VA Health Care:

Monitoring of Cardiac Surgery and Kidney Transplantation

HRD-88-70: Published: May 26, 1988. Publicly Released: Jun 14, 1988.

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Pursuant to a congressional request, GAO reviewed the Veterans Administration's (VA) monitoring of its Cardiac Surgery Program and Kidney Transplant Program, focusing on whether VA: (1) developed adequate performance standards; (2) centers met these standards; and (3) adequately monitored centers' performance.

GAO found that VA: (1) required its cardiac surgery centers to perform at least 100 procedures a year; (2) set a 5-percent maximum mortality rate for coronary artery bypass grafts and an overall maximum mortality rate for all procedures of not more than twice its national average; (3) raised its standard for the minimum annual number of cardiac surgical procedures to 150 starting in 1988; (4) relied on semiannual reviews of patients' medical records to monitor cardiac surgery centers, although such reviews failed to address nonsurgical problems such as staff recruitment and retention, patient selection, infection control, and outdated equipment and facilities; and (5) did not require site visits even if centers were not meeting performance standards, and made only five site visits during fiscal years 1986 and 1987. GAO also found that VA: (1) reduced its performance standard for kidney transplants from 15 to 12 a year; (2) did not establish standards for patient and transplanted kidney survival rates, although a Department of Health and Human Services (HHS) task force proposed such standards; and (3) conducted very limited monitoring of centers' kidney transplant programs. In addition, GAO found that, in fiscal year 1987: (1) 28 of 43 cardiac surgery centers met VA utilization and mortality standards; and (2) four of nine kidney transplant programs met the VA standards.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Cardiac Surgery Consultants Committee received the criteria and recommended approval. The final draft criteria was presented to the full committee on June 5, 1989 and approved by the Chief Medical Director on June 16, 1989.

    Recommendation: The Administrator of Veterans Affairs should direct the Chief Medical Director to require that a site visit be conducted at each cardiac surgery center that does not meet the mortality standards for a prescribed time period, such as 12 consecutive months.

    Agency Affected: Veterans Administration

  2. Status: Closed - Implemented

    Comments: New sharing agreements have been modified to collect utilization data starting in October 1989.

    Recommendation: To better assess whether contract hospitals are providing cardiac surgery to veterans at an overall level consistent with VA standards, the Administrator of Veterans Affairs should require that the Chief Medical Director develop a procedure for collecting and monitoring these hospitals' utilization and mortality information for nonveterans as well as veterans.

    Agency Affected: Veterans Administration

  3. Status: Closed - Implemented

    Comments: VA adopted HHS task force patient and kidney graft survival rates as performance standards. The Director of Surgical Services annually reviews the centers' performance against these standards. Centers' not meeting these standards will be considered for termination by the Chief Medical Director, according to the Director of Surgical Service.

    Recommendation: The Administrator of Veterans Affairs should require the Chief Medical Director to: (1) adopt the HHS task force patient and kidney graft survival rates or establish alternative standards; and (2) regularly monitor the centers' performance against these standards. If a center does not show potential for meeting these standards, the Chief Medical Director should consider terminating the centers' kidney transplant activities.

    Agency Affected: Veterans Administration


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