May 8, 2023
CHICAGO: By most measures, surgical care provided to United States military veterans in Veterans Affairs (VA) centers across the country is as good as, or better than, the same care delivered at non-VA medical centers, according to a new systematic review published in the Journal of the American College of Surgeons (JACS).
The VA health system is a national healthcare system serving millions of U.S. military veterans with specific healthcare needs. However, long wait times for appointments and limited access to high-quality specialty care have long been a problem for veterans facing chronic health conditions. In response to these concerns, the Veterans Access Choice and Accountability Act of 2014 and the Mission Act of 2017 were enacted, giving veterans the ability to seek healthcare outside the VA health system.
“Surgery involves many steps of care,” said lead study author Mariah B. Blegen, MD, a fellow in the department of surgery at the David Geffen School of Medicine of UCLA. “This updated review is important because it tells us that the veterans at the VA are getting good care. Quality improvement, through the VA National Surgical Quality Improvement Program (VA NSQIP) has been the focus of the VA for several decades and I think this effort is paying off.”
VA NSQIP was developed in the 1990s in response to a lack of national data and risk-adjusted models for surgical specialties at the VA. Since its creation, VA NSQIP has helped track millions of surgical cases and improve outcomes, including improved postoperative mortality and morbidity rates.
“VA NSQIP was born out of the need to address critical gaps in surgical care. The database continues to drive statistically reliable research that can help VA hospitals better assess its surgical outcomes and develop quality improvement programs to continuously respond to patient needs,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care.
After the success of VA NSQIP in improving outcomes in VA hospitals, the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) was launched in 2001 to expand the program to private sector hospitals. Today, ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based program that helps participating hospitals measure and improve the quality of surgical care. The collection of this clinical data allows for comparisons of surgical outcomes among all participating hospitals.
To compare VA with non-VA care, researchers conducted a systematic review of all available studies conducted between 2015 and 2021. In total, 18 nationally representative studies were included that evaluated the same four quality measures — quality of care, access to care, cost and efficiency, and patient satisfaction — across a range of surgical specialties provided in VA sites and non-VA medical centers. Operations reported on in the studies included orthopedic surgery, cataract surgery, lung resections, kidney transplants, and coronary artery bypass grafting.
The studies used three comparison groups: VA care compared to either veterans receiving non-VA care (paid for by the VA); veterans receiving non-VA care (not paid for by the VA); or a general population receiving non-VA care. All studies were controlled for differences in the populations. This review updates two similar studies conducted in 2009 and 2015.
Eleven of the 13 studies focusing on quality and safety outcomes showed that the quality and safety of surgical care provided in VA health centers was the same as, if not better than, care received in non-VA health centers. One study, focusing on elective joint replacement, showed that VA patients were less likely to develop any complications after undergoing surgery, compared to veterans in a non-VA site. Another study reported much lower readmissions among veterans undergoing joint replacement at VA hospitals compared to veterans having the procedure done in a non-VA setting.
A study on lung surgery showed that veterans in VA healthcare settings had a lower 30-day mortality rate than the general population in non-VA settings. Further, a study on kidney transplants showed no difference in the mortality rates between VA sites and other medical centers. Similarly, a study on coronary artery bypass surgery showed mortality and readmissions rates among veterans were similar between VA hospitals and non-VA sites.
“Among the studies included in the review that had the most robust comparison of veterans in the VA and non-VA sites, all of these outcomes were at least equal or showed better outcomes for veterans, apart from cost or length of stay,” Dr. Blegen said. “Overall, this is good news for how veterans are doing in terms of quality and safety.”
Four out of the six studies focusing on access to healthcare indicated that there was no consistent advantage to receiving care in a VA setting over care outside the VA system. The studies covered time to care and geographic access. For orthopedic appointments, average wait times were about six days shorter in VA sites compared to non-VA settings, and for urology appointments, wait times in VA sites were two weeks shorter than non-VA sites. Geographic access to care in the VA system is mixed. In some cases, the travel distance to a VA-health center was greater than to a non-VA facility, while in other cases less travel time was needed to get VA care.
For cost of care and efficiency measures, one study showed that the average cost for total knee arthroplasty was almost twice as high for VA care compared to non-VA care. Similarly, cataract surgery and elective coronary artery bypass surgery cost substantially more at a VA medical center. Further, two studies showed that veterans at VA hospitals had longer lengths of stays, compared to the general population at non-VA hospitals.
The researchers note that since only one study was included on patient experience, which showed no difference in overall hospital ratings, no conclusion can be drawn at this point.
“We need to provide better information to patients on the available quality of care, so that they can make informed decisions about where they can get the type of care that will work best for their unique needs,” Dr. Blegen said. “We hope this review will help policymakers make decisions in the future about the VA health care system.”
One limitation of the systematic review is that the findings from the most represented operations in the included studies — cataract surgery and joint replacements — may not be generalizable to all surgical procedures. Additionally, this review summarized studies that aggregated national data, therefore, the results may not apply to local medical centers. National trends do not always apply to individual healthcare systems.
Coauthors are Jamie Ko, MPH; Garrett Salzman, MD, MS; Meron M. Begashaw, MPH; Jesus G. Ulloa, MD, FACS, MS, MBA; Mark D. Girgis, MD; Paul Shekelle, MD, PhD; and Melinda A. Maggard-Gibbons, MD, FACS, MSH.
The study was supported by the Veterans Health Administration Quality Enhancement Research Initiative.
The authors have no relevant disclosures to report.
This article is published as an article in press on the JACS website.
Citation: Blegen M, Ko J, Salzman G, et al. Comparing Quality of Surgical Care between the U.S. Department of Veterans Affairs and non-Veterans Affairs Settings: A Systematic Review. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000000720.
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The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 87,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
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