Comparing VA to Non-VA Care
J Gen Intern Med
LETTERS Comparing VA to Non-VA Care
William B. Weeks 0 1
0 Table 1 National Studies Comparing Risk-Adjusted Outcomes that Might Be Important to Veterans and Were Plausibly Directly Related to Care Provided Within the VA , USA
1 The Dartmouth Institute , Lebanon, NH , USA
TFrom a review of 58 studies comparing the safety and
o the editors,
effectiveness of VA and non-VA care, O’Hanlon et al.
concluded that the VA Boften (but not always) performs better
than or similarly to other systems of care.^1 There are several
reasons, however, to question this conclusion.
Twenty-two articles were not national in scope; rather, they
reported data from single or few VA medical centers or
Veterans Integrated Service Networks (VISNs), so their findings
may not be representative of the VA overall. Within the VA,
there is substantial variation across geographic settings, as one
of the reviewed papers shows.2 Similarly, some used the
National Surgical Quality Improvement Project dataset to
compare relevant and risk-adjusted outcomes data in VA and
non-VA settings. However, only a select group of non-VA care
h o s p i t a l s— w h i c h m a y n o t r e p r e s e n t n o n - VA c a r e
Several papers sought to compare VA and non-VA care on
process indicators, but since many veterans using VA services
also obtain care outside the VA, these comparisons can be
flawed by non-reciprocal recording biases. If, for instance, a
veteran obtains a screening colonoscopy in a private sector
facility, the VA records that a colonoscopy was completed and
gets Bcredit^ for it. In 2009, 66 % of older, dual-eligible VA
primary care users in 15 VISNs obtained their colonoscopies
outside the VA.3 Because the veteran population is relatively
small, however, non-VA providers may Bcapture^ very little
care performed within the VA. Furthermore, in several studies
examining longer-term outcomes, patients in BVA care^ might
have obtained much of their follow-up care outside the VA. To
fairly compare VA to non-VA care, studies with longer-term
follow-up should have compared veterans who received only
VA care to non-VA users; none did.
Several studies lacked relevance. One paper compared
VAusing and non-VA patients only on the non-VA care they
received.4 Another compared rates of decline in risk-adjusted
quality indicators, but not VA to non-VA care.2 One examined
survey data asking about infection prevention practices among
a subset of VA and non-VA hospitals.5
Only six articles used national data to compare risk-adjusted
outcomes that might be important to veterans and plausibly
associated with VA or non-VA care: five indicated that VA care was
worse or worsening (though not necessarily statistically so), and
the one in which VA care was Bmixed^ was replicated with data
from a year later indicating that VA care was worse (Table 1).
The review hardly demonstrates that VA care is better than
Risk-adjusted outcome measure
Adjusted odds of death within 30 days
of admission for acute myocardial
infarction relative to all private sector
60-day mortality after pancreatectomy
(because follow-up care might have
been provided in both VA and non-VA
settings, 3-year survival rates are ignored)
90-day rates of cataract procedure
complications requiring corrective
Kidney transplant graft failure and
patient survival after kidney transplant
Patient safety indicators (PSIs)
Patient safety Indicators
Though results were not statistically different, odds of VA mortality were slightly higher and worsening over time
Though results were not statistically different, 60-day VA mortality rates were much higher
VA had higher rates of corrective procedures for complications
VA had higher graft failure and mortality
VA had higher rates of PSIs
VA had higher rates of some PSIs and
lower for others
1. O 'Hanlon C , Huang C , Sloss E , et al. Comparing VA and non-VA quality of care: a systematic review . J Gen Intern Med . 2016 . doi: 10 .1007/ 211606 - 016-3775-2.
2. Borzecki AM , Christiansen CL , Loveland S , Chew P , Rosen AK . Trends in the inpatient quality indicators: the Veterans Health Administration experience . Med Care . 2010 ; 48 : 694 - 702 .
3. Malhotra A , Vaughan-Sarrazin M , Rosenthal GE . Elderly veterans with dual eligibility for VA and Medicare services: where do they obtain a colonoscopy? Am J Manag Care . 2015 ; 21 : e264 - e270 .
4. Vaughan-Sarrazin MS , Wakefield B , Rosenthal GE . Mortality of Department of Veterans Affairs patients undergoing coronary revascularization in private sector hospitals . Health Serv Res . 2007 ; 42 : 1802 - 1821 .
5. Krein SL , Hofer TP , Kowalski CP , et al. Use of central venous catheterrelated bloodstream infection prevention practices by US hospitals . Mayo Clin Proc . 2007 ; 82 : 672 - 678 .
6. Fihn SD , Vaughan-Sarrazin M , Lowy E , et al. Declining mortality following acute myocardial infarction in the Department of Veterans Affairs health care system . BMC Cardiovasc Disord . 2009 ; 9 : 44 .
7. Bilimoria KY , Bentrem DJ , Tomlinson JS , et al. Quality of pancreatic cancer care at Veterans Administration compared with non-Veterans Administration hospitals . Am J Surg . 2007 ; 194 : 588 - 593 .
8. French DD , Margo CE , Campbell RR . Comparison of complication rates in veterans receiving cataract surgery through the Veterans Health Administration and Medicare . Med Care . 2012 ; 50 : 620 - 626 .
9. Chakkera HA , O'Hare AM , Johansen KL , et al. Influence of race on kidney transplant outcomes within and outside the Department of Veterans Affairs . J Am Soc Nephrol . 2005 ; 16 : 269 - 277 .
10. Rivard PE , Elixhauser A , Christiansen CL , Shibei Z , Rosen AK . Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals . Med Care Res Rev . 2010 ; 67 : 321 - 341 .
11. Rosen AK , Rivard P , Zhao S , et al. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Med Care . 2005 ; 43 : 873 - 884 .