Characteristics and Outcomes of Patients With Advanced Chronic Systolic Heart Failure Receiving Care at the Veterans Affairs Versus Other Hospitals

Abstract

Background Characteristics and outcomes of patients with heart failure and reduced ejection fraction (HFrEF) receiving care at Veterans Affairs (VA) vs. non-VA hospitals have not been previously reported. Methods and Results In the randomized controlled Beta-Blocker Evaluation of Survival Trial (BEST; 1995–1999), of the 2707 (bucindolol=1353; placebo=1354) patients with HFrEF (EF ≤35%), 918 received care at VA hospitals, of which 98% (n=898) were men. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were men. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary endpoint of 2-year all-cause mortality (35% VA vs. 32% non-VA; hazard ratio {HR}, 1.09; 95% confidence interval {CI}, 0.94–1.26), which remained unchanged after adjustment for age and race (HR, 1.00; 95% CI, 0.86–1.16) or multivariable-adjustment including cardiovascular morbidities (HR, 0.94; 95% CI, 0.80–1.10). There was no between-group differences in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular EF <20% and peripheral arterial disease were significant predictors of mortality for both groups. African America race, New York Heart Association class IV symptoms, atrial fibrillation and right ventricular EF <20% were associated with higher mortality among non-VA hospital patients only; however, these differences from VA patients were not significant. Conclusions Patients with HFrEF receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to those younger and healthier receiving care at non-VA hospitals.

Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias in Older African American and White Veterans

“…One possible explanation of the lower overall estimate of AD/ADRD in our study is that AD/ADRD is under-diagnosed or under-documented in the VA system [27]. Another possible explanation is that Veterans have a lower risk of AD/ADRD due to intense physical exercise during early military years and a more disciplined lifestyle thereafter [28]. However, the finding of a higher risk of AD/ADRD among African American Veterans is consistent with previous reports [25,26,[29][30][31][32][33].…”

Quality of life assessed 6 months after hospitalisation for acute heart failure: an analysis from REPORT‐HF (international REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure)

“…[22][23][24][25] An analysis conducted in the Veterans Health Administration, which resembles universal healthcare, suggests differences in health outcomes between races may not be evident when healthcare access is equal. 26 Women in this study were, on average, older and more often had HFpEF, making it difficult to disentangle age and underlying disease from potential associations with sex and health status. The odds of being 'alive and well' were 1.22 times better for men compared to women, although CIs did not reach the threshold for statistical significance.…”

Temporal Trends and Hospital Variation in Mineralocorticoid Receptor Antagonist Use in Veterans Discharged With Heart Failure

“…Features common to VA hospitals such as a national formulary, electronic medical record, and academic affiliations may favor a homogeneous pattern of MRA utilization. Furthermore, veterans with HF are typically older, more symptomatic, and have more comorbidities than non‐VA patients yet have similar outcomes . Sixth, we utilized a LVEF cutoff of <40%, rather than ≤35%, due to limitations of the VA clinical data sets, though some studies on this topic have also utilized a cutoff of LVEF <40% …”

“…Furthermore, veterans with HF are typically older, more symptomatic, and have more comorbidities than non-VA patients yet have similar outcomes. 23 Sixth, we utilized a LVEF cutoff of <40%, rather than ≤35%, due to limitations of the VA clinical data sets, though some studies on this topic have also utilized a cutoff of LVEF <40%. 6 There was a temporal decline in MRA prescription among Ideal candidates from 2003 to 2009 as well as important hospital-level variation in MRA use for Ideal and Non-Ideal candidates in the VA system, suggesting the importance of system factors in MRA prescribing in addition to patient factors.…”