Because risk factors for cardiovascular disease, such as SAA, are often observed to accumulate over a period of years, much VA research is aimed at interventions that can lower these risks and prevent heart failure – and some of this research has challenged the medical profession’s working assumptions. When the American College of Cardiology and the American Heart Association issued new guidelines for lipid management in 2013, it was a direct result of investigations conducted by Dr. Rod Hayward and colleagues at the VA Center for Clinical Management Research in Ann Arbor, Michigan. Hayward’s work suggested that the prevailing practice of setting fixed targets for LDL cholesterol levels among heart patients wasn’t supported by clinical evidence, and that a more tailored, individualized approach to treatment could improve outcomes.

Dr. Karen Saban, an associate professor at Loyola University Chicago and health research scientist and nurse at the Center for Innovation in Complex Care Management at the Edward Hines, Jr. VA Hospital, is investigating the efficacy of an eight-week stress-reduction therapy aimed at reducing cardiovascular risk in women veterans. “We know that women veterans do have higher levels of stress,” said Saban. “And we also know that their use of VA services has more than doubled in the last decade. The peak age of women who are using VA services is around 47. So they are getting close to that age where cardiovascular disease can be a real issue.”

The eight-week course used for Saban’s study is a standard intervention known as Mindfulness-Based Stress Reduction (MBSR), which was developed in the 1970s and has been validated through applications among diverse populations; Saban’s study is the first to examine the extent to which MBSR improves quality of life and cardiovascular health in women veterans. The effectiveness of mindfulness techniques, such as meditation and yoga, in reducing stress will be measured by means of several known inflammatory biomarkers – including cortisol, a stress-response hormone – before, during, and up to six months after the program. “We’re hoping,” she said, “to see sustainability of the program for intervention.”

Interventions such as that designed by Saban, if proven effective, are attractive because of their relatively low cost, which is of increasing concern as health care costs rise and the VA patient population continues to age. Over the past several years, at the Corporal Michael J. Crescenz VAMC in Philadelphia, Dr. Peter Groeneveld, a staff physician and researcher, has focused research on whether some of cardiology’s higher-cost technologies have influenced the outcomes of heart failure care. Most recently, Groeneveld and his colleagues have studied the proliferation of cardiovascular imaging technologies, such as echocardiography, computed tomography (CT), cardiac MRI, and nuclear imaging.

“There is not a lot of good data to guide the appropriate use of these technologies,” said Groeneveld. “They’re costly to use, involving expensive equipment and interpretation by highly trained radiologists. So the question really is, in terms of using limited heart failure clinical dollars most effectively: What is the right frequency for using these imaging tests?”

Groeneveld and his colleagues examined patient data from the nation’s 50 largest urban centers, comparing the use of echocardiography among 65-and-older veterans from both the VA and Medicare populations, who were matched on a wide array of demographic and clinical data. The investigators discovered that echocardiography is used three times more frequently outside of VA than within the VA health care system. “Roughly speaking, a heart failure patient outside of VA gets an echocardiogram about once every eight months,” he said, “and a VA patient gets one every two years.”

The most interesting result of Groeneveld’s study is that outcomes for veterans in the VA system didn’t differ in any significant way from those who opted for care within the Medicare system. “[They] are doing just as well clinically, and they’re surviving just as long. They are hospitalized just as frequently. They’re living independently with the same frequency. So there’s not a lot of good evidence that the three times greater rate of echocardiography used outside of VA is leading to better outcomes among veterans who don’t get their care at VA … And in this era, where VA – and really everyone – is facing constrained budgets for managing high-cost chronic disease populations, it really is going to become critical to understand and guide the use of expensive technologies in a way that really optimizes patient outcomes without overusing tests that don’t improve veterans’ health.”

The VA research program, embedded within its nationwide network of health care facilities, is perhaps uniquely positioned to measure the effectiveness of this multidisciplinary approach, to help the VA’s medical professionals leverage their expertise, and ultimately to improve the quality of life for veteran heart patients.

With a chronic condition such as heart failure, where comprehensive, patient-centered care is difficult and resource intensive, Kelley said it’s more important than ever to weigh the costs and benefits of interventions – for the patient as well as the health system. A newly launched study by Dr. Wen-Chih Wu, a physician researcher at the Providence VAMC and an associate professor at the Brown University School of Medicine, is recruiting participants from among veteran heart patients who have been recently discharged from the Providence and Phoenix VA Hospitals, to test the efficacy of shared medical appointments involving a multidisciplinary group approach: A team involving experts in nutrition, nursing, behavior, and medication management, in addition to a patient’s regular physician.

The ultimate aim of such an approach, said Kelley, is to reduce the rate of cardiac re-hospitalizations – which are traumatic for patients and their families, and costly to the system. “There is a point in a patient’s trajectory,” she said, “where we need to look at palliative care modalities in helping people have a good quality of life as they live with their chronic conditions.” The VA research program, embedded within its nationwide network of health care facilities, is perhaps uniquely positioned to measure the effectiveness of this multidisciplinary approach, to help the VA’s medical professionals leverage their expertise, and ultimately to improve the quality of life for veteran heart patients.

This article was first published in The Year in Veterans Affairs & Military Medicine.