Original Research

A National Survey of Veterans Affairs Medical Centers’ Cardiology Services

A survey found that of cardiology services were widely available at facilities across the US Department of Veterans Affairs, but the types of services varied considerably based on facility complexity.

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References

The US Department of Veterans Affairs (VA) remains the largest integrated health care system in the US serving 9 million veterans. Two recent studies that compared 30-day mortality and readmission rates between VA and non-VA hospitals among older men with acute myocardial infarction (AMI), and heart failure (HF). The studies found that hospitalization at VA hospitals was associated with lower risk-standardized 30-day all-cause mortality rates for MI and HF when compared with hospitalization at non-VA hospitals.1,2

However, it is unknown whether the delivery of cardiovascular care is optimized in the VA system. For example, in comparisons between generalist-led hospitalized care for MI and HF, several studies have demonstrated that cardiology-led care has been associated with lower rates of mortality.3-5 Although data on the types of cardiac technology and use of cardiac procedures were described previously, we have not found detailed information on the types of inpatient cardiology services provided at VA medical centers nationwide.1,6,7 To develop further improvements in delivery of cardiovascular care within the VA, a better understanding of the types of resources that are currently available within the VA system must be made available. In this article, we present results of a national survey of cardiology services at VA facilities.

Methods

From February to March of 2017, we conducted a comprehensive nation-wide survey of all VA facilities to quantify the availability of cardiology services, excluding cardiothoracic surgical services. The survey questions are listed in the Appendix. The chief of medicine and the chief of cardiology were each e-mailed 3 times at every facility. If no response was received from a facility, we e-mailed the chief of staff 3 times. If there still was no response, the remaining facilities were contacted by phone and study authors (PE and WB) spoke to individuals directly regarding the structure of cardiology services at a facility. Responses were categorized by facility level of complexity. Complexity designation was determined by the VA Central Office (VACO)—level 1 facilities represent the most complex and level 3 facilities are the least complex. VACO also divides facility complexity into sublevels, for example level 1A facilities generally are associated with academic medical centers and provide the highest levels (tertiary or quaternary) of care.8

Results were coded according to a predetermined rubric for how cardiology services are structured (admitting service, consult service, inpatient, outpatient, other) and for how they were staffed (attending only, house staff, or advanced practice providers (APPs). After the first wave of surveys, 2 additional questions were added to the survey tool; these asked about employed vs contracted cardiologist and use of APPs. The results were tabulated and simple percentages calculated to express the prevalence of each structure and staffing model.

The study was reviewed and approved by the University of Utah/Salt Lake City VA Medical Center joint institutional review board and all authors completed human subjects research training.

Results

Study authors initially identified all 168 VA medical center facilities operating in 2017. Initial polling revealed that multiple facilities either were substations or had agreements for cardiology services from larger facilities, with 1 facility having 2 campuses with different levels of service at each. After adjusting for these nuances, the total number of potential respondents was 139. We obtained a response from 122 of the 139 facilities for an overall survey completion rate of 88%. Response rates varied by complexity level (Table 1). The survey received responses from all Level 1A and 1B facilities, 96% from Level 1C facilities; 83% (20/24) from level 2 facilities, and 62% (18/30) from level 3 facilities. (Please note that in the reference document providing detailed descriptions of the VA level of complexity has different numbers for each facility type given that there has been reassignments of the levels since our survey was completed.)8

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