Lowell Chang is a Cardiologist and Associate Chief of Cardiology, Jason Carr is a Pulmonary Critical Care Fellow, Charles Lui is an Interventional Cardiologist, Kimberly Selzman is an Eletrophysiologist and Chief of Cardiology, Caroline Milne is an Internist and Residency Training Director for Internal Medicine, Paul Eleazer is a Hospitalist and Chief of Medicine, John Nord is an Internist and Deputy Chief of Staff, all at George E. Wahlen Veterans Administration Medical Center, Department of Internal Medicine in Salt Lake City, Utah. Wade Brown is a Pulmonary Critical Care Fellow at Vanderbilt University, Division of Pulmonary and Critical Care Medicine, Nashville, Tennessee. Lowell Chang is an Adjunct Instructor in the division of cardiovascular medicine, Jason Carr is a Pulmonary Critical Care Fellow, Charles Lui and Kimberly Selzman are Professors in the division of cardiovascular medicine, Caroline Milne is a Professor and Vice Chair for Education and Program Director of the Internal Medicine Training Program, John Nord is an Assistant Professor of Medicine, and Paul Eleazer is a Professor of Medicine, all at the University of Utah School of Medicine in Salt Lake City, Utah. Correspondence: Lowell Chang (lowell.chang@hsc.utah.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
We were specifically interested in inpatient cardiology services and whether facilities provided only consult services or inpatient services led by a cardiology attending. Having inpatient services does not exclude the availability of consult-liaison services (Table 2).
Higher complexity facilities (1A and 1B) were more likely to have dedicated, cardiology-led inpatient services, while lower complexity facilities relied on a cardiology consult service. Two-thirds of Level 3 facilities did not have inpatient cardiology services available.
Dedicated cardiovascular care unit (CCU) teams were the most common inpatient service provided, present in more than half of all Level 1 facilities and 83% of Level 1A facilities (Table 3). Cardiology-led floor teams were available in 45% and 33% of level 1A and 1B facilities, respectively, but were much less common in Level 1C and Levels 2 and 3 facilities (4%, 10%, 0%, respectively). Only 31% of Level 1 facilities had both a CCU team and a cardiology-led inpatient floor team. Inpatient consulting cardiologists were commonly available at Levels 1 and 2 facilities; however, only 33% of Level 3 facilities had inpatient consulting cardiologists.
Housestaff-managed inpatient services, teams consisting of, but not limited to, medical residents in training, led by a cardiology attending were present in 73% of Level 1 facilities. Interestingly, Level 1B facilities were more likely to have housestaff-led services than were Level 1A facilities (90% and 80% respectively). Inpatient advanced heart failure services were less common and available only in Level 1 facilities. We did not survey the specific details of the other (eg, led by a noncardiology attending physician) models of inpatient cardiology care provided.
Cardiac catheterization (including interventional cardiology and electrophysiology [EP]) services, varied considerably. Ninety percent of Level 1A facilities offered interventional services, compared with only 52% of Level 1C facilities offered interventions. EP services were divided into simple (device only) and complex (ablations). As noted, complex EP services were more common in more complex facilities; for example, 10% of Level 2 facilities offered device placement but none had advanced EP services.
Outpatient services were widely available. Most facilities offered outpatient consultative cardiology services, ranging from 95% (Level 1) to 89% (Level 3) and outpatient cardiology continuity clinics 99% (Level 1) to 72% (Level 3).
Regardless of level of complexity, > 80% of facilities employed cardiologists. Many also used contract cardiologists. No facility utilized only contracted cardiologists. Use of nurse practitioners (NPs) and physician assistants (PAs) to assist with managing inpatient services was relatively common, with 61% of Level 1 facilities using such services.
Discussion
Studies of patient outcomes for various conditions, including cardiac conditions, in the 1990s found that when compared with non-VA health-care systems, patient outcomes in the VA were less favorable.9 During the late 1990s, the VA embraced quality and safety initiatives that have continued to the present time.9,10 Recent studies have found that, in most (but not all) cases, VA patient outcomes are as good as, and in many cases better, than are non-VA patient outcomes.1,10,11 The exact changes that have improved care are not clear, though studies of other health care systems have considered variation in services and costs in relationship to morbidity and mortality outcomes.12-14 In the context of better patient outcomes in VA hospitals, the present study provides insight into the cardiology services available at VA facilities throughout the nation.
