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PubMed2003

Methods for estimating private sector payments for VA acute inpatient stays.

OBJECTIVES: To describe methods for estimating hypothetical private sector payments for Veterans Health Administration (VA) acute inpatient stays. METHODS: We assumed all VA hospitalizations would have occurred under a hypothetical VA system that paid private sector providers but had the current benefit package for VA patients. We compared aggregate budgets for VA inpatient care (less physician salaries) at six VA hospitals over federal fiscal year 1999 to aggregated hypothetical private sector payments developed using VA diagnosis-related groups matched to metropolitan-based average Medicare payments. Counts of care came from the VA's statistical analysis system (SAS) inpatient files. Inpatient stays with both medical or surgical and psychiatric or rehabilitation care were counted as two stays. An external auditor conducted three reviews of VA coding practices during the study year, and the appropriateness of admissions was examined using a commercial utilization review tool. RESULTS: For 30,518 inpatient discharges, hypothetical payments were $188 million, compared with the VA budget of $171 million. Fifteen of the 25 most frequent diagnosis-related groups in the VA were also in the top 25 for Medicare in 1998 and 1999. Audits established that the overall financial impact of VA coding problems was similar to that in the private sector. DISCUSSION: Differences in organization, practice, and incentives limit estimates of the financial impact of shifting VA acute inpatient care to the private sector.

Budgets↗
PubMedDate not supplied

The first private sector health insurance company in Ghana.

This article analyses the development of Ghana's first private sector health insurance company, the Nationwide Medical Insurance Company. Taking both policy and practical considerations into account (stakeholders' perspectives, economic viability, equity and efficiency), it is structured around key questions which help to define the position and roles of stakeholders--the insurance agency itself, contributors, beneficiaries, and providers--and how they relate to one another and the insurance scheme. These relationships will to a large extent determine Nationwide's long-term success or failure. By creating a unique alliance between physician providers and private sector companies, Nationwide has used employers' interest in cost containment and physicians' interest in expanding their client base as an entrée into the virgin territory of health insurance, and created a hybrid variety of private sector insurance with some of the attributes of a health maintenance organization or managed care. The case study is unusual in that, while public sector programs are often open to academic scrutiny, researchers have rarely had access to detailed data on the establishment of a single private sector insurance company in a developing country. Given that Ghana is planning to launch a national health insurance plan, the article concludes by considering what the experience of this private sector initiative might have to offer public sector planners.

Cost Control↗
PubMed2003

Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market.

OBJECTIVE: To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market. DESIGN: Retrospective cohort study. SETTING: A large VA hospital and 27 private sector hospitals in the same metropolitan area. PATIENTS: Consecutive VA (N = 1,960) and private sector (N = 157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses. MEASUREMENTS: Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis. MAIN RESULTS: Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P =.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P <.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P =.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P <.001), and the odds of death in VA patients were actually lower (P <.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P <.001) in VA patients for all 9 diagnoses. CONCLUSIONS: If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.

Aged↗
PubMed1991

Stress and well-being in nurses: a comparison of the public and private sectors.

Nurses in the public and private sectors were compared with regard to occupational stress and its sources and self-reported health and well-being. While both groups reported similar high levels of stress experience, most noticeably arising from high work loads and the experience of death and dying, group differences did emerge from an examination of the sources of stress. Whereas N.H.S. nurses were more troubled by high work loads, private sector nurses reported uncertainty over treatment as a more frequent source of stress than did their N.H.S. counterparts. Levels of self-reported mental and physical health symptomatology did not differ between groups. Nevertheless, overall nursing stress scores and symptomatology were significantly correlated, and workload was the best independent predictor of health and well-being status.

Burnout, Professional↗
PubMed2005

Creating conditions for greater private sector participation in achieving contraceptive security.

The growing gap between donor/government funding and the expected need for contraceptives is an issue of great concern for most developing countries. Addressing this resource shortfall, and meeting the goals of contraceptive security requires that countries mobilize the full and active participation of the private sector in the contraceptive market. Private sector involvement will not only increase the resource base available for contraceptives, it can also free up scarce donor and government resources to serve those who have the greatest need for public subsidies. This paper provides an overview of policy processes, strategies, and tools that can be used in developing countries to create an enabling environment for greater private sector participation, foster complementary public-private sector roles, and enhance the contribution of the private sector to contraceptive security.

Commerce↗
PubMed2004

A comparison of prescribing practices between public and private sector physicians in Uganda.

INTRODUCTION: Previous studies in the public sector in Uganda have demonstrated major prescribing problems due to polypharmacy and irrational use of antibiotics and injections. Little is known about prescribing in the private sector although there is little government regulation influencing practice in this sector. The introduction of policies such as the Uganda National Standard Treatment Guidelines (UNSTG) was expected to improve prescribing practices in the public and private sectors. This paper measures appropriateness of prescribing practices in the public and private sectors in Uganda for the treatment of Acute Respiratory Infections (ARI) and malaria in adult patients. DESIGN AND SAMPLING: We combined a prospective survey of treatment for simulated patients presenting with symptoms of malaria and ARI in 119 randomly selected private clinics and a retrospective survey of 600 prescription records for malaria and ARI (300 for each condition) randomly selected from 10 public health units in the Kampala, Masaka, and Jinja urban areas. OUTCOME MEASURES: Percentage of drug appropriately prescribed in each condition, % injection prescription, percentage antibiotic prescription, average number of drugs per case, average standardized cost per prescription, distribution of types of drugs prescribed. RESULTS: The overall appropriateness of prescribing for ARI and malaria was poor in both public and private sectors. Treatment of malaria was significantly less appropriate in the public sector compared to the private sector (14% vs. 27%, p = 0.002), with injectable chloroquine much more commonly prescribed. Prescribing of antibiotics for ARI was nearly universal in both sectors, with some prescriptions containing up to three antibiotics; newer, more expensive antibiotics were more commonly prescribed in the private sector. Polypharmacy and unnecessary prescribing of vitamins were common in both conditions and both sectors. CONCLUSIONS: Prescribing for adult malaria and ARI by both private and public practitioners did not conform to the UNSTGs. Although practitioners were largely the same in both sectors, prescribing practices often differed dramatically. The extent of inappropriate prescribing in both sectors calls for in-depth investigation of the system factors and motivations that underlie problem practices, and the development of interventions that target these causative factors.

Acute Disease↗
PubMed2003

Public and private sector responses to essential drugs policies: a multilevel analysis of drug prescription and selling practices in Mali.

Many African countries have introduced cost recovery mechanisms based on the sale of drugs and measures aimed at improving drug supply. This study compares prescribing and selling practices in Mali, in 3 cities where the public sector contributes differentially to the supply of drugs on the market. Multilevel models are used to analyse the content and cost of 700 medication transactions observed in 14 private and public legal points of sale. Results show that the objective of improving access to drugs seems to have been achieved in the sites studied. Costs of prescriptions were lower where public health services had been revitalized. Affordable generic drugs were accessible and widely used, even in the private sector. However, measures intended to rationalize the prescription and delivery of drugs did not always have the desired effect. While agents in the public sector tended to prescribe fewer antibiotics, injectables, or brand-name drugs, the data confirm the virtual absence of advice concerning the use or the side effects of the drugs in both public and private sectors. In addition, data supported the notion that the public and private sectors are closely intertwined. Notably, availability of drugs in the public sector contributed to diminishing the prices charged in the private sector. Similarly, the use that agents in the public sector made of the opportunities afforded by the presence of the private pharmaceutical sector provided another illustration of interrelatedness. Finally, the data showed that the presence of a private sector, which has not been affected by measures aimed at rationalizing prescription and sales practices, limits the effects of measures implemented in the public sector. More assertive policies, based on strategies encompassing actors in the private sector, are needed to increase the safety and effectiveness of prescription and sales practices.

Community Health Centers↗
PubMed2005

Combining DRGs and per diem payments in the private sector: the Equitable Payment Model.

The many types of payment models used in the Australian private sector are reviewed. Their features are compared and contrasted to those desirable in an optimal private sector payment model. The EPM(TM) (Equitable Payment Model) is discussed and its consistency with the desirable features of an optimal private sector payment model outlined. These include being based on a robust classification system, nationally benchmarked length of stay (LOS) results, nationally benchmarked relative cost and encouraging continual improvement in efficiency to the benefit of both health funds and private hospitals. The advantages in the context of the private sector of EPM(TM) being a per diem model, albeit very different to current per diem models, are discussed. The advantages of EPM(TM) for hospitals and health funds are outlined.

Acute Disease↗
PubMedDate not supplied

Using severity-adjusted mortality to compare performance in a Veterans Affairs hospital and in private-sector hospitals.

The objective of this study was to compare hospital mortality in Veterans Affairs (VA) and private-sector patients. The study included 5016 patients admitted to 1 VA hospital. Admission severity of illness was measured using a commercial methodology that was developed in a nationwide database of 850,000 patients from 111 private-sector hospitals. The method uses data abstracted from patients' medical records to predict the risk of death in individual patients, based on the normative database. Analyses compared actual and predicted mortality rates in VA patients. VA patients had higher (P < .05) severity of illness than private-sector patients. The observed mortality rate in VA patients was 4.0% and was similar (P = .09) to the predicted risk of death (4.4%; 95% confidence interval 4.0-4.9%). In subgroup analyses, actual and predicted mortality rates were similar in medical and surgical patients and in groups stratified according to severity of illness, except in the highest severity stratum, in which actual mortality was lower than predicted mortality (57% vs 73%; P < .001). We found that in-hospital mortality in 1 VA hospital and a nationwide sample of private-sector hospitals were similar, after adjusting for severity of illness. Although not directly generalizable to other VA hospitals, our findings nonetheless suggest that the quality of VA and private-sector care may be similar with respect to one important and widely used measure.

Aged↗
PubMed1998

Improving the quality of private sector delivery of public health services: challenges and strategies.

Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi-faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge.

Developing Countries↗
PubMed2006

Does federal health care policy influence switching between the public and private sectors in individuals?

OBJECTIVE: The aim of this study was to determine if changes in Australian Federal health policy have influenced individual behaviour regarding utilisation of private health insurance in Western Australia. METHOD: The WA Data Linkage System was used to extract all hospital morbidity records in Western Australia from 1980 to 2001. For each individual, episodes were grouped into hospital couplets classified according to the mix of public and privately insured events. Logistic regression was used to estimate the likelihood of switching towards or away from the private sector, according to the time between episodes in each of five health care policy eras. RESULTS: The odds of a switch away from the private sector increased by 29% with each additional year between episodes, while the odds of a switch towards the private sector increased by 15% per intra-couplet year. In those with a private first episode the odds of switching decreased approximately exponentially across the five eras whereas the odds of switching in those with a public first episode stabilised after 1985. In the last era (1999-2001) the odds of switching away from the private sector reduced substantially. CONCLUSION: Our analysis suggests that the recent policies supporting PHI (30% rebate and Lifetime Health Cover) appear to have been effective at modifying individual behaviour to reduce the drift away from the private sector. However, the reported increases in utilisation of PHI were only partially explained by switching of existing demand in patients who had been previously hospitalised as public patients, suggesting that the policy reforms had generated, rather than merely shifted, demand for health care. This finding has significant policy implications for Australia.

Adolescent↗
PubMed2003

Promoting safe motherhood through the private sector in low- and middle-income countries.

The formal private sector could play a significant role in determining whether success or failure is achieved in working towards goals for safe motherhood in many low- and middle-income settings. Established private providers, especially nurses/midwives, have the potential to contribute to safe motherhood practices if they are involved in the care continuum. However, they have largely been overlooked by policy-makers in low-income settings. The private sector (mainly doctors) contributes to overprovision and high Caesarean section rates in settings where it provides care to wealthier segments of the population; such care is often funded through third-party payment schemes. In poorer settings, especially rural areas, private nurses/midwives and the women who choose to use them are likely to experience similar constraints to those encountered in the public sector - for example, poor or unaffordable access to higher level facilities for the management of obstetrical emergencies. Policy-makers at the country-level need to map the health system and understand the nature and distribution of the private sector, and what influences it. This potential resource could then be mobilized to work towards the achievement of safe motherhood goals.

Adolescent↗
PubMed1995

Efficiency and quality in the public and private sectors in Senegal.

It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access.

Efficiency, Organizational↗
PubMed2004

Strategies for engaging the private sector in sexual and reproductive health: how effective are they?

The private health sector provides a significant portion of sexual and reproductive health (SRH) services in developing countries. Yet little is known about which strategies for intervening with private providers can improve quality or coverage of services. We conducted a systematic review of the literature through PubMed from 1980 to 2003 to assess the effectiveness of private sector strategies for SRH services in developing countries. The strategies examined were regulating, contracting, financing, franchising, social marketing, training and collaborating. Over 700 studies were examined, though most were descriptive papers, with only 71 meeting our inclusion criteria of having a private sector strategy for one or more SRH services and the measurement of an outcome in the provider or the beneficiary. Nearly all studies (96%) had at least one positive association between SRH and the private sector strategy. About three-quarters of the studies involved training private providers, though combinations of strategies tended to give better results. Maternity services were most commonly addressed (55% of studies), followed by prevention and treatment of sexually transmitted diseases (32%). Using study design to rate the strength of evidence, we found that the evidence about effectiveness of private sector strategies on SRH services is weak. Most studies did not use comparison groups, or they relied on cross-sectional designs. Nearly all studies examined short-term effects, largely measuring changes in providers rather than changes in health status or other effects on beneficiaries. Five studies with more robust designs (randomized controlled trials) demonstrated that contraceptive use could be increased through supporting private providers, and showed cases where the knowledge and practices of private providers could be improved through training, regulation and incentives. Although tools to work with the private sector offer considerable promise, without stronger research designs, key questions regarding their feasibility and impact remain unanswered.

Delivery of Health Care↗
PubMed2003

Shifting the burden: the private sector's response to the AIDS epidemic in Africa.

As the economic burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organizations, and the burden is being systematically shifted away from the private sector. Common practices that transfer the burden to households and government include pre-employment screening, reductions in employee benefits, restructured employment contracts, outsourcing of low skilled jobs, selective retrenchments, and changes in production technologies. Between 1997 and 1999 more than two-thirds of large South African employers reduced the level of health care benefits or increased employee contributions. Most firms also have replaced defined-benefit retirement funds, which expose the firm to large annual costs but provide long-term support for families, with defined-contribution funds, which eliminate risks to the firm but provide little for families of younger workers who die of AIDS. Contracting out previously permanent jobs is also shielding firms from benefit and turnover costs, effectively shifting the responsibility to care for affected workers and their families to households, nongovernmental organizations, and the government. Many of these changes are responses to globalization that would have occurred in the absence of AIDS, but they are devastating for the households of employees with HIV/AIDS. We argue that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.

Acquired Immunodeficiency Syndrome↗
PubMed2005

New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG.

OBJECTIVE: To determine whether patients' use of the Veterans Health Administration health care system (VHA) is an independent risk factor for mortality following coronary artery bypass grafting (CABG) in the private sector in New York. DATA SOURCES: VHA administrative and New York Department of Health Cardiac Surgery Reporting System (CSRS) databases for surgeries performed in 1999 and 2000. STUDY DESIGN: Prospective cohort study comparing observed, expected, and risk-adjusted mortality rates following private sector CABG for 2,326 male New York State residents aged 45 years and older who used the VHA (VHA users) and 21,607 who did not (non-VHA users). DATA COLLECTION METHODS: We linked VHA administrative databases to New York's CSRS to identify VHA users who obtained CABG in the private sector in New York in 1999 and 2000. Using CSRS risk factors and previously validated risk-adjustment model, we compared patient characteristics and expected and risk-adjusted mortality rates of VHA users to non-VHA users. PRINCIPAL FINDINGS: Compared with non-VHA users, patients undergoing private sector CABG who had used the VHA were older, had more severe cardiac disease, and were more likely to have the following comorbidities associated with increased risk of mortality: diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, and history of stroke (p<.001 for all); a calcified aorta (p=.009); and a high creatinine level (p=.003). Observed (2.28 versus 1.80 percent) and expected (2.48 versus 1.78 percent) mortality rates were higher for VHA users than for non-VHA users. The risk-adjusted mortality rate for VHA users (1.70 percent; 95 percent confidence interval [CI]: 1.27-2.22) was not statistically different than that for the non-VHA users (1.87 percent; 95 percent CI: 1.69-2.06). Use of the VHA was not an independent risk factor for mortality in the risk-adjustment model. CONCLUSIONS: Although VHA users had a greater illness burden, use of the VHA was not found to be an independent risk factor for mortality following private sector CABG in New York. The New York Department of Health risk adjustment model adequately applies to veterans who obtain CABG in the private sector in New York.

Aged↗
PubMed2003

Benchmarking the quality of schizophrenia pharmacotherapy: a comparison of the Department of Veterans Affairs and the private sector.

BACKGROUND: Comparing quality of care between large health care systems is important for health systems management. This study used measures of the quality of pharmacotherapy for patients with schizophrenia and compared these measures across a sample of patients from the Department of Veterans Affairs (VA) and the private sector. METHODS: A random sample of all patients diagnosed with schizophrenia in the VA during fiscal year (FY) 2000 was identified using administrative data. In the private sector, a sample of patients diagnosed with schizophrenia in 2000 was identified using MEDSTAT's MarketScan database. For both groups, use of antipsychotic medications was studied and measures of the quality of pharmacotherapy were constructed, including whether patients were prescribed any antipsychotic medication, one of the newer atypical antipsychotics, and whether dosing adhered to established treatment recommendations. These measures were compared across the two groups using logistic regression models, controlling for age, gender, and comorbid diagnoses. RESULTS: Most patients with a diagnosis of schizophrenia (82% in the VA and 73% in the private sector) received an antipsychotic medication, usually one of the newer atypical drugs. Patients in the VA were more likely to be dosed above treatment recommendations, and less likely to be dosed below treatment recommendations. Overall, differences in proportion schizophrenia patients dosed according to recommendations were not statistically different across the two systems (60% in the VA, 58% in the private sector). CONCLUSIONS: Differences between the two systems were mixed, with the VA outperforming the private sector with respect to some measures and doing worse on others. IMPLICATIONS FOR HEALTH CARE PROVISION: Although the VA and the private sector were comparable with respect to the quality measures used in this study, there is room for improvement in both systems. Treatment recommendations are based on the best available clinical evidence of effectiveness and safety. Quality of care might be improved with better adherence to these recommendations. IMPLICATIONS FOR HEALTH POLICIES: Relatively low rates of adherence to treatment recommendations may be due to lack of awareness of these recommendations among prescribing physicians, or a belief that the recommendations are inadequate. To the extent that low rates of adherence to treatment recommendations are caused by a lack of awareness among physicians, policies should be developed to disseminate this information and encourage the appropriate use of these medications. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed to understand physician prescribing decisions for these medications. To the extent that physicians feel treatment recommendations for these drugs are inadequate, further research is needed to refine the recommendations.

Antipsychotic Agents↗
PubMed2003

In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals.

OBJECTIVES: Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions. RESEARCH DESIGN: Retrospective Cohort Study. SUBJECTS: Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696). METHODS: Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P <0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD). RESULTS: Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P <0.001) with increasing volume (3.6% in low [<500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [>1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P <0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01). CONCLUSIONS: VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.

Age Distribution↗