1. Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care Ashish K. Jha, MD Jonathan B. Perlin, MD PHD Kenneth W. Kizer, MD MPH R. Adams Dudley, MD MBA Citation: Jha AK et al. New England Journal of Medicine, 2003; 348(22):2218-27 Presented at: Is There a Future for Integrated Care Systems in the Consumer Era? AcademyHealth Annual Research Meeting June 6, 2004

2. VA Performance in Preventive Services Preventive Care FY 1994/95FY 2000p-value Percent (n) Mammography 64% (424)90% (3622)<0.001 Influenza vaccine 28% (42,717)78% (42,061)<0.001 Pneumococcal vaccine 27% (45,502)81% (44,481)<0.001 Colorectal cancer screen 33% (43,368)68% (43,465)<0.001 Cervical cancer screen 62% (5016)93% (3837)<0.001

3. VA Performance in Chronic Disease Management Chronic Disease ManagementFY 1994/95FY 2000p-value Diabetes Percent (n) Annual HgbA1c 52% (4,624)94% (25,768)<0.001 Annual Eye exam 48% (4,624)67% (24,314)<0.001 Bi-annual Lipid screen Not Measured89% (25,768)N/A Hypertension BP < 140/90 25% (800)46% (58,453)<0.01 Depression Annual Screening Not Measured73% (58,495)N/A

4. VA Performance in Inpatient Care Inpatient care FY 1994/95FY 2000p-value Acute MI Percent (n) ASA within 24 hours Not Measured93% (5,919)N/A ASA at discharge 89% (855)98% (3,705)<0.001 Beta-blockers at discharge 70% (849)95% (3,705)<0.001 CHF 15. EF Checked Not Measured94% (13,373)N/A 16. ACE-I if EF < 40% Not Measured93% (13,373)N/A

5. VA versus Medicare Topic VA 1997-1999 Medicare 1997-1999 VA 2000 Medicare 2000-2001 Preventive Services Mammography 89%56%90%77% Influenza vaccine 71%66%78%71% Pneumococcal vaccine 73%46%81%64% Diabetes Annual Hb A1c 91%71%94%70% Annual eye exam 73%69%67%74% Bi-annual Lipid screen 71%57%89%60% P-value for all comparison < 0.01

6. VA versus Medicare Topic VA 1997-1999 Medicare 1997-1999 VA 2000 Medicare 2000-2001 Myocardial Infarction ASA within 24 hours 96%84%93%84% ASA at discharge 95%85%98%84% ß-blocker at discharge 93%72%95%78% ACE-I if EF < 40% Not Measured69%90%71% Smoking Cessation Not Measured39%62%38% CHF EF Checked 92%65%94%71% ACE-I if EF < 40% 94%69%93%66% P-value for all comparison < 0.01

7. Discussion VA Transformation Large gains in quality Due to re-engineering efforts Comparison to Medicare VA quality better than Medicare now, for nearly all measures BUT USED TO BE WORSE! Implies Re-engineering and rapid improvement may be more feasible in an integrated delivery system ON THE OTHER HAND: VA’s poor initial performance shows an IDS can go badly wrong if neglected It’s not enough just to integrate; commitment to high quality—and likely performance measurement and accountability—are key

8. Another Point to Note The VA-Medicare comparisons are only recently feasible, because our performance measurement tools have improved recently-- especially in the domains of chronic and acute (vs. preventive) care These domains are more likely to show benefits from integration, so differences between IDSs and other systems may become more visible over time