A Synthesis of the Evidence Comparing Care in VA vs. Non-VA Settings

The quality of VA care has long been a subject of debate, even after its health care system transformation starting in the mid-90s. Although there have been some exceptions, the media has often portrayed VA health care in a less than optimal light. Regardless, VA has established itself as an innovative health care system, as evidenced in the early adoption of an advanced electronic medical record and its recent efforts to create patient-centered primary care teams.

Recently, investigators at the West Los  Angeles VA Evidence-Based Practice Center conducted a literature review to compare and contrast studies that assess VA and non-VA quality of care for surgical, non-surgical, and other medical conditions. Investigators reviewed 55 articles published after 1990: 17 articles addressed surgical conditions, and 38 addressed medical and other non-surgical conditions. Findings from their report include:

• Ten comparative studies assessing the use of preventive services, care for acute and chronic medical conditions, and changes in health status, including mortality, showed superior performance–as measured by greater adherence to accepted processes of care, better health outcomes, or improved patient ratings of care–for health care delivered in the VA compared with care delivered outside the VA.
• Studies of the quality of hospital and nursing home care demonstrate similar risk-adjusted mortality rates in VA facilities compared with non-VA facilities. VA hospitals had somewhat better patient safety outcomes compared with non-VA hospitals.
• Studies of the quality of mental health care demonstrate that the quality of antidepressant prescribing is slightly better in VA compared to private sector settings.
• Elderly VA patients were less likely to be prescribed potentially inappropriate medications than elderly patients receiving care through Medicare managed care plans.
• Stroke patients receiving rehabilitation in VA settings were discharged with better functional outcomes.
• Of four general surgery studies, three revealed no significant differences in adjusted post-operative morbidity rates, while one found significantly lower rates of post-operative morbidity in the VA setting compared with the private sector.
• Three of the four studies assessed risk-adjusted mortality rates, and of these, two found no significant difference across settings.
• Of three solid organ transplant articles, two found no significant differences in patient survival when comparing VA patients with non-VA patients. Additionally, one of these found no significant difference in graft survival between these two groups.

Conclusions:

Overall, the available literature suggests that the care provided in the VA compares favorably to non-VA care systems, albeit with some caveats. Studies that used accepted process of care measures and intermediate outcomes measures, such as control of blood pressure or hemoglobin A1c, for quality measurements almost always found VA performed better than non-VA comparison groups. Studies looking at risk-adjusted outcomes generally have found no differences between VA and non-VA care, with some reports of better outcomes in VA and a few reports of worse outcomes in VA, compared to non-VA care. The studies of processes of care are mostly those about medical conditions, while the studies of outcomes are mostly about surgical conditions and interventional procedures.

Reference: Asch, S, Glassman P, Matula S, Trivedi A, Miake-Lye I and Shekelle P. Comparison of Quality of Care in VA and Non-VA Settings: A Systematic Review. VA-ESP Project # 05-226; 2010.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate syntheses of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

See the full reports online.