Elizabeth L George1,2,3, Nader N Massarweh4,5,6, Ada Youk7,8, Katherine M Reitz9, Myrick C Shinall10, Rui Chen3, Amber W Trickey3, Patrick R Varley11, Jason Johanning12,13, Paula K Shireman14,15, Shipra Arya1,3,16, Daniel E Hall7,9,17,18. 1. Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California. 2. Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California. 3. Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California. 4. Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. 5. Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. 6. Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas. 7. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. 8. Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. 9. Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. 10. Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. 11. Department of Surgery, University of Wisconsin, Madison. 12. Department of Surgery, University of Nebraska Medical Center, Omaha. 13. Nebraska Western Iowa Veterans Affairs Health System, Omaha. 14. Department of Surgery, University of Texas Health San Antonio, San Antonio. 15. South Texas Veterans Health Care System, San Antonio. 16. Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California. 17. Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. 18. Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
Abstract
Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures: Surgical care in either a VA or private sector setting. Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results: Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures: Surgical care in either a VA or private sector setting. Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results: Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
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