the community option promoted due to perceived excessive VHA appointment wait times or distance from VHA facilities, and when community care is deemed to be in the veterans’ “best medical interest.”

Figure 2.

Trend of Veterans Undergoing Community Care Percutaneous Coronary Artery Intervention

The probability of veterans undergoing PCI procedures in the community increased by 1.3-fold over a 3-year period.⁷ Reproduced with permission.

Quality of care

Several studies have evaluated the quality of cardiovascular care delivered by VHA and compared it to non-VHA community care. Table 1 summarizes these key comparison studies.

Table 1.

Studies Comparing Quality and Outcomes of Cardiovascular Care Between VHA and Non-VHA (Community Care)

First Author (Year)	Study Population	Health Metric	Comparator	Mean Age (y)	Outcome	Result
Jones et al8 (2015)	2,707	Systolic HF	Non-VHA	63 (VHA) 59 (non-VHA)	All-cause mortality	No difference
Axon et al9 (2015)	13,977	HF	Non-VHA (dual users)	71	Emergency room visit for HF hospitalization, HF readmission	Increased rates of health care utilization in dual users (VHA and non-VHA)
Nuti et al10 (2016)	103 VHA 1,500 non-VHA	HF AMI	Non-VHA	76	30-day mortality and hospital readmission rates	Mortality lower in VHA Readmission rates higher in VHA
Anhang Price et al11 (2018)	135 VHA hospitals	HF AMI	402 non-VHA hospitals	Not available	30-day mortality 30-day readmission	Mortality was lower in VHA for both conditions Readmissions higher in VHA for both conditions
Yoon et al12 (2023)	414,861	HF AMI CABG	Non-VHA	75	30-day mortality 30-day readmission rate	Lower in VHA hospitals for HF and CABG
Trivedi et al3 (2011)	Systematic review (4 studies)	Myocardial infarction Acute coronary syndrome	Non-VHA	Not available	Evidence based care, mortality, rates of appropriate angiography	Higher rates of evidence-based drug therapy in VHA Lower rate of angiography in VHA No difference in mortality
Barnett et al13 (2018)	19,055	Elective PCI (13,237) CABG (5,818)	Community Care Referral	<65	Cost, mortality, travel time, wait time	PCI in CC had higher mortality at higher cost CABG cost higher in VHA No difference in mortality
Waldo et al7 (2020)	8,913	Elective PCI (67% VHA)	Community care (33%)	Not available	Mortality	Higher mortality in community care post PCI
Waldo et al14 (2022)	12,837	Elective PCI (7,704 VHA)	Community care (5,133)	Not available	Mortality	Higher mortality in community care associated with: •Lower rates of antiplatelet (P2Y12) prescription •No follow-up visit post PCI
Lynch et al15 (2010)	21,111	Type 2 diabetes	Non-VHA	Not applicable	Self-care and preventive care	Higher rates of foot examination, dilated eye exam, flu, and pneumonia vaccine
Florez et al16 (2021)	5,047	Type 2 diabetes	Non-VHA	60	Diabetes care target	Higher rates of lipid lowering therapy and anti-hypertensive therapy in VHA
Rajan et al17 (2021)	492,479	Type 2 diabetes	Medicare	85	Hospitalization rate	Increased when primary care is non-VHA
Thorpe et al18 (2018)	50,763	Hypertension Dementia	Medicare Part D	Not applicable	Appropriate supply of blood pressure medications	Using both VHA and Part D was associated with increased risk of medication under and over supply

AMI = acute myocardial infarction; HF = heart failure; CABG = coronary artery bypass grafting; PCI = percutaneous coronary intervention; VHA = Veterans Health Administration.

Heart failure

In a large trial of patients with systolic HF (ejection fraction <35%) in 2015, the all-cause mortality and all-cause and HF hospitalization rates between VHA-treated veterans and community-treated nonveterans were compared. Although the veteran cohort was older with a higher burden of comorbidities, their risk of mortality (35% vs 32%; P = 0.274) and hospitalization (11% vs 8%, P = 0.120) was not higher than the younger, healthier nonveterans,⁸ suggesting that VHA care is at least comparable to non-VHA care. In 2016, a cross-sectional study of Medicare beneficiaries hospitalized for HF at VHA or community hospitals within the same metropolitan area showed that the 30-day mortality rates trended lower in the VHA cohort (11.4% vs 11.9%, P = 0.08), while readmission rates were higher (24.7% vs 23.5%, P < 0.001).¹⁰ Similar findings were seen in a 2018 study comparing quality of inpatient HF care between VHA and non-VHA hospitals (mortality 11.0% vs 11.8%, P < 0.001; readmission 23.4% vs 22.6%; P < 0.001).¹¹ In 2023, a large cross-sectional study of veterans (593,578 hospitalizations: 105,812 age <65 years, 487,766 age ≥65 years) hospitalized at either VHA or community hospitals showed both the 30-day mortality and readmission rates were lower in VHA hospitals (age ≥65 years: mortality 6.0% vs 10.4%, P < 0.001, readmission 22.3% vs 24.6%, P < 0.001; age <65 years: mortality 2.3% vs 3.0%, P = 0.04, readmission 20.9% vs 26.6%, P < 0.001), even after adjusting for differences in covariates.¹² Improvement in the VHA hospital readmission rate was corroborated by a study showing a decreasing rate of HF readmissions over a decade (2009-2010 vs 2015-2017: OR: 0.85, 95% CI: 0.83-0.88),¹⁹ while a similar study of community hospitals showed that readmission rates increased during the same period.^20,21 A retrospective analysis of veterans with HF who received care only in the VHA vs dual user (VHA and non-VHA care) showed lower rates of emergency room visits for HF and lower HF hospitalization and readmission rates only in the VHA-care patients.⁹ Favorable HF outcomes could be a result of the positive impact of VHA social support programs. VA Homeless Programs reduce housing instability by coordinating local, state, and federal resources for veterans. VA Long Term Care Services provide adult day health care, home health aides, respite care for caregivers, and residential skilled care.

Ischemic heart disease

Older studies comparing VHA and non-VHA patients admitted for acute myocardial infarction (AMI) showed greater utilization of evidence-based drug therapy in the VHA.³ A 2016 observational study of VHA-treated veterans vs community-treated nonveterans comparing rates of inpatient mortality after AMI found that VHA consistently outperformed community care with lower 30-day all-cause mortality rates although the risk of readmission was higher.¹⁰ In another study in 2018, comparison of VHA vs community hospitals showed a trend toward lower mortality after AMI in the VHA hospitals (14.3% vs 14.7%, P = 0.06) but with increased readmission rates (18.6% vs 17.8%, P < 0.001).¹¹ A recent 2023 study comparing veterans admitted to VHA vs community hospitals found that the unweighted 30-day mortality was lower in patients with AMI admitted to VHA hospitals (age ≥65 years 9.8% vs 12.0%, P < 0.001; age <65 years 2.9% vs 3.7%, P < 0.001), although the differences became nonsignificant after adjusting for covariates.¹² Finally, Hess et al. showed that within a group of 106 VHA facilities, the relative AMI mortality rate decreased by 5.5% per year between 2011 and 2014 and had less inter-facility variation than in community hospitals. However, the VHA AMI readmission rate did not improve significantly over time (relative decrease 0.4% per year), indicating this outcome metric remains a challenge.²²

Coronary revascularization

An observational study in 2018 showed that veterans receiving elective percutaneous coronary intervention (PCI) performed in VHA hospitals had a lower 30-day mortality than those in community hospitals (0.65% vs 1.54%, P < 0.001) with no difference in readmission rates (7.73% vs 7.04%, P = 0.66).¹³ The lower mortality in the VHA-delivered PCI group was associated with an increased average net distance traveled of 53.6 miles. Consistent with these results, another study showed that increasing distance from VHA PCI center was not associated with higher risk of death or AMI.²³ Another process of care, same day discharge, occurred in 10% of PCIs in the VHA compared to 29% of cases outside of VHA; however, same day discharge has not been associated with lower mortality.^24,25 The findings of reduced PCI mortality in the VHA was reaffirmed in 2020 with an analysis of 30,310 veterans who underwent elective PCI between 2015 and 2018.⁷ This study demonstrated a significantly lower 1-year mortality in veterans treated in the VHA as compared to those treated in the community (HR: 1.33; 95% CI: 1.09-1.62; absolute risk difference: 1.4% 95% CI: 0.2%-2.6%).⁷ This was likely related to better periprocedural care (1-month mortality HR: 2.43, 95% CI 1.50-3.94; absolute risk difference 0.7%, 95% CI 0.3%-1.2%) as well as more complete postprocedural follow-up and increased utilization rates of guideline-indicated medications, including anti-platelet therapy, among veterans treated in VHA.¹⁴

In a study of veterans <65 years of age undergoing elective coronary artery bypass grafting (CABG) surgeries between 2008 and 2011 either at VHA or community hospitals, there was no difference in the 30-day mortality (1.33% vs 1.51%, P = 0.74) or 30-day readmission rates (8.13% vs 7.00%, P = 0.28) between the 2 groups, although mean travel distance was reduced by 73 miles in the community care group.¹³ The lack of CABG mortality difference was reaffirmed in a 2023 study comparing VHA with community care, although 30-day readmission rates were now lower in the VHA.¹²

Transcatheter aortic valve replacement

Like the general medical community, VHA is providing more structural heart interventions, including transcatheter aortic valve replacement (TAVR) through stringently developed programs with national outcome monitoring and feedback.²⁶ Perhaps because of these processes, veterans undergoing TAVR in the VHA^27,28 have similar rates of major adverse events or conversion to open surgery when compared to historical controls from the community²⁹ despite relatively low institutional volumes.³⁰

Cardiovascular disease risk factors and prevention

Hyperlipidemia

No direct contemporary comparisons of low-density lipoproteins lowering in VHA vs community care systems have been published.³¹ However, a study of VHA-enrollees who suffered AMI or underwent coronary revascularization between 2015 and 2019 showed that 71% filled prescriptions for high-dose, high-intensity statin after discharge, which is at least comparable to Medicare beneficiaries.³² This statin prescription fill rate persisted at 1 year at 75%.^33,34

Diabetes

VHA-enrollees with type 2 diabetes have historically enjoyed superior processes of care than nonveterans under community care.^15,35 A recent study comparing veterans and nonveterans with diabetes showed more veterans were treated with lipid (70.8% vs 59.5%, P < 0.001) and blood pressure (74.9% vs 65.4%, P < 0.001) lowering medications, and more often had low-density lipoproteins <70 mg/dL (32.9% vs 24.2%, P < 0.05).¹⁶ Among those with diabetes and cardiovascular disease, more veterans had blood pressure <140/90 mm Hg (80.2% vs 70.1%, P < 0.05) after adjusting for demographics.¹⁶ A study of veterans with diabetes enrolled in both VHA and Medicare found that having a usual care provider outside VHA was associated with significantly (7% to 19%) higher odds of hospitalization (Table 1).¹⁷

Hypertension

Direct comparisons of hypertension control in VHA-enrollees vs community-treated patients are limited to older studies, which showed similar levels of control, with better control among Black veterans vs nonveterans.³⁶ A study that compared indicators of quality of hypertension care between 12 VHA and community health systems found that VHA demonstrated better adherence to quality indicators (78% vs 65%, absolute difference 13%, 95% CI: 8%-20%).³⁷ With regards to continuity of care, a study of veterans with dementia and hypertension found that patients who used both VHA and Medicare Part D for prescription had higher rates of medication undersupply or oversupply compared to those who used only used VHA.¹⁸

Access to care

Publicity of long wait times for veterans for VHA healthcare appeared to be a major driver of the CHOICE and MISSION acts. However, no other U.S. health care system had made their wait times publicly available, and anecdotes of long wait times for community care were prevalent. Since the acts’ passage, wait times for veterans for both VHA and community care have improved, with the wait-times between FY2015 and FY2018 decreasing for the top 10 services, including cardiology tests and procedures. For urban veterans, VHA wait times decline was 2.61% compared to 0.91% for community care (P < 0.0001). For rural veterans, the decline in wait times was similar (VHA 1.17% vs community care 0.87%, P = 0.186).³⁸ In a 2022 study, VHA wait times in a majority of regions were lower than those for community care.³⁹ Data on cardiovascular care wait times are limited, but a study of veterans undergoing cardiothoracic surgery showed VHA offered shorter wait times (2021: 23.1 days vs 30.0 days in the community).⁴⁰ An additional problem faced by rural veterans is a shortage of nearby healthcare facilities and providers. More rural veterans used VHA-authorized community care than urban veterans (2018: 30.1% vs 18.9%).³⁸ However, even though overall reduced travel time for veterans using community cardiovascular care has been demonstrated, 37% continued to wait >30 days for appointments.³⁸

VA quality enhancing programs

THE CART program

The CART (Clinical assessment, reporting, and tracking) Program is a quality and safety organization for several medical specialties in the VHA, including cardiology. Through a unique software application, denoted as the CART Application Suite, quality and safety information for all invasive cardiovascular procedures performed throughout the VHA is collected.⁴¹ These data are compiled during the clinical documentation by the patients’ physicians. CART leverages this information to create point-of-care analytics to inform and improve the quality,42, 43, 44, 45 facilitate clinical case review with national experts who provide consensus opinions regarding best practices,⁴⁶ and produces reports including process metrics and clinical outcomes at the facility and provider level to facilitate local quality improvement initiatives. These efforts have been demonstrated to garner more trust from the interventional community than similar quality programs that operate outside the VHA.⁴⁷ As such, the CART Program has been highlighted as a model quality improvement initiative for cardiovascular medicine, both inside and outside the VHA.⁴⁸

National cardiac device surveillance program

Clinical trials have shown that home remote monitoring of cardiac implantable electronic devices (CIEDs) decreased the time to the recognition of important clinical events, reduced the risk of implantable cardiac defibrillation shocks, reduced hospitalizations, improved mortality, reduced the need for in person visits, and improved patient satisfaction.⁴⁹ The National cardiac device surveillance program (NCDSP) promotes and facilitates centralized remote monitoring for all VHA CIED clinics, ensuring all patients have the equipment needed to do remote monitoring. As patients send remote transmissions, NCDSP staff review the transmissions, notify local clinics if there are important clinical findings, and make their interpretation and the data available to the VHA clinicians using an online portal as well as electronic medical record. In recent years, adherence to remote monitoring has increased from 71% to 85% in VHA clinics, which compares very favorably to the 53% to 76% adherence reported in settings outside the VHA, where the higher adherence rates used definitions less stringent that the one employed by the NCDSP.50, 51, 52 In addition to improving adherence, the NCDSP database is a key source of information on lead and device safety,^53,54 publishing important reports on the survival of suspect lead models⁵⁵, and partnering with the Federal Drug Administration to show that data from remote monitoring is likely superior to standard methods of identifying lead failure.⁵⁶

Telecardiology

Unencumbered by payor and/or reimbursement requirements, the VHA has been able to greatly expand its telehealth services in recent years. Remote monitoring of heart rate, blood pressure, pulse oximetry, and weight has been widely used for many years in VHA to facilitate care. While routinely available to the veterans’ clinicians, specific pilot programs utilizing this data have shown dramatic improvement in blood pressure control and heart failure outcomes.⁵⁷ Telemedicine has also been used for CIED follow-up visits which have been shown to be noninferior to in-person visits, with a nationwide program soon to be implemented, which will improve equity in rural areas without electrophysiology subspecialty care.⁵⁸ Video appointments, including electronic stethoscope auscultation, have extended effective telecardiology visits to most cardiac conditions.⁵⁹ Provider-to-provider electronic-consultation queries have facilitated care within tertiary care facilities and between primary and corresponding tertiary care facilities and allowed formulation of care plans prior to the veterans’ initial cardiology consultative visits. This integration reduced the median referral times from 24 to 13 days.⁶⁰ VHA home-based cardiac rehabilitation after AMI, PCI, or heart surgery has expanded the use of this guideline-recommended treatment in areas where traditional programs may not be available and has been associated with a 36% lower mortality hazard than nonparticipants.⁶¹

Study Limitations

There are no randomized trials of VHA vs non-VHA care, and thus there may be residual confounding in the studies we examined. In addition, our review did not consider the treatment of important comorbidities of post-traumatic stress syndrome, traumatic brain injury, and toxins exposure that may have occurred during military service that will benefit from coordinated VHA care. Furthermore, since VHA is diverse with regional differences, the reported favorable outcomes may not be applicable to all VHA facilities. Finally, the total VHA and community cardiovascular care cost is not available. Although the mean adjusted PCI cost between 2008 and 2011 was higher in the community than VHA ($22,025 vs $15,683, P < 0.001),¹³ current and projected figures cannot be extrapolated.

Conclusions

Much of the cardiovascular care delivered directly by the VHA that has been studied to date has been demonstrated to be equivalent or better than that delivered by non-VHA community due to well-established integration of high-quality medical care, extensive social support programs, and innovation (Central Illustration). Direct comparisons have shown reduced HF mortality and readmissions, reduced or similar AMI mortality, reduced elective PCI mortality, similar CABG mortality with reduced readmissions, and better risk factor control in high cardiovascular risk veterans like those with diabetes. VHA TAVR outcomes are likely similar to those in the community. AMI readmissions after VHA hospitalization require attention. Hypertension and hyperlipidemia control between the VHA and community should be studied. The unique VHA-specific quality programs including CART, NCDSP, and telecardiology have and will continue to enhance VHA direct care quality.

Central Illustration.

Comparison of VHA and Community Cardiovascular Care

Many VHA cardiovascular care outcomes are either comparable or superior to outcomes at non-VHA community hospitals. The readmission rate after acute myocardial infarction is lower in community hospitals. Created with Biorender.com.

Proposed roadmap

Delivering high-quality care to veterans is the overarching mission of the VHA. Our review demonstrates that VHA cardiovascular care quality is comparable or better than in the community. Thus, many veterans with access-to-care difficulties would experience greater health benefits from directly improving their access to VHA than from referring them to community care. In cases of prolonged appointment wait times (measured in real time and defined by community wait times or a reasonable standard), the efficiency of high-quality VHA cardiovascular care system should be maximized, and where needed, additional resources should be invested (Figure 3). In cases of prolonged travel times, telecardiology should be expanded, with additional in-person cardiovascular services (eg echocardiography, stress testing, and provider) incorporated into the extensive network of VHA community-based outpatient clinics currently devoted mainly to primary care. Additionally, veteran transportation and hospitality systems can be developed for veterans and their families. VHA quality programs such as CART should be expanded to encompass all specialties and services. If transfer of a veteran's care to the community remains desirable, VHA should scrutinize the quality of non-VHA care. VHA should continue to collaborate with the Centers for Medicare and Medicaid Services to share clinical and outcomes data so that both VHA and veterans can compare hospital performance between VHA and non-VHA care facilities in their communities.⁶² These measures are important steps to assist the government in fulfilling its obligation to the veterans to provide optimal cardiovascular health care.

Figure 3.

Current State and Roadmap to Future State of VHA Cardiovascular Care

VHA care utilization is discordant to its care quality in the current state. Increased federal funding of VHA quality-enhancing and innovative programs will favorably realign VHA market share and quality of care. Created with Biorender.com.

Funding Support and Author Disclosures

Dr Waldo has received unrelated investigator-initiated support from Abiomed, Cardiovascular Systems Incorporated, Janssen Pharmaceuticals, the National Institutes of Health, and VA Health Services Research & Development. Dr Shah has received funding from Abbott Vascular and the United States Food and Drug Administration. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.