To the editors,
From a review of 58 studies comparing the safety and effectiveness of VA and non-VA care, O’Hanlon et al. concluded that the VA “often (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 hospitals—which may not represent non-VA care generally—were included.
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 “credit” 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 “capture” very little care performed within the VA. Furthermore, in several studies examining longer-term outcomes, patients in “VA 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 VA-using 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 “mixed” was replicated with data from a year later indicating that VA care was worse (Table 1).
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
| Author (year) | Data years | Risk-adjusted outcome measure | Findings |
|---|---|---|---|
| Fihn, SD (2009)6 | 2000–2005 | Adjusted odds of death within 30 days of admission for acute myocardial infarction relative to all private sector hospitals | Though results were not statistically different, odds of VA mortality were slightly higher and worsening over time |
| Bilimoria, KY (2007)7 | 1985–2004 | 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) | Though results were not statistically different, 60-day VA mortality rates were much higher |
| French, DD (2012)8 | 2007 | 90-day rates of cataract procedure complications requiring corrective procedures | VA had higher rates of corrective procedures for complications |
| Chakkera, HA (2005)9 | 1991–2001 | Kidney transplant graft failure and patient survival after kidney transplant | VA had higher graft failure and mortality rates |
| Rivard, PE (2010)10 | 2003–2004 | Patient safety indicators (PSIs) | VA had higher rates of PSIs |
| Rosen, AK (2005)11 | 2000–2001 | Patient safety Indicators | VA had higher rates of some PSIs and lower for others |
The review hardly demonstrates that VA care is better than non-VA care.
References
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