MANAGEMENT BRIEF

Number 15 Overviews of Health Care Topics for VA Senior Managers June 2000

The Number One Cause of Death: Heart Disease

“HSR&D is working to improve the level of care for VA heart patients by examining the quality,

cost, access, and outcomes of care related to heart disease.”

John G. Demakis, MD

Director, Health Services Research and Development Service

What types of heart disease are most prevalent

among veterans?

Two of the most prevalent types of heart disease among

veterans and the nation include ischemic heart disease (IHD)

and chronic heart failure (CHF). Despite the dramatic decrease in IHD mortality rates over the last three decades, it

remains the number one cause of death in the United States.

Ischemic heart disease, which encompasses acute myocardial

infarction (AMI) and unstable angina, is also one of the most

frequent indications for medical care in the VA. For example,

in 1997 there were more than 150,000 VA hospital admissions

for IHD.1 Chronic heart failure is also highly prevalent,

affecting 2 to 3 out of every 100 adults age 65-74. And the

incidence of CHF is increasing in the U.S., partly due to an

aging baby-boom population.2 Among veterans, CHF is a

prevalent and costly condition.

How does heart disease impact veterans’ health?

Ischemic heart disease can significantly affect one’s

quality of life. For example, in an ongoing study of veterans

discharged with acute myocardial infarction or unstable angina, 51% experience chest pain three times per week or

more, and 15% experience chest pain on a daily basis.

Further, persons with chronic heart failure report among the

worst physical and social functioning.3

 Shortness of breath,

fatigue, and poor exercise tolerance are frequent symptoms of

heart failure. And CHF is a lethal disease. About two-thirds

of veterans with CHF die within five years of their initial

hospitalization.2

Why is heart disease an important issue for

VA managers?

Hospital and resource use associated with heart disease is

tremendous. For example, in 1996 the typical patient with

CHF who received VA treatment had 14 hospital days per

12 months of follow-up care, 6-7 visits with the primary care

physician, two urgent care visits, and 14 additional outpatient

visits for testing and consultation.2 VA health care resource

use for veterans with IHD is also intense and costly – over

$100 billion in indirect and direct costs annually. In FY97

there were 15,182 hospitalizations for acute myocardial infarction and 23,033 for unstable angina, with a mean cost of

$18,485 for a patient with AMI, and $34,491 for patients with

unstable angina who had bypass surgery.1

Therapies that can relieve or control symptoms of these

heart conditions are available, yet are often underused. A

national survey showed that in 1995 only 36-40 percent of

patients with heart failure received pharmacologic treatment

with ACE inhibitors. In addition, significant proportions of

patients do not receive advice on salt restrictions and/or have

poorly controlled high blood pressure.2

 And despite recently

developed national practice guidelines for the treatment of

IHD that have been disseminated by cardiology specialty

societies and within VA, a significant number of patients are

not treated with guideline recommended therapies.1

VA HSR&D Management Brief June 2000 Page 1 of 3
VA HSR&D Management Brief Number 15, June 2000 Page 2 of 3

Lower quality of life may predict mortality in patients

with coronary artery disease

Patient-reported quality of life (QOL) measures are potentially useful as predictors of outcomes. This HSR&D study

examined the relationship between QOL and five-year mortality (all cause) among VA outpatients with coronary artery

disease (CAD). The three VA General Internal Medicine

Clinics who participated in this study were pilot sites for the

Ambulatory Care Quality Improvement Project (ACQUIP).

This prospective cohort study examined 1,679 VA patients

with coronary artery disease who responded to ACQUIP

quality of life surveys. Quality of life was measured using

four scales of the Seattle Angina Questionnaire (SAQ): physical functioning, disease perception, angina frequency, and

angina stability. All scales were scored 0 (worst health) to

100 (best health).

During the five year follow-up period, 28 percent of the

cohort died. Patients who survived five years were stratified

into two groups – those scoring greater than 50 or less than

50 on all scales. For both the physical function and angina

frequency scales, patients who scored greater than 50 had

significantly lower mortality. Therefore, poorer quality of life,

as measured by SAQ physical function and angina frequency

scales, appears to be a significant predictor of all cause mortality in veterans with coronary artery disease. Quality of life,

as measured by the disease perception and symptom stability

scales, did not significantly relate to risk of death. If disease

specific quality of life instruments such as the SAQ can predict mortality, they can potentially be used to identify patients

at risk for adverse outcomes. If identified, these patients

could benefit from targeted interventions and preventive

measures.

McDonell MB, Spertus JA, Fihn SD. Quality of life

and 5-year mortality among veterans with coronary artery

disease: Results from the Ambulatory Care Quality Improvement Project. Journal of General Internal Medicine, 2000;

15 (supp. 1): 82.

HSR&D SDR 96-002 (randomized trial) and CSHS 91-007

(pilot study)

Exercise improves quality of life in patients

with chronic heart failure

Chronic heart failure (CHF) is a syndrome of impaired

ventricular function that results in symptoms such as fatigue

and decreased ability to exercise. This often leads to an increasingly sedentary lifestyle and a deterioration of muscle

function for veterans with CHF. Until recently, the prescription for patients with CHF was rest and minimization

of physical exertion. This HSR&D study sought to determine whether patients with CHF who completed an individualized 24-week program of cardiopulmonary training

for six months would have better quality of life (QOL)

than patients who did not participate in the training and, instead, met weekly with an investigator. In this study better

QOL was defined by: significantly greater aerobic fitness,

higher levels of daily activity, fewer symptoms secondary

to CHF, greater self-efficacy, and reduced use of health

care resources.

Preliminary data from this study show a 26 percent

improvement in vitality (energy) in the exercising group

compared to 4 percent in the control group. Further, after

six weeks of low-intensity cardiopulmonary training,

exercisers increased their walking duration by 26 percent

compared to a 3 percent improvement in the control group.

This study has the potential to promote a new mode of

exercise training that could be valuable to patient rehabilitation programs, in addition to improving QOL and patient

satisfaction.

Collins E, et al. Can exercise training improve QOL

in heart failure patients? A pilot study. Journal of Heart

& Lung Transplantation 1998; 17:78.

HSR&D NRI 95-213

Study helps VA improve patterns of care for

veterans with acute myocardial infarction

Acute myocardial infarction (AMI) is a leading cause of

morbidity and mortality in the US general population and

among veterans. The Center for the Study of Practice Patterns in Veterans with AMI was created to conduct health

services research that informs clinical policy on effective

treatment for veterans with AMI. Using both administrative and clinical data sources, the AMI Center investigates

variation in practice patterns in veterans with AMI who

are hospitalized in both VA medical centers and Medicarefinanced hospitals.

Thus far there have been several findings of note:

1) The 30 day mortality for veterans with AMI decreased

by 23 percent between 1988 and 1997; 2) use of cardiac

catheterization increased by 30 percent, bypass surgery

by 50 percent, and coronary angioplasty by 176 percent

between 1988 and 1995; 3) of VA users who were hospitalized for AMI in 1996, 70 percent were initially admitted to

There is a substantial amount of ongoing research on heart disease in the VA and the larger

U.S. health care community. Below are recent findings from a few HSR&D studies that focus on

some important issues related to the treatment and prevention of heart disease.
For more information about this issue of

MANAGEMENT BRIEF, or to send comments, contact:

Gerry McGlynn, M.Ed., MDRC, Manager,

Information Dissemination Program, 150 S. Huntington

Avenue, Boston, MA 02130. Phone: 617-278-4433.

Fax: 617-278-4438.

Visit the Research and Development web page at

http://www.va.gov/resdev or the Intranet site at

http://vaww.va.gov/resdev, or utilize the MDRC

Fax-on-Demand system at (617) 278-4492 to see

additional MDRC publications and reports.

This is our fifteenth MANAGEMENT BRIEF. Please fax us your

suggestions and comments:

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The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within VA’s Office of Research &

Development, Health Services Research & Development Service. The

purpose of the MANAGEMENT BRIEF is to provide VA senior management

with a concise and timely overview of a specific health care topic that

includes topic definition, benefits, VA research activities, and resources

for further information.

a Medicare-financed facility; and 4) mortality was similar

between VA users initially hospitalized in VA or Medicarefinanced hospitals between 1992 and 1996. Information

such as this helps policy makers, clinicians, and administrators better understand patterns of VA and non-VA care and

helps establish national baseline measures that can be used

to evaluate the effectiveness and quality of cardiac care for

veterans.

Wright SM, Petersen LA, Daley J. Increasing use of

Medicare services by veterans with acute myocardial

infarction. Medical Care 1999; 37:529-37.

Wright SM, Petersen LA, Daley J. Availability of cardiac

technology: Trends in procedure use and outcomes for

patients with acute myocardial infarction. Medical Care

Research and Review 1998; 55:239-54..

Petersen LA, Wright SM. Does the VA provide ‘primary’

primary care? Journal of General Internal Medicine 1999;

14:318-319.

HSR&D PPR 94-001; HSR&D Career Development Award,

RCD 95-306; and IHD-99-001-RRQ

Evaluating VA quality of care for veterans with

ischemic heart disease

VA must provide a full range of health services, such as

cardiac consultation and other sub-specialty care to veterans

across the nation. This HSR&D study was designed to provide timely, relevant information to administrative and clinical decision makers to assist them in providing optimal

cardiac consultation in a variety of geographic areas.

Two thousand patients admitted with ischemic heart disease (half with myocardial infarction and half with unstable

angina) were followed for six months post-discharge to

evaluate care. Preliminary results of this observational study

include information on cardiac procedures and discharge

medications. For example, the rate of cardiac catheterization

was 50 percent; coronary angioplasty, 18 percent; and bypass

surgery, 9 percent. These rates were comparable to the private

sector. Discharge medication use of guideline recommended

therapies were equal or greater than non-VA patients: aspirin

(87 percent), beta-blockers (71 percent), and ace inhibitors

(54 percent). Results of this study will be used to evaluate

cardiac procedure use and guideline compliance in veteran

patients with ischemic heart disease, so optimal practice

patterns may be systematized.

Every NR, et al. A comparison of the national registry of

myocardial infarction with the cooperative cardiovascular

project. Journal of the American College of Cardiology 1999;

33:1886-1894.

Every NR, Ritchie JL. Variations in the use of cardiac

procedures: What is the explanation? [ed. comment]

American Heart Journal 1999; 137:588-589.

HSR&D RCD 94-304

VA HSR&D Management Brief Number 15, June 2000 Page 3 of 3

References:

1. Every NR, Fihn SD, Sales AE, et al. for the QUERI IHD

Executive Committee. Quality Enhancement Research

Initiative in ischemic heart disease: a quality initiative

from the Department of Veterans Affairs. Medical Care

2000; 38(Suppl 6): I-49-I-59.

2. Ashton CM, Bozkurt B, Colucci WB, et al. Veterans Affairs

Quality Enhancement Research Initiative in chronic heart

failure. Medical Care 2000; 38(Suppl 6): I-26-I-37.

3. Stewart AL, Greenfield S, Hays RD, et al. Functional

status and well-being of patients with chronic conditions.

Results from the Medical Outcomes Study. JAMA.

1989 Aug 18; 262(7):907-13.