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William B. Weeks, MD, MBA, Alan N. West, PhD, Amy E. Wallace, MD, MPH, Richard E. Lee, MA, MPH, David C. Goodman, MD, Justin B. Dimick, MD, MPH and James P. Bagian, MD, PE

William B. Weeks is with the Veterans Administration (VA) Outcomes Group Research Enhancement Award Program, VA Medical Center, White River Junction, Vt, and the Department of Psychiatry, Dartmouth Medical School, and the Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH. Alan N. West and Richard E. Lee are with the VA Outcomes Group Research Enhancement Award Program, VA Medical Center, White River Junction. Amy E. Wallace is with the VA Outcomes Group Research Enhancement Award Program, VA Medical Center, White River Junction, and the Department of Psychiatry, Dartmouth Medical School, Hanover. David C. Goodman is with the Department of Pediatrics, Dartmouth Medical School, and the Dartmouth Institute for Health Policy and Clinical Practice, Hanover. Justin B. Dimick is with the VA Outcomes Group Research Enhancement Award Program, VA Medical Center, White River Junction, and the Department of Surgery, University of Michigan, Ann Arbor. James P. Bagian is with the Veterans Health Administration and the VA National Center for Patient Safety, Ann Arbor, Mich, and the Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Md.

Correspondence: Requests for reprints should be sent to William B. Weeks, MD, MBA, 215 N Main St, VAMC (11Q), White River Junction, VT 05009 (e-mail: wbw{at}dartmouth.edu).

Objectives. We quantified older (65 years and older) Veterans Health Administration (VHA) patients’ use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals.

Methods. Using a merged VHA–Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals.

Results. Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time.

Conclusions. Policy that directs older VHA enrollees’ private-sector care to high-performance hospitals promises to reduce mortality for VHA’s service population and warrants further exploration.