Abstract 4341265: Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans

Introduction/Background: The Department of Veterans Affairs’ (VA’s) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for Veterans to obtain care outside the VA. However, the MISSION Act's impact on healthcare quality and outcomes is uncertain. Goals: To measure the MISSION Act’s association with travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR). Hypothesis: MISSION Act implementation in mid-2019 likely reduced travel times to care, but also may have negatively impacted cardiovascular procedural outcomes. Methods/Approach: This was a retrospective difference-in-differences (DiD) cohort study of Veterans receiving PCI, CABG, or AVR between October, 2016 and September, 2022. We compared Veterans made eligible for non-VA care under the MISSION Act by living >60 minutes from the nearest VA Medical Center (VAMC), versus MISSION-Act-ineligible Veterans living ≤60 minutes from a VAMC. Main outcome measures were average travel time to the procedure site and major adverse cardiovascular events (MACE) within 30 days of the procedure. Results/Data: The cohort comprised Veterans receiving PCI (n=43,000), CABG (n=23,301), or AVR (n=14,682). After MISSION Act implementation, mean PCI travel times increased by 1.3 minutes for “near” patients and decreased by 29.2 minutes for “far” patients (DiD=-30.5 minutes, P<.001). Mean CABG travel times increased by 9.4 minutes for “near” patients and decreased by 18.1 minutes for “far” patients (DiD=-27.4 minutes, P<.001). Mean AVR travel times increased by 10.0 minutes for “near” patients and decreased by 23.0 minutes for “far” patients (DiD=-33.1 minutes, P<.001). After MISSION Act implementation, mean PCI MACE rates decreased by .5 percentage points for “near” patients and increased by 2.3 percentage points for “far” patients (DiD=2.8 percentage points, P=<.001). Mean CABG MACE rates decreased by 6.5 percentage points for “near” patients and increased by 1.6 percentage points for “far” patients (DiD=8.1 percentage points, P<.001). AVR MACE rates were not statistically different (p=.45). Conclusion(s): MISSION Act implementation was associated with substantial decreases in travel times among Veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act Implementation was also associated with worsened 30-day MACE rates.