Long-acting injectable vs oral risperidone for schizophrenia and co-occurring alcohol use disorder: a randomized trial.

OBJECTIVE: Alcohol use disorders worsen the course of schizophrenia. Although the atypical antipsychotic clozapine appears to decrease alcohol use in schizophrenia, risperidone does not. We have proposed that risperidone's relatively potent dopamine D2 receptor blockade may partly underlie its lack of effect on alcohol use. Since long-acting injectable (LAI) risperidone both results in lower average steady-state plasma concentrations than oral risperidone (with lower D2 receptor occupancy) and encourages adherence, it may be more likely to decrease heavy alcohol use (days per week of drinking 5 or more drinks per day) than oral risperidone. METHOD: Ninety-five patients with DSM-IV-TR diagnoses of schizophrenia and alcohol use disorder were randomized to 6 months of oral or LAI risperidone between 2005 and 2008. Explanatory (efficacy) analyses were carried out to evaluate the potential benefits of LAI under suitably controlled conditions (in contrast to real-world settings), with intent-to-treat analyses being secondary. RESULTS: Explanatory analyses showed that heavy drinking in the oral group worsened over time (P = .024) and that there was a statistical trend toward significance in the difference between the changes in heavy drinking days in the oral and LAI groups (P = .054). Furthermore, the 2 groups differed in the mean number of drinking days per week (P = .035). The intent-to-treat analyses showed no difference in heavy drinking but did show a difference in average drinking days per week similar to that obtained from the explanatory analyses (P = .018). Neither explanatory nor intent-to-treat analyses showed any between-group differences in alcohol use as measured by intensity or the Alcohol Use Scale. The plasma concentrations of the active metabolite 9-hydroxyrisperidone were significantly lower in patients taking LAI (P < .05), despite their significantly (overall) better treatment adherence (P < .005). CONCLUSION: For the population considered here, schizophrenia patients with alcohol use disorder appear to continue drinking some alcohol while taking either form of risperidone. Nonetheless, our data suggest that injectable risperidone may be a better choice than the oral form for these dual diagnosis patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00130923.

Impact of rural residence on survival of male veterans affairs patients after age 65.

OBJECTIVES: More than 1 in 5 Veterans Affairs (VA) users lives in a rural setting. Rural veterans face different barriers to health care than their urban counterparts, but their risk of death relative to their urban counterparts is unknown. The objective of our study was to compare survival between rural and urban VA users. METHODS: We linked the Large Health Survey of Veteran Enrollees conducted in 1999 to the Veterans Administration vital status registry. We used time-to-event regression models controlling for patient race, education, ZIP-code median income, and marital and smoking status. FINDINGS: Of the 372,463 male veterans of age 65 or greater, 80,931 lived in rural settings. Age-adjusted mortality was 5.9% higher (95% CI, 4.5%-7.2%) in rural residents compared to urban residents. After adjusting for age, education, and ZIP-code median income, rural residents had 3.0% lower mortality (95% CI, 1.5%-4.4%). Compared to urban and suburban VA users, rural VA users' mortality at age 65 was 12% lower, but this advantage gradually diminished by age 75. CONCLUSION: Mortality after the age of 65 for male VA users is higher in rural dwellers than in urban dwellers. However, among veterans of the same socioeconomic characteristics, rural-dwelling veterans have up to 15% better mortality than urban-dwelling veterans until the age of 75.

A cross-sectional, multi-year examination of rural and urban Veterans Administration users: 2002-2006.

We compared demographic profiles across two rural-urban classification schemes to determine whether rural-urban disparities in health status persisted among Veterans Administration (VA) users over time. Using demographic and SF-12 survey data collected from 2002 to 2006, we conducted serial cross-sectional analyses of demographic variables and health status for veterans residing in VA- and rural-urban commuting area (RUCA)-defined rural-urban groups. VA and RUCA definitions yielded similar results for the "urban" population; however, VA- and RUCA-defined "rural" categories represent dissimilar populations. Compared to earlier years, the VA user population in 2006 was younger, more educated, wealthier, and more likely to be employed and privately insured. For all years and using both VA and RUCA rural-urban definitions, physical component summary (PCS) scores were lower but mental component summary (MCS) scores were slightly higher for more rural compared to urban veterans. Anticipating and meeting the needs of rural VA users will require accurate identification of those who lack access to services and therefore defining "rural" appropriately.

A longitudinal analysis of rural and urban veterans' health-related quality of life.

CONTEXT: Cross-sectional studies have identified rural-urban disparities in veterans' health-related quality-of-life (HRQOL) scores. PURPOSE: To determine whether longitudinal analyses confirmed that these disparities in veterans' HRQOL scores persisted. METHODS: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans' HRQOL scores were changing at different rates over the time period examined. FINDINGS: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. CONCLUSIONS: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.

Absence of race- or gender-specific income disparities among full-time white and Asian general internists working for the Veterans Administration.

BACKGROUND: Gender-based, but not race-based, income disparities exist among general internists who practice medicine in the private sector. OBJECTIVE: The aim of this study was to assess whether race- or gender-based income disparities existed among full-time white and Asian general internists who worked for the Veterans Health Administration of the US Department of Veterans Affairs (VA) between fiscal years 2004 and 2007, and whether any disparities changed after the VA enacted physician pay reform in early 2006. METHODS: A retrospective study was conducted of all nonsupervisory, board-certified, full-time white or Asian VA general internists who did not change their location of practice between fiscal years 2004 and 2007. A longitudinal cohort design and linear regression modeling, adjusted for physician characteristics, were used to compare race- and gender-specific incomes in fiscal years 2004-2007. RESULTS: A total of 176 physicians were included in the study: 82 white males, 33 Asian males, 30 white females, and 31 Asian females. In all fiscal years examined, white males had the highest mean annual incomes, though not statistically significantly so. Regression analyses for fiscal years 2004 through 2006 revealed that physician age and years of service were predictive of total income. After physician pay reform was enacted, Asian male VA primary care physicians had higher annual incomes than did physicians in all other race or gender categories, after adjustment for age and years of VA service, though these differences were not statistically significant. CONCLUSIONS: No significant gender-based income disparities were noted among these white and Asian VA physicians. Our findings for white and Asian general internists suggest that the VA' s goal of maintaining a racially diverse workforce may have been effected, in part, through use of market pay among primary care general internists.

Racial, socioeconomic, and rural-urban disparities in obesity-related bariatric surgery.

BACKGROUND: Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. METHODS: We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. RESULTS: After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). CONCLUSIONS: Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

Women, alcohol, and the military: cultural changes and reductions in later alcohol problems among female veterans.

OBJECTIVE: Women working in traditionally male-dominated environments are at higher risk for alcohol use disorders (AUDs). The male-dominated U.S. military has additional risk factors associated with problem drinking, including isolation from family and exposure to life-threatening stressors. In the 1980s, the military conformed to all U.S. states' 21-year minimum legal drinking age (MLDA), and established prevention and intervention policies for abusive drinking. METHODS: Using a serial cross-sectional design, we explored trends in annual alcohol treatment rates among female veterans versus civilians. From the Department of Health's Treatment Episode Data Set, we extracted AUD admissions from years 1992-2003 for female veterans and civilians in four age categories. Using age-specific population figures, we calculated annual AUD treatment rates and odds ratios for female veterans versus civilians. We used time-series analyses to examine trends in annual AUD treatment for female veterans and civilians across the years examined. RESULTS: In 1992, odds ratios of alcohol treatment episodes for female veterans compared to civilians ranged from 1.9 for 25-29-year-olds to 4.2 for 40-44-year-olds (all p < 0.01). Female veterans' annual alcohol treatment rates dropped substantially from 1992 to 2003, while rates for female civilians ages 25-34 dropped marginally and those for civilians ages 35-44 increased. Time-series analysis showed a statistically significant drop in rates for veterans from 1992 to 2003 and a significant difference between veterans' and civilians' rates, but demonstrated that female civilian annual treatment rates remained static from 1992 to 2003. CONCLUSIONS: Prior to the military's efforts to reduce underage and problem drinking, female veterans' alcohol treatment rates exceeded those of same-age civilians. However, with increasing exposure to an environment that discourages abusive drinking, female veterans' annual rates of alcohol treatment fell to below those for same-age civilians.

Practical and policy implications of using different rural-urban classification systems: a case study of inpatient service utilization among Veterans Administration users.

CONTEXT: Several classification systems exist for defining rural areas, which may lead to different interpretations of rural health services data. PURPOSE: To compare rural classification systems on their implications for estimating Veterans Administration (VA) utilization. METHODS: Using 7 classification systems, we counted VA health care enrollees who lived in each category, and number admitted to VA hospitals or non-VA hospitals under Medicare. For dual VA-Medicare enrollees over age 65, we compared VA and private sector hospitalizations on numbers of admissions and bed-days of care. We compared VA enrollees' relative proportions across rural to urban categories for each classification system and evaluated discordance between systems at the veterans-integrated service networks (VISN) level. FINDINGS: Enrollment and inpatient utilization counts for rural veterans vary considerably from one classification system to another, though the systems generally agree that admission rates, length of stay, and reliance on the VA for care are lower for rural veterans. Among older dual VA and Medicare enrollees, rural residents rely on non-VA facilities more, though this effect also varies widely depending on the classification scheme. VISNs vary greatly in the proportions of patients who are rural residents, and in the degree to which classification systems are discordant in designating patients as rural. CONCLUSIONS: Decisions about allocating VA health care resources to target "rural" patients may be affected greatly by the rural classification system chosen, and the impact of this choice will affect some hospital networks much more than others.

How do race and sex affect the earnings of primary care physicians?

To explore the connection between primary care physicians' race and sex and their annual incomes, we used restricted versions of Community Tracking Study Physician Surveys administered in 1998-99, 2001-02, and 2004-05. Compared to white male primary care physicians, we inconsistently found lower yearly incomes for their black male peers but consistently found significantly lower incomes for their female peers of any race, after differences in work effort, physician characteristics, and practice characteristics were adjusted for. Sex-based differences persisted over time. Our findings suggest that addressing the underlying causes of sex-based income differences should be a priority for health professional organizations, particularly as more women enter the physician workforce.

Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals?

CONTEXT: Unplanned readmission within 30 days of discharge is an indicator of hospital quality. PURPOSE: We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts. METHODS: We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity. FINDINGS: Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital. CONCLUSIONS: Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.

Does the VA offer good health care value?

OBJECTIVES: We sought to determine whether the VA provides health care at a low cost. METHODS: For fiscal years 2001-2007, we used data from the National Center for Health Statistics to calculate the VA's average per capita health care costs. We used data from the Medical Expenditure Panel Survey to calculate the average market value of health care received by patients who used the VA for health care. Finally, we examined several measures of health care quality provided by the VA and the private sector. RESULTS: Overall, VA health care costs 33 percent more than it would if purchased in the private sector (95 percent Confidence interval: 19 percent - 52 percent more); VA inpatient care costs were 56 percent higher (95 percent Confidence interval: 27 percent - 105 percent higher). The VA maintains a quality advantage in outpatient care, but its inpatient advantage has narrowed over recent years, and there is evidence that VA surgical care has worse outcomes than private sector surgical care. CONCLUSIONS: The VA's health care costs are considerably higher than could be purchased in the private sector. The VA should consider outsourcing inpatient services to high performance private sector hospitals.

The impact of the Department of Veterans Affairs Health Care Personnel Enhancement Act of 2004 on VA physicians' salaries and retention.

OBJECTIVE: To determine whether the Department of Veterans Affairs Health Care Personnel Enhancement Act (the Act), which was designed to achieve VA physician salary parity with American Academy of Medical Colleges (AAMC) Associate Professors and enacted in 2006, had achieved its goal. METHODS: Using VA human resources datasets and data from the AAMC, we calculated mean VA physician salaries, with 95 percent confidence intervals, for 15 different medical specialties. For each specialty, we compared VA salaries to the median, 25th, and 75th percentile of AAMC Associate Professors' incomes. RESULTS: The Act's passage resulted in a $20,000 annual increase in VA physicians' salaries. VA primary care physicians, medical subspecialists, and psychiatrists had salaries that were comparable to their AAMC counterparts prior to and after enactment of the Act. However, VA surgical specialists', anesthesiologists', and radiologists' salaries lagged their AAMC counterparts both before and after the Act's enactment. Income increases were negatively correlated with full-time workforce changes. CONCLUSIONS: VA does not appear to provide comparable salaries for physicians necessary for surgical care. In certain cases, VA should consider outsourcing surgical services.

Research on rural veterans: an analysis of the literature.

CONTEXT: The Veterans Health Administration (VA) provides comprehensive health care services to veterans across the United States. Recently, the VA established an Office of Rural Health to address the health care needs of rural veterans. PURPOSE: To review the literature on rural veterans' health care needs in order to identify areas for future research. METHODS: We conducted a literature review of articles listed in the Medline, CINAHL, and BIOSIS datasets since 1950. We reviewed and summarized the findings of 50 articles that specifically examined rural veterans. FINDINGS: The literature on rural veterans included 4 articles examining access to care, 7 evaluating distance technology, 4 examining new models of care delivery, 11 studying rural veterans' patient characteristics, 10 evaluating programs provided in a rural setting, 6 examining rural health care settings, and 8 exploring rural veterans' health services utilization patterns. Most studies were small, based on data obtained before 2000, and consisted of uncontrolled, retrospective, descriptive studies of health care provided in rural VA settings. Definitions of rural were inconsistent, and in 20% of the articles examined the rural aspect of the setting was incidental to the study. CONCLUSIONS: The literature on rural veterans' health care needs warrants expansion and investment so that policy makers can make informed decisions in an environment of limited resources and competing interests.

The U.S. military as a natural experiment: changes in drinking age, military environment, and later alcohol treatment episodes among veterans.

Before 1982, soldiers consumed alcohol legally on U.S. bases, regardless of age. By 1988, the military established policies to discourage underage and problem drinking and, along with the civilian population, fully transitioned to a 21-year minimum legal drinking age. We explored whether these changes were associated with changes in later alcohol treatment episodes among male veterans and civilians from years 1992 to 2003. Treatment rates for veterans and civilians were calculated using administrative databases for four age cohorts. Alcohol treatment rates were similar and odds ratios were > or = 1.0 for veterans compared with same-aged civilians in 1992; however, by 2003, veterans' treatment rates fell by 60% for ages 25 to 34 compared with a 20 to 25% reduction for civilians, and odds ratios fell to between 0.80 and 0.60 those of civilians. The military's concerted efforts to enforce the 21-year minimum legal drinking age were associated with greater reductions in later alcohol treatment episodes among veterans compared with civilians.

Comparing the characteristics, utilization, efficiency, and outcomes of VA and non-VA inpatient care provided to VA enrollees: a case study in New York.

OBJECTIVE: To compare the characteristics, utilization, and outcomes of Veterans Health Administration (VA) and non-VA inpatient care provided to VA enrollees in New York. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 110,716 residents of New York State who were enrolled in the VA and had 266,869 inpatient admissions in VA and non-VA hospitals in New York. For each admission, we determined the system of care used (VA or non-VA), patient demographics, and characteristics of the admission, and we calculated VA patients' relative reliance on the VA for inpatient care. For each Major Diagnostic Category (MDC), we examined reliance, patient characteristics, and lengths-of-stay for 2 groups: veterans who were younger than age 65 and those age 65 or older. RESULTS: Fifty-three percent of younger patients' inpatient admissions were in the VA, whereas 32% of older patients' were; however, relative reliance on the VA varied dramatically across the 19 MDCs examined. Across age groups, patients admitted to VA hospitals were younger, less likely to be white, and less likely to live in a rural setting. Those using VA hospitals had lower Charlson scores and received less complex care. For both age groups and across all MDCs, admissions to VA hospitals had substantially higher diagnosis related group-specific observed-to-expected lengths-of-stay. CONCLUSIONS: Younger and older veterans use VA and non-VA hospitals differently for inpatient services. Comprehensive inpatient datasets could inform planners about VA's service market and VA managers about achievable performance benchmarks that are relevant to VA's service population.

When VA patients have non-VA hospitalizations, who pays for what services, and what are the research implications? A New York case study.

OBJECTIVE: To determine, for Veterans Health Administration (VA) enrollees who lived and were hospitalized in New York State between 1998 and 2000, the primary payers for their non-VA admissions, whether the primary payer mix varied by condition treated, and whether the Medicare claims data that VA acquired on its Medicare-enrolled patients captured all or most of their non-VA inpatient care. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 75,046 residents of New York State who were enrolled in the VA and had 159,843 inpatient admissions in New York hospitals not in the VA system. For each admission, we determined the major diagnostic category, the primary payer for the admission, and whether the patient was Medicare-enrolled. Our analyses separated veterans into those younger than age 65 and those ages 65 or older. RESULTS: The payer mix for younger veterans' non-VA admissions varied considerably by major diagnostic category. Among veterans who also were Medicare enrollees, Medicare did not pay for 10% of the non-VA hospitalizations of older patients or 20% of those for younger patients. CONCLUSIONS: Using only Medicare claims data may significantly underestimate VA patients' reliance on non-VA inpatient care. To better inform planners about VA's service market and diagnosis-specific service utilization patterns across VA and non-VA providers, VA should work with states to develop comprehensive inpatient datasets.

Rural veterans and access to high-quality care for high-risk surgeries.

OBJECTIVES: To determine whether older Veterans Health Administration (VA) health care enrollees obtain most high-risk surgeries in non-VA hospitals under Medicare, whether residence in less populous areas increases this reliance on non-VA care or the likelihood of obtaining it in hospitals with higher mortality rates, and whether directing VA enrollees to better hospitals would add a substantial travel burden. DATA SOURCES: VA and Medicare hospital discharge data from 2000 and 2001 for VA enrollees 65 years or older who received any of 14 high-risk elective procedures, including heart, vascular, and cancer surgeries. STUDY DESIGN/DATA EXTRACTION: We compared urban, suburban, and rural patients on use of VA versus non-VA hospitals, use of non-VA hospitals of higher versus lower mortality rates, travel times to get to these hospitals, and the additional travel burden if they had gone to lower mortality hospitals. PRINCIPAL FINDINGS: Regardless of residence, VA enrollees obtained most high-risk surgeries in non-VA hospitals. Urban veterans were most likely to get heart or cancer surgeries in lower mortality hospitals, but rural veterans were most likely to get vascular surgeries in lower mortality hospitals. Average travel times to lower or higher mortality hospitals did not differ greatly. CONCLUSIONS: Accessing better hospitals need not add a great travel burden for rural veterans.

Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes.

CONTEXT: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. PURPOSE: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. METHODS: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. FINDINGS: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: -$14,569, -$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. CONCLUSIONS: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.

Is a management degree worth the investment for physicians? A survey of members of the American College of Physician Executives.

In a survey of 568 physician members of the American College of Physician Executives (ACPE), most of whom had advanced management degrees (MBA, MMM, MPH), approximately 90% of respondents reported that their investment in the education was "worth it." The return on investment was independent of the quality of the academic institution, although primary care physicians stood to gain more relative to specialists. Salary comparisons showed that female physicians had approximately 20% lower incomes than male physicians, confirming the presence of a "glass ceiling" for female physician executives as seen in other medical specialties. These findings have implications for early and mid-career physicians and physician recruiters.

Reducing avoidable deaths among veterans: directing private-sector surgical care to high-performance hospitals.

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.