Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

Comparison of Quality of Care

in VA and Non-VA Settings:

A Systematic Review

Department of Veterans Affairs

Health Services Research & Development Service

September 2010

Investigators:

Principal Investigators: 

Paul G. Shekelle, MD, PhD

Steven Asch, MD, MPH

Co-Investigators: 

Peter Glassman, MBBS, MSc

Sierra Matula, MD

Amal Trivedi, MD, MPH

Research Associate:

Isomi Miake-Lye, BA

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Evidence-based Synthesis Program (ESP) Center

West Los Angeles VA Medical Center

Los Angeles, CA

Paul G. Shekelle, MD, PhD, Director
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

PREFACE

HSR&D’s Evidence-based Synthesis Program (ESP) was established to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to VA managers 

and policymakers, as they work to improve the health and healthcare of Veterans. The ESP 

disseminates these reports throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• the implementation of effective services to improve patient outcomes and to support VA 

clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, an ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and VISN Clinical Management 

Officers. The Steering Committee provides program oversight and guides strategic planning, 

coordinates dissemination activities, and develops collaborations with VA leadership to identify 

new ESP topics of importance to Veterans and the VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: 

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 based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of Research 

and Development, Health Services Research and Development. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; 

the findings and conclusions do not necessarily represent the views of the Department 

of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No 

investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or 

pending, or royalties) that conflict with material presented in the report.
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

TABLE OF CONTENTS

Executive Summary............................................................................................................................................ iv

Background................................................................................................................................................... iv

Methods........................................................................................................................................................ iv

Results .......................................................................................................................................................... iv

Conclusions .................................................................................................................................................. vi

Introduction .......................................................................................................................................................... 1

Background.................................................................................................................................................... 1

Methods................................................................................................................................................................... 1

Topic Development........................................................................................................................................ 1

Search Strategy.............................................................................................................................................. 1

Study Selection.............................................................................................................................................. 1

Data Abstraction ............................................................................................................................................ 2

Quality Assessment ....................................................................................................................................... 2

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ..................................................................................................................................................................... 3

Literature Flow .............................................................................................................................................. 3

Description of Evidence ................................................................................................................................ 4

Surgical Conditions ....................................................................................................................................... 4

General Surgery ........................................................................................................................................ 5

Solid Organ Transplantation ..................................................................................................................... 6

Vascular Surgery....................................................................................................................................... 8

Surgical Oncology .................................................................................................................................... 9

Cardiac Surgery ...................................................................................................................................... 11

Endocrine Surgery .................................................................................................................................. 12

Medical and Other Non-Surgical Conditions.............................................................................................. 13

General.................................................................................................................................................... 13

Cardiovascular........................................................................................................................................ 15

Diabetes .................................................................................................................................................. 17

Hospital and Nursing Home Care........................................................................................................... 18

Mental Health ......................................................................................................................................... 19

Other Studies .......................................................................................................................................... 20

Summary and Discussion.................................................................................................................................. 22

Limitations................................................................................................................................................... 22

Publication Bias...................................................................................................................................... 22

Study Quality.......................................................................................................................................... 22

Conclusions ................................................................................................................................................. 23

Future Research........................................................................................................................................... 25

References............................................................................................................................................................ 27

Figures

Figure 1 Literature Flow................................................................................................................................ 4

Appendices

Appendix 1. Evidence Table of Surgical Studies ........................................................................................ 32

Appendix 2. Evidence Table of Medical and Non-surgical Studies............................................................ 38

Appendix 3. Screener Form......................................................................................................................... 51

Appendix 4. Data Abstraction Form............................................................................................................ 53

Appendix 5. Data Abstraction Grading Guidelines..................................................................................... 54

Appendix 6. Search Strategy ....................................................................................................................... 55

Appendix 7. Peer Review Comments Table................................................................................................ 55 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

EXECUTIVE SUMMARY

BACKGROUND

It remains unclear where the Veterans Health Administration (VA) finds itself in the spectrum 

of care currently available in the United States. The quality of care provided by the VA has been 

subject to debate since, and well before, the VA’s system transformation starting in the mid-90s. 

Media and entertainment vehicles have, rightly or wrongly, not infrequently portrayed VA care 

in less than optimal light, although there have been notable exceptions1

. Regardless of media 

views, the VA has established itself as an innovative healthcare system, including implementation 

of its advanced electronic medical record, with broad clinical and educational missions.

The immediate objective of this project is to conduct a systematic literature review of the 

published literature comparing the quality of medical and surgical care provided by the VA to 

relevant non-VA healthcare facilities and systems.

The Key Question was:

Compare and contrast studies that assess VA and non-VA quality of care for surgical, nonsurgical and other medical conditions.

METHODS

We were first given a list of articles by VA Central Office that represented examples of articles 

addressing possible VA and non-VA comparisons. Once these were reviewed, we then completed a 

Medline search for similar types of articles. Between the initial list and the subsequent search, we 

retrieved 222 articles. These were then screened by two physicians trained in the critical analysis 

of literature. Articles that both agreed were to be included were then reviewed, and all data were 

narratively summarized. When differences in the initial assessment (inclusion vs not) occurred, the 

specific articles were then discussed with at least one other senior member of the review team.

RESULTS

Of the 222 articles, mentioned above, 175 unique articles were identified and screened. Of these, 

98 articles were initially rejected because there was no comparison of quality in VA and nonVA settings in the United States. After 22 articles were excluded because the comparisons were 

found to be non-contemporaneous, or had unequal or unrepresentative samples, used dissimilar 

or indirect measures of quality, had methodological problems, or were published before 1990 

(which was used as an a priori cut off point), our first data abstraction included 55 articles. The 

55 articles were categorized as either addressing surgical conditions (n=17) or medical and other 

non-surgical conditions (n=38).

Surgical Conditions

Ten of the seventeen articles, or more than half the available studies, came from the Patient 

Safety and Surgery Study, which was performed between 2001 and 2004, and grew out of 

collaboration between the American College of Sugeons and VA’s National Surgical Quality 

Improvement Program.

Of four general surgery studies, three revealed no significant differences in adjusted postoperative 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

morbidity rates while one found significantly lower rates of postoperative 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. One study found significantly 

higher risk adjusted rates of postoperative mortality among male patients at the VA compared with 

the private sector. All four of these studies were part of the Patient Safety in Surgery Study.

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. This study also included a sub-analysis of 

health related quality of life (HRQOL) among heart and liver transplant recipients and found no 

significant difference in functional status or mental component scoring, but noted a trend toward 

lower physical component scores among VA patients by 7 years post-transplant. One study found 

that compared with privately insured patients, VA patients with end-stage renal disease were both 

less likely to be listed for a kidney transplant and less likely to receive a transplant when listed. 

Of the three vascular surgery studies, two found significantly lower risk adjusted rates of 

postoperative morbidity in the VA and one found no significant difference in morbidity rates. There 

were no significant differences in risk adjusted mortality rates throughout these three studies. Two 

of the three vascular surgery studies were part of the Patient Safety in Surgery Study.

Of the three studies pertaining to surgical oncology, two focused on pancreatic cancer and one 

focused on breast cancer. One of the pancreatic cancer studies based on the National Cancer 

Data Base (NCDB) found no significant difference in postoperative mortality. The other study 

on pancreatic cancer based on the Patient Safety in Surgery Study found increased risk adjusted 

postoperative rates of morbidity and mortality in VA. The breast cancer study found no significant 

difference in risk adjusted postoperative morbidity among female patients. Two of the three surgical 

oncology studies came from the Patient Safety in Surgery Study (one pancreatic cancer study, one 

breast cancer study).

Two articles pertained to cardiac surgery. Of these, one focused on patient perceptions of numerous 

aspects of patient care after coronary artery bypass grafting in VA and non-VA hospitals. This 

study found that, after risk adjustment, VA patients were more likely than non-VA patients to report 

a problem with patient care. The second article compared severity adjusted mortality rates after 

CABG among VA and non-VA hospitals. After adjusting for patient-level predictors and hospital 

volume, the study found that the odds of death were higher in VA patients than in private sector 

patients.

In both of the endocrine surgery studies, there were no significant differences in postoperative 

morbidity or adverse event rates. Both endocrine surgery studies came out of the Patient Safety in 

Surgery Study.

Medical and Other Non-surgical Conditions

Of 10 general comparative studies assessing use of preventive services, acute and chronic care for 

multiple medical acute and chronic medical conditions, changes in broad health status including 

risk-adjusted morality, and patient satisfaction, each showed superior performance, as measured by 

greater adherence to accepted processes of care, better health outcomes or improved patient ratings 

of care, for care delivered in the VA compared with care delivered outside the VA. The studies used 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

data from 1995 to 2004.

Of the 6 studies that assessed cardiovascular outcomes, 5 studies of mortality following an acute 

myocardial infarction or percutaneous coronary transluminal angioplasty found no clear survival 

differences between VA and non-VA settings and one study found greater control of blood pressure 

in the VA. Of the 3 studies that assessed use of processes of care following an acute myocardial 

infarction, all three found greater rates of evidence-based drug therapy in VA, and one study found 

lower use of clinically-appropriate angiography in the VA. Of note, all of these cardiovascular 

studies use data that are between 7 to 18 years old.

Four studies of the quality of diabetes care demonstrate a performance advantage on some 

measures for the VA compared with commercial managed care and other non-VA populations.

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. Veterans in VA nursing homes were less likely 

to develop a pressure ulcer but more likely to experience functional decline compared to veterans 

in community nursing homes. In addition, the VA had higher use of infection control practices, but 

greater readmission rates and equivalent racial mortality differences.

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. One study of national data 

found VA patients with schizophrenia were more likely to receive an antipsychotic medication in 

the outpatient setting, but a study of data from two states found VA outpatients were less likely to 

receive an antipsychotic medication and psychosocial services. Among patients discharged after a 

hospitalization for schizophrenia, readmission and outpatient visit follow-up rates were worse in 

the VA, but continuity of care was better compared to the private sector.

Elderly VA patients were less likely to be prescribed potentially inappropriate medications than 

elderly patients in Medicare managed care plans. A study of survival following a diagnosis of 

lung carcinoma in Pennsylvania found worse survival for VA patients in that state. Stroke patients 

receiving rehabilitation in VA settings were discharged with better functional outcomes. VA patients 

had greater satisfaction with hearing aid fittings and somewhat greater self-reported benefit from 

hearing aid placement.

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.
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

INTRODUCTION

Background

As noted by Ashton et al, VA healthcare system transformation began in 1995, moving from a 

hospital-based system to a more comprehensive healthcare model with the goal of providing 

the best health care in America2

. There have been numerous reports comparing VA health care 

quality with non-VA care, both scholarly and in the lay media1, 3-5. However, there has not been 

a systematic evaluation of the published evidence comparing care across systems. Therefore, 

VA Central Office asked the Evidence Synthesis Program located at the VA Greater Los Angeles 

Healthcare System, West Los Angeles campus to perform such a review. 

METHODS

Topic Development

This project was nominated by William Duncan, Associate Deputy Undersecretary of Health for 

Quality and Safety. 

The final key question was:

Compare and contrast studies that assess VA and non-VA quality of care for surgical, nonsurgical and other medical conditions.

Search Strategy

We were first given a list of articles by VA Central Office that represented examples of articles 

addressing possible VA and non-VA comparisons. Once these were reviewed, we then completed 

a Medline search for similar types of articles. Between the initial list and the subsequent search, 

we retrieved 222 articles. These were then screened by two physicians trained in the critical 

analysis of literature. Articles that both agreed were to be included were then reviewed, and all 

data were narratively summarized. When differences in the initial assessment (inclusion vs not) 

occurred, the specific articles were then discussed with at least one other senior member of the 

review team. Because of the focus on US health care, we searched Medline only. The search 

strategy is listed in Appendix 6. 

Study Selection

Articles were reviewed utilizing a two page screening form (see Appendix 3). Each article was 

reviewed by two physicians, one with a surgical background and the other specializing in internal 

medicine. To be included in our report, the article had to present a comparison of quality of 

clinical data in VA and United States (US) non-VA settings, and had to have been published no 

earlier than 1990. The screening form also collected basic information about the articles: whether 

or not the data for the comparison was sufficiently contemporaneous (within 1 to 2 years of each 

other); how VA and non-VA data were assembled; from what geographical area(s) VA and nonVA data were collected and analyzed; what conditions were covered in the quality assessment; 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

what features of quality were measured (structure, process, and/or outcomes); and how similar 

were the specifications for the quality assessments comparing VA and non-VA samples.

Data Abstraction

Data were independently abstracted using a one-page abstraction form (see Appendix 4). Data 

for surgically related articles were abstracted by our surgical reviewer, and for non-surgical 

articles the internal medicine reviewer completed the abstraction process. Once the forms were 

completed, all data were reviewed by the review team. The following data were abstracted from 

included trials: sample size for both VA and non-VA sources, years of data collection covered for 

both VA and non-VA sources; control variables; primary outcomes; and secondary or associated 

findings.

Quality Assessment

Each article was given an overall assessment, which was based on the following criteria: 

time frames; samples (both VA and non-VA); quality measurements; outcomes; importance 

of measures; and statistical methods. Each of these factors was assigned a grade (A, B, or 

C) based on the data abstraction grading guidelines developed (see Appendix 5). The overall 

assessment was predicated on the global assessment of the article, considering the individual 

components, but was not an average. Thus an article that had, for example, a critical flaw in 

methodology would be a “C,” even if other issues were satisfactory. During this phase, or during 

the initial assessment or data abstraction phases, disagreements or questions about the articles 

or information were discussed with at least one senior member of the team in order to reach 

concurrence.

Data Synthesis

We first classified articles as dealing with surgical or medical therapy. Within these categories, 

we further grouped articles according to their clinical content area, for example, one group 

contained medical studies about the quality of cardiovascular disease care. Within these 

categories, studies were still sufficiently heterogenous to preclude meta-analysis. Consequently, 

our synthesis is narrative.

Peer Review

A draft version of this report was sent to six peer reviewers, of which one responded. Her 

comments and our responses are presented in Appendix 7. Peer Review Comments Table.
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

RESULTS

Literature Flow

In total, we examined 222 articles, from the “VHA Clinical Quality and Patient Safety: A review 

of the medical literature” and our second systematic literature search.

Of the titles identified in the review, 47 articles were rejected as duplicates. This left 175 articles 

to be screened.

From this initial screening, 98 articles were rejected because there was no comparison of 

quality in VA and US non-VA settings. Four more articles were rejected for falling before the 

cutoff date of 1990. Our data abstraction thus included 73 articles, 18 of which were rejected, 

having received a grade of C or having failed to meet the initial inclusion criteria upon further 

inspection.

Upon categorization, these final 55 articles were divided between surgical articles (n=17) and 

non-surgical/medical articles (n=38). Within the surgical category, there were 4 general surgury, 

3 vascular surgery, 3 oncologic surgery, 3 solid organ transplantation, 2 cardiac surgery, and 

2 endocrine articles. Within the medical category there were 10 general, 8 cardiovascular, 8 

hospital care, 4 diabetes, 4 mental health care, and 4 other articles (See Figure 1).
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Figure 1 Literature Flow

47 Rejected, Duplicates

222 Articles Requested

175 Articles Screened

120 Rejected:

98- No comparison of quality 

in VA and US non-VA 

settings

18- Graded as “C”

 4-Outside time range

55 Articles Assessed

Surgical (n=17)

4-General

3-Oncology

3-Solid Organ Transplantation

3-Vascular

2- Cardiac Surgery

2- Endocrine

Medical (n=38)

10- General

 8- Cardiovascular

 8- Hospital/ Nursing home care

 4- Diabetes

 4- Mental health care

 4- Other

Sample articles from VA Central Office

(n= 107)

Literature Search

(n= 115)

Description of Evidence

We evaluated studies that compared quality of care for medical and surgical conditions in the 

Veterans Health Administration (VA) with clinical care in settings outside the VA. We summarize 

these data in the next two sections.

Surgical Conditions

We found 17 comparisons that met the inclusion criteria and pertained to the field of surgery6-22. 

Four of these addressed general surgery conditions9, 13, 16, 17, three addressed solid organ 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

transplantation6, 10, 18, three addressed vascular surgery14, 15, 22, three addressed surgical oncology7, 

11, 19, two addressed cardiac surgery8, 20, and two addressed endocrine surgery12, 21. Ten of the 

seventeen articles came out of the Patient Safety in Surgery Study which was performed from 

October 1, 2001 through September 30, 20049, 11-17, 19, 21. The Patient Safety in Surgery Study 

grew out of collaboration between the American College of Surgeons and the VA, and aimed to 

determine if implementation of the National Surgical Quality Improvement Program (NSQIP) in 

the private sector could reduce postoperative mortality and morbidity in non-VA settings. This 

study compared risk adjusted postoperative morbidity and mortality for a number of general and 

vascular surgical conditions between the VA system and 14 university medical centers that had 

volunteered to be early adopters of NSQIP. 

General Surgery

Four articles fell into the general surgery category9, 13, 16, 17; of these, two addressed general 

surgery broadly9, 13, one addressed liver resections16 and one addressed bariatric surgery17. All 

four of these articles were based on data from the Patient Safety in Surgery Study described 

above. The primary outcomes across studies were postoperative morbidity and mortality. 

Findings across these studies were heterogeneous.

Of the two broad general surgery papers, one focused on men and the other focused on women 

undergoing general surgery operations. Henderson and colleagues evaluated 94,098 general 

surgery operations in men at 128 VA medical centers and compared this with 18,399 general 

surgery operations in men in 14 university hospitals13. The main types of surgery performed were 

different in each population. Unadjusted postoperative morbidity and mortality rates were higher 

in the private sector compared with the VA. Stepwise logistic regression, adjusting for patient 

and disease characteristics, revealed no significant difference in postoperative morbidity across 

sites. However there were significantly greater odds of postoperative mortality in the VA (OR 

1.23, 95% CI (1.08-1.41). Additional analysis revealed differences in unadjusted mortality rate 

by procedure type. Unadjusted mortality rates were comparable among the five most common 

general surgical operations performed in the VA and the private sector (open inguinal hernia, 

partial colectomy, laparoscopic cholecystectomy, umbilical hernia, ventral hernia), however 

unadjusted mortality rates were higher in the VA for less common, more complex operations 

(pancreatectomy, adrenalectomy, bariatric operation, thyroidectomy/parathyroidectomy and 

hepatectomy). Risk adjustments evaluated general surgery broadly and did not account for 

specific type of surgery.

Fink and colleagues reviewed 5,157 female patients in the VA and 27,367 female patients in the 

private sector who underwent general surgery operations during the Patient Safety in Surgery9

. 

As in the study of male patients, certain procedures were performed more frequently in each 

of the two settings: more endocrine and laparoscopic procedures in the private sector and more 

lumpectomies and radical mastectomies in the VA. Unadjusted morbidity rates were higher 

in the private sector, likely attributable to the significantly higher incidence of urinary tract 

infections in this population. Unadjusted mortality rates were comparable across systems of care. 

After stepwise logistic regression to adjust for patient and disease characteristics there were 

significantly lower risk adjusted odds of developing a postoperative complication among the VA 

cohort compared with the private sector (OR 0.80, 95% CI 0.71-0.90); there was no significant 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

difference in risk adjusted postoperative mortality among women undergoing general surgery 

operations. Risk adjustments evaluated general surgery broadly and did not account for specific 

type of surgery. 

Lancaster and colleagues reviewed 237 VA and 783 private sector hepatectomies as part of the 

Patient Safety in Surgery Study16. Unadjusted morbidity and mortality rates were higher in the 

VA. After adjusting for pre-operative patient characteristics, lifestyle factors and intra-operative 

characteristics, morbidity and mortality rates were not significantly different between the VA and 

private sector university hospitals studied (morbidity 0.940, 95% CI 0.623-1.421and mortality 

OR 1.623, 95% CI 0.609-4.324).

Lautz and colleagues evaluated 374 patients who underwent bariatric surgery in 12 VA hospitals 

and 2,064 patients who underwent bariatric surgery in the 12 private sector hospitals as part 

of the Patient Safety in Surgery Study17. Male and female VA patients were significantly more 

likely to undergo an open operation, had surgeries with higher mean relative value units and 

were hospitalized longer than private sector patients. Unadjusted morbidity and mortality rates 

were comparable in women across cohorts. After risk adjustment, there were still no significant 

differences in postoperative morbidity among women in the VA versus private sector. Unadjusted 

and adjusted morbidity rates were higher among men treated at the VA compared with the private 

sector (adjusted OR 2.99, 95% CI 1.28-4.10). Unadjusted mortality rates were significantly 

higher among men treated at the VA compared with the private sector. There were too few deaths 

to allow for determination of risk adjusted rates. 

Summary: Of four general surgery studies, three revealed no significant differences in adjusted 

postoperative morbidity rates while one found significantly lower rates of postoperative 

morbidity in the VA setting compared with the private sector. Three of the 4 studies assessed 

risk adjusted mortality rates and of these, two found no significant difference across settings. 

One study found significantly higher risk adjusted rates of postoperative mortality among male 

patients at the VA compared with the private sector. 

Solid Organ Transplantation

Three articles addressed solid organ transplantation in VA and non-VA patients. Of these, one 

addressed orthotopic liver transplant only6

, one addressed renal transplantation10, and one 

evaluated outcomes after liver, heart, renal and lung transplant18. Two studies compared survival. 

Of these, one evaluated mortality at one, three and five years post-OLT6, and one evaluated graft 

survival and patient survival after heart, lung, kidney and liver transplant18. The latter study 

also evaluated health related quality of life as a secondary outcome. The final study assessed 

differences in time to renal transplantation10.

Austin and colleagues studied 149 VA patients and 285 private sector patients who underwent 

orthotopic liver transplantation (OLT) at a single medical center between September 1991 and 

December 20006

. They aimed to determine whether there was a difference in mortality after 

OLT in US veterans compared with non-veterans and to evaluate what, if any, factors made a 

difference. Veterans received their pre and post transplant care at the Portland Veterans Affairs 

Medical Center (PVAMC) and non-Veterans received pre and post transplant care at the Oregon 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Health and Science University hospital; however, all patients were transplanted in the operating 

rooms of the VA and received initial postoperative intensive care at the VA. The outcome 

of interest was mortality at one, three and five years post transplant. Veterans had increased 

mortality rates as assessed by Kaplan-Meier curves. After adjusting for gender, donor age, 

recipient age, etiology of liver disease and MELD score, hospital status was not a significant 

predictor of mortality RR 1.15 (95% CI 0.94-1.43). In multivariate analysis, donor age was most 

predictive of survival. Austin et al found no significant difference between patient groups when 

evaluating time spent on the waiting list between evaluation and treatment. At the time of initial 

evaluation, patients who were veterans had lower average serum albumin levels and a higher 

percentage of patients with Child’s class C liver disease suggesting that perhaps veterans were 

referred later in the disease course. This study was limited in its retrospective nature, and in its 

inability to account for cause of death or account for pre transplant comorbidities. Additionally, 

use of the MELD score became standard during the course of the study, and thus the patient 

population included across this ten year time period may not be representative of patients who 

are eligible for or undergo transplant today. Due to missing data, 60 patients (43 university 

patients and 17 veterans) were excluded from the analyses. Five year survival was significantly 

different between the included and excluded patients overall (50% versus 73% respectively) 

potentially causing a bias in the results. Finally, this study was unable to account for post 

transplant substance abuse.

Moore et al were interested in comparing comprehensive outcomes in VA transplant patients 

compared with non-VA transplant patients18. They studied all adult patients from Vanderbilt 

University Medical Center and the VA Tennessee Valley Healthcare System who underwent a 

primary liver, kidney, heart or lung transplant between 1990 and 2002. All patients received 

heart, liver and lung transplants at VUMC; renal transplants were performed at both centers. VA 

patients received up to 3 months of postoperative care at VUMC prior to transfer back to the 

VA setting. Groups were distinguished primarily by payer status. Primary outcomes were graft 

survival and patient survival. Additionally, health related quality of life (HRQOL) was assessed 

in a subset of patients using Karnofsky functional performance and the SF-36. A total of 380 VA 

patients (141 liver, 54 heart, 183 kidney, 2 lung) were compared with 1,429 non-VA patients (280 

liver, 246 heart, 749 kidney, 154 lung). Due to the limited number of lung transplant recipients, 

comparisons of outcomes were not performed in this subgroup. Cumulative graft survival was 

not significantly different between the two patient populations for liver transplant (p=0.97), heart 

transplant (p=0.67) or renal transplant (p=0.84). Similarly, cumulative patient survival was not 

significantly different between the two populations for liver (p=0.94, heart (p=0.75) or renal 

(p=0.12) transplant patients. HRQOL was assessed in a subset of 77 liver and 70 heart transplant 

recipients. Overall, there were significant improvements in functional performance from pretransplant to 2 years post-transplant ((49+2 versus 90+2; (p<0.001. However, there was no 

significant difference in functional performance between VA and non-VA patients from the pre 

to post-transplant state (p=0.065). Additionally, there was no significant difference in functional 

performance between VA and non-VA patients at three (p=0.50) or seven years (p=0.17) posttransplant. SF-36 mental component scores measured post-transplant were not significantly 

different between the two patient populations. However, physical component scales diverged 

after 7 years post-transplant, with VA patients reporting slightly worse physical component scale 

(PCS) scores compared with non-VA patients (35+2 versus 39+1, p=0.05); mental component 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

scale scores remained similar over time (47+2 versus 49+1, p=0.29 at 7 years post transplant). 

This study was limited in its cross sectional nature regarding HRQOL data; in addition, the 

patient populations were restricted to a single transplant program, potentially limiting the 

generalizability of the findings. Recurrence of hepatitis C and other patient level characteristics 

over time could not be taken into account, thus limiting ability to interpret the meaning behind 

the PCS scores long term. Additionally, the article does not make clear how the subset of heart 

and liver transplants was selected in order to evaluate HRQOL nor is the breakdown specified of 

VA and non-VA patients in this subset.

Gill et al used national data from the US Renal Data System from April 1, 1995 through 

December 31, 2004 to compare the time to transplantation among ESRD patients either covered 

by VA or insured by private insurance or Medicare/Medicaid10. A total of 7,395 VA patients were 

compared with 144,651 privately insured patients and an additional 357,345 insured by Medicare 

or Medicaid. After adjusting for patient demographics, clinical characteristics and state rates 

of transplantation, they found that VA-covered and Medicare/Medicaid-insured patients were 

approximately 35% less likely to receive transplants than patients with private insurance (hazard 

ratio [HR] 0.65; 95% CI 0.60 to 0.70; P < 0.0001). VA patients were less likely to be placed on 

the wait-list (HR 0.71; 95% CI 0.67 to 0.76). VA patients who were on the wait list also received 

transplants less frequently than privately insured patients (HR 0.89; 95% CI 0.82 to 0.96). VA 

patients with supplemental private insurance had the same likelihood of transplantation as nonVA patients with private insurance. Study limitations included unmeasured variables and inability 

to account for VA covered patients who had access to transplantation outside of the VA.

Summary: 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. This study also included a subanalysis of health related quality of life (HRQOL) among heart and liver transplant recipients 

and found no significant difference in functional status or mental component scoring, but noted 

a trend toward lower physical component scores among VA patients by 7 years post-transplant. 

One study found that compared with privately insured patients, VA patients with end-stage 

renal disease were both less likely to be listed for a kidney transplant and less likely to receive a 

transplant when listed. 

Vascular Surgery

Three studies compared quality of care in the VA and the private sector in vascular surgery14, 

15, 22. Two were from the Patient Safety in Surgery Study looking at male and female patients 

respectively14, 15. Hutter and colleagues evaluated 30,058 operations in men in the VA and 

5174 in the private sector as part of the Patient Safety in Surgery Study14. The two populations 

had significantly different preoperative risk profiles. There were significantly different types 

and frequencies of vascular surgeries in the groups; for example, there were more carotid 

endarterectomies in the VA and more open abdominal aortic aneurysm repairs in the private 

sector. Unadjusted postoperative morbidity and mortality rates were higher in the private sector. 

After stepwise logistic regression adjusting for preoperative and intraoperative variables there 

was a significantly lower odds of perioperative complications in the VA (OR 0.84, 95% CI 0.78-

0.92). There was no significant difference in risk adjusted mortality between the VA and private 
9

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

sector (p=0.195), although it was not clear how the relevant indicator variable for system of care 

was used in the model.

Johnson and colleagues used data from the Patient Safety in Surgery Study to compare 458 

female VA patients and 3,535 non-VA female patients who underwent vascular surgery15. The 

two populations differed across many categories in assessing preoperative risk profile with 

private sector patients having a greater incidence of various preoperative morbidities. Private 

sector vascular operations were more likely to be emergencies. Types and frequencies of vascular 

surgery operations differed considerably across hospital type. For example VA patients had 

carotid endarterectomies, saphenous vein ligation and arteriovenous fistulas more commonly 

than private sector patients; private sector patients underwent above the knee amputations, 

femoral popliteal bypass with artificial graft material, femorotibial bypass and open abdominal 

aortic aneurysm more frequently than VA patients. Unadjusted postoperative morbidity and 

mortality were higher in the private sector. After stepwise logistic regression adjusting for patient 

and intra-operative characteristics, there was no significant difference in 30 day mortality rates 

among VA and PS female vascular patients; there was a significantly lower odds of experiencing 

a postoperative complication among VA patients compared with private sector patients (OR 0.60, 

05%CI 0.44-0.81). Both the Hutter and Johnson studies were unable to account for endovascular 

procedures performed outside the operating room (such as in the radiology or cardiology suites). 

Weiss and colleagues evaluated perioperative mortality, stroke and cardiac complications in patients 

undergoing carotid endarterectomy in Connecticut from October 1997-September 22. VA data was 

derived from the Connecticut VA database that comprised data submitted to the VA-NSQIP. Private 

sector data was derived from the Connecticut Hospital Association database. They evaluated 

140 carotid endarterectomies in the VA setting and 6,949 CEAs in the private sector. Based on a 

modified Charlson comorbidity score, patients in the VA had higher comorbidities than patients 

in the private sector. Unadjusted rates of mortality, stroke and cardiac complications were higher 

in the VA, though these differences were not significant. After adjusting for patient and disease 

characteristics, there were no significant differences in postoperative mortality, stroke or rate of 

cardiac complications. This study was limited by the small sample size and narrow geographic 

region and thus may not be generalizable to other VA or private sector settings. Additionally, the 

data sources were different for each cohort with VA data taken from NSQIP which includes chart 

abstraction while private sector data were derived from inpatient registries.

Summary: Of the three vascular surgery studies, two found significantly lower risk adjusted rates 

of postoperative morbidity in the VA and one found no significant difference in morbidity rates. 

There were no significant differences in risk adjusted mortality rates throughout these three studies. 

Surgical Oncology

Of the three articles on surgical oncology7, 11, 19, two focused on pancreatic cancer7, 11 and one 

focused on breast cancer19. The pancreatic cancer papers were derived from two data sources. 

Bilimoria and colleagues used the National Cancer Data Base (NCDB) to evaluate 513 VA 

patients, 12,576 academic hospital patients and 18,299 community hospital patients who 

underwent treatment for stage I and II pancreatic cancer from 1985-20047

. The cohorts differed 

significantly in the distributions of age, gender, race, disease stage, income, insurance and 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Charlson comorbidity score. The outcomes assessed included 60 day and 3 year mortality, as 

well as stage appropriate treatment including receipt of neoadjuvant therapy and resection. After 

adjusting for patient, surgical, disease and hospital characteristics, they found that mortality rates 

were comparable between the VA, academic and community hospital settings for resection of 

stage I and II pancreatic cancer. After risk adjustment, there was no difference in use of surgery 

or adjuvant chemotherapy between VA and academic hospitals (p=0.54), however VA hospitals 

were significantly more likely to use surgery and adjuvant chemotherapy than community 

hospitals (p<0.001). The use of NCDB only accounts for hospitals accredited by the American 

College of Surgeons Commission on Cancer thus there is a potential selection bias; additionally, 

this limits the generalizability of the findings to participating centers. Comorbidity data was only 

available through the NCDB starting in 2003, thus risk adjustment on patient characteristics was 

limited to the tail end of the study period. Finally, the reference group in the analyses was the VA 

which was also the smallest sample size. 

The second article on pancreatic cancer was by Glasgow and colleagues; they used the Patient 

Safety in Surgery Study to compare postoperative morbidity and mortality after pancreatectomy 

for pancreatic cancer at 83 VA hospitals and 14 private sector hospitals11. Three hundred 

and seventy seven VA patients and 692 private sector patients were included. There were 

considerable differences in preoperative comorbidity profiles across cohorts. VA patients 

were less likely to be admitted from home and more likely to receive a blood transfusion 

intraoperatively. Using stepwise logistic regression to adjust for case mix differences, patient 

characteristics and intra-operative variables, they found higher rates of both 30 day postoperative 

morbidity (OR 1.58, 95% CI 1.08-2.31) and mortality (OR 2.53, 95% CI 1.02-2.38) in the VA 

compared with the private sector. These findings persisted after stratifying analyses by Whipple 

procedure or pancreaticoduodenectomy. 

The final article pertaining to surgical oncology was done by Neumayer and colleagues as part 

of the Patient Safety in Surgery Study to compare postoperative morbidity from breast cancer 

surgery in the VA and private sector19. There were 644 VA patients and 3,179 private sector 

patients identified. The majority of the patients were female (n=3,634) and results were stratified 

by gender. Both male and female VA patients had more preoperative comorbidities, higher rates 

of mastectomy and higher unadjusted complication rates than their private sector counterparts. 

Stepwise logistic regression was done in the female cohort, adjusting for patient factors, disease 

characteristics, surgeon traits and type of surgery. There was no significant difference in risk 

adjusted 30 day morbidity between female patients in the VA and private sector (OR 1.40, 95% CI 

0.89-2.20). Risk adjusted outcomes were not reported for the male cohort of breast cancer patients.

Summary: Of the three studies pertaining to surgical oncology, two focused on pancreatic cancer 

and one focused on breast cancer. One of the pancreatic cancer studies based on the National 

Cancer Data Base (NCDB) found no significant difference in postoperative mortality. The other 

study on pancreatic cancer based on the Patient Safety in Surgery Study found increased risk 

adjusted postoperative rates of morbidity and mortality in VA. The breast cancer study found no 

significant difference in risk adjusted postoperative morbidity among female patients. Two of the 

three surgical oncology studies came from the Patient Safety in Surgery Study (one pancreatic 

cancer study, one breast cancer study).
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Cardiac surgery

Two articles pertained to cardiac surgery8, 20. Of these, one focused on patient perceptions 

of numerous aspects of patient care after coronary artery bypass grafting in VA and non-VA 

hospitals8. The second article compared severity adjusted mortality rates after CABG among VA 

and non-VA hospitals20.

Feria et al compared perceptions of aspects of patient care among male patients undergoing 

coronary artery bypass graft (CABG) in both VA and non-VA settings between 1995 and 19988

. 

The domains of patient care that were examined included respect for patient preferences, 

emotional support, patient education and communication, coordination of care, concern for 

physical comfort, family participation, transition to discharge, access, and courtesy. The VA 

sample consisted of 808 patients who underwent CABG at 43 VA hospitals. Perceptions were 

evaluated in postoperative surveys collected through the VA National Performance Feedback 

Center. The non-VA sample consisted of 2271 patients who underwent CABG at 102 nonVA hospitals. Data were extracted from routine postoperative surveys by the Picker Institute; 

hospitals were included only if they had contracted with the Picker Institute. After controlling 

for age, race, self-reported health status, and diagnosis related group, VA patients were more 

likely than non-VA patients to note a problem with patient care in 8 of the 9 dimensions with 

the exception of transition to discharge (p<0.001). Adjusted differences in the percentage of 

questions for which VA patients reported a problem relative to non-VA patients were significant 

in these 8 domains, including access (3.2, 95% CI 1.5-4.8), coordination of care (4.8, 95% CI 

3.0-6.6), courtesy (2,9, 95% CI 1.4-4.5), patient education and information (7.1, 95% CI 4.4-9.8), 

emotional support (5.5, 95% CI 2.7-8.3), family participation (5.5, 95% CI 2.3-8.7), concern 

for physical comfort and(3.9, 95% CI 2.3-5.5) respect for patient preferences (6.2, 95% CI 3.6-

8.7). A sub-analysis limited to teaching hospital settings found that VA patients remained more 

likely to note a problem with care in 5 dimensions including coordination of care, courtesy, 

patient education and information, emotional support and concern for physical comfort. Adjusted 

differences in percentage of questions for which VA patients reported a problem relative to 

non-VA patients were significant across 7 of the 9 dimensions of care including access (2.7, 

95% CI 0.4-5.3), coordination of care (4.1, 95% CI 1.3-6.9), courtesy (2,3, 95% CI 0.5-4.2), 

patient education and information (6.0, 95% CI 2.9-9.1), emotional support (4.0 95% CI 0.9-

7.1), concern for physical comfort and(3.0, 95% CI 1.2-4.8) respect for patient preferences (5.1, 

95% CI 2.2-8.0). Limitations to this study included the many unmeasured variables, such as 

socioeconomic status, education level, literacy, patient autonomy in selecting providers, type 

and severity of comorbidities, emergency or elective surgery and hospital size and location. The 

non-VA sample was limited to hospitals contracting with the Picker Institute which accounted 

for only about 9% of US non-VA hospitals; the overall analysis was limited to a male population. 

Given these issues, the results may not be generalizable.

Rosenthal et al compared severity adjusted mortality after CABG among VA hospitals and 

private sector in two geographic regions between October 1993 and December 199620. They 

studied 19,266 patients from 43 VA hospitals using data from the VA Continuous Improvement 

in Cardiac Surgery Program. An additional 44,247 patients from 32 New York state hospitals 

were studied using data from the New York State Cardiac Surgery Reporting System and 9,696 

patients from 10 hospitals in the northeast Ohio were studied using data from the Cleveland 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Health Quality Choice. Each of these well established data sources contains slightly different 

information pertaining to patient and disease related traits; the VA CICSP contains about 90 

components; the Cleveland Health Quality Choice collects about 250 items and the NY State 

Cardiac Surgery Reporting System collects data on 100 elements. VA patients were more likely 

to have congestive heart failure, chronic obstructive pulmonary disease, cerebrovascular disease, 

peripheral vascular disease and diabetes requiring medication than private sector patients. After 

adjusting for patient-level predictors and hospital volume, the study found that the odds of 

death were higher in VA patients than in private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P 

<0.001). When comparing VA patients with those from NY State hospitals, a similar difference 

was found. However the comparison between VA and Northeast Ohio hospitals did not find a 

statistically significant difference in mortality rates. After stratifying by hospital volume, the odds 

of death among hospitals that performed 500 to 1000 CABG procedures annually were higher in 

VA hospitals than in private hospitals (OR 1.50, 95% CI 1.16-1.92, p=0.002) though this was not 

noted for lower CABG volumes (i.e., < 500) Limitations of this study included dependence on 

administrative data, unmeasured variable bias, potential systematic differences in data collection 

by the three data repositories used and geographic limitations to comparison groups potentially 

limiting generalizability of the findings. Additionally, the study period of 1993 to1996 may not 

represent current outcomes or performance.

Summary: Two articles pertained to cardiac surgery. Of these, one focused on patient perceptions 

of numerous aspects of patient care after coronary artery bypass grafting in VA and non-VA 

hospitals. This study found that, after risk adjustment, VA patients were more likely than nonVA patients to report a problem with patient care. The second article compared severity adjusted 

mortality rates after CABG among VA and non-VA hospitals. After adjusting for patient-level 

predictors and hospital volume, the study found that the odds of death were higher in VA patients 

than in private sector patients.

Endocrine Surgery

Two articles addressed issues in endocrine surgery12, 21. Each of these was from the Patient 

Safety in Surgery Study. One looked at 30 day postoperative morbidity and mortality 

after adrenalectomy21, the other looked at the same outcomes after thyroidectomy or 

parathyroidectomy12. Turrentine and colleagues evaluated 178 patients in 81 VA hospitals and 

371 patients in 14 private sector hospitals who underwent adrenalectomy21. VA patients were 

more likely to be older, male and to have greater preoperative risk profiles. VA operations were 

less likely to be laparoscopic. Unadjusted morbidity and mortality rates were higher in the VA 

compared with the private sector, however after adjusting for patient characteristics (including 

demographics, comorbidities, lab values), provider characteristics and wound class, there was no 

significant difference in postoperative morbidity among VA patients compared with private sector 

patients (OR 1.55, 95% CI 0.49-1.36). The mortality rate was too low for adjustment. 

Hall and colleagues used the Patient Safety in Surgery Study to evaluate 2,814 VA patients and 

4,268 patients in the private sector who underwent thyroidectomy or parathyroidectomy12. There 

were significantly different distributions of types of surgery at different sites with proportionally 

more parathyroid operations done at the VA. Unadjusted morbidity and mortality rates were 

significantly higher in the VA. Because the event rates for morbidity and mortality were very 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

low, a combined variable was built for an outcome of ‘any adverse event’. Stepwise logistic 

regression evaluated adverse event rates, accounting for disease type, surgical specialty and 

patient characteristics. Risk adjusted adverse event rates did not differ significantly across sites 

(OR 1.25, 95% CI 0.87-1.78).

Summary: In both of the endocrine studies, there were no significant differences in postoperative 

morbidity or adverse event rates. 

Medical and Other Non-Surgical Conditions

We identified 38 studies that compared quality of care for medical or other non-surgical 

conditions in the VA with clinical care in settings outside the VA23-54 26, 55-57 25, 27, 58-61. Of these, 

10 studies (classified into a “general” category) assessed primary preventive services, multiple 

medical conditions, health status (including risk-adjusted mortality), or patient satisfaction 23, 28-30, 

32, 40-42, 45, 46; 8 studies assessed cardiovascular conditions24, 34-36, 38, 47-49; 4 studies assessed diabetes31, 

39, 50, 51; 8 studies assessed hospital and nursing home care33, 37, 43, 44, 53, 54, 60, 61; 4 studies assessed 

mental health care26, 55-57; and 4 studies assessed other conditions25, 27, 58, 59. 

General

We identified 3 studies of preventive services and all found substantially higher rates of influenza 

and pneumococcal vaccination for the elderly in the VA compared to samples drawn from 

outside the VA28, 30, 32. These studies rely on self-reported survey data from the Medicare Current 

Beneficiary Survey (MCBS) and the Behavioral Risk Factor Surveillance System (BRFSS). The 

MCBS, sponsored by the Centers for Medicare and Medicaid Services, is a survey of the health 

status, health care utilization, and demographic characteristics of a nationally-representative 

sample of aged, disabled, or institutionalized Medicare beneficiaries. The BRFSS, sponsored by 

the Centers for Disease Control and Prevention, is an annual state-based system of health surveys 

that collects information on the health risk behaviors, preventive health practices, and health care 

access of a nationally representative sample of nearly 350,000 adults. 

Keyhani et al. used data from the 2000 to 2003 MCBS to examine use of pneumococcal and 

influenza vaccination and serum cholesterol screening among veterans age 65 and older using 

the VA exclusively compared to veterans age 65 and older using the Medicare fee-for-service and 

the Medicare managed care programs32. In this study, veterans using the VA reported 10% greater 

use of influenza vaccination (P< 0.05), 14% greater use of pneumococcal vaccination (P< 0.01), 

and a non-significant 6% greater use of serum cholesterol screening (P= 0.1), than did veterans 

receiving care through Medicare HMOs. Veterans receiving care through the Medicare fee-forservice program reported lower use of all three of these preventive services compared to veterans 

using the VA.

Jha et al. also assessed rates of vaccination using quality of care data abstracted from VA medical 

records among persons 65 and older in the VA compared to a similar age group of communitydwelling persons responding to the BRFSS30. Influenza and pneumonia vaccination rates were 

significantly greater in the VA compared to those reported in the BRFSS. In 2003, the absolute 

differences between the VA and the community based sample were approximately 10 percentage 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

points for influenza vaccination and 30 percentage points for pneumococcal vaccination. The 

study was limited by non-equivalent methods of assessment of vaccination; chart review was 

used in the VA sample and self-report was used in the non-VA sample. 

Finally, Chi et al used data from the 2003 BRFSS to assess influenza and pneumonia vaccination 

rates for veterans using the VA, veterans not using the VA, and non-veterans28. They found that 

for both influenza and pneumococcal vaccination, veterans using the VA had higher vaccination 

rates than both veterans not using the VA and non-veterans. Compared to veterans not using 

the VA, veterans using the VA had an 8 percentage point greater adjusted rate of receiving 

an influenza vaccination (72% vs. 80%, P < 0.001)) and a 17 percentage point greater rate of 

receiving pneumococcal vaccination (64% vs. 81%, P < 0.001) 

We identified 3 studies that compared quality of care for multiple acute and chronic medical 

conditions23, 29, 40. Jha et al. compared quality of care in the VA and Medicare fee-for-service using 

13 equivalent process of care measures29. The study assessed care for patients with diabetes, 

acute myocardial infarction, and congestive heart failure using data from the VA’s External Peer 

Review Program (EPRP), a previously published study of Medicare quality, and the Behavioral 

Risk Factor Surveillance System. The VA had statistically significant greater performance rates 

than the Medicare fee-for-service program on all 11 similar indicators from 1997 to 1999 and of 

12 of 13 indicators in 2000. The exception was eye exams for patients with diabetes. In 2000, the 

VA equaled or exceeded 90% on 8 of 13 indicators while Medicare’s highest performance on any 

indicator was 84%.

Asch et al. assessed clinical performance on over 300 process of care indicators in a sample of 

596 VA patients in 2 VISNs and a random sample of 992 adults from 12 communities that were 

selected to be representative of non-rural communities in the United States23. The authors found 

that, overall, VA patients were more likely than patients in the national sample to receive the 

care specified by the indicators (67% vs. 51%; difference, 16 percentage points [CI, 14 to 18 

percentage points]). The VA outperformed the non-VA sample for both chronic care (72% vs. 

59%; difference, 13 percentage points [CI, 10 to 17 percentage points]) and preventive care (64% 

vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute 

care. The biggest difference was in performance measures targeted by the VA (adjusted scores, 

67% vs. 43%; difference, 24 percentage points [CI, 21 to 26 percentage points]).

Finally, Ross et al. compared self-reported use of 17 preventive services for cancer prevention, 

cardiovascular risk reduction, diabetes mellitus management, and infectious disease prevention 

among insured adults receiving and not receiving care in the VA40. The data were derived from 

the 2000 and 2004 BRFSS. The study found that in 2000, persons receiving VAMC care were 

more likely to receive 6 of the 17 services; in 2004, persons receiving VAMC care reported 

greater use of 12 of the 17 services. In 2004, the performance advantage for the VA among 

these 12 services ranged from 10% greater use of cholesterol screening to 40% greater use 

of colorectal cancer screening. In 2004, there were no services for which rates of use were 

significantly greater for insured populations outside the VA than for patients using the VA. 

We identified 3 studies that assessed changes in risk adjusted mortality and health status for 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

elderly VA patients compared to elderly patients enrolled in Medicare Advantage (MA) plans41, 

42, 46. Selim et al. surveyed a cohort of VA and MA enrollees at baseline and then 2 years later 

using the Short Form 36, a validated measure of health status42. They also linked these surveys 

to the death master file to assess status. In analyses adjusting for demographic characteristics, 

clinical conditions, and baseline health status, MA enrollees had a greater risk of 2 year 

mortality compared to VA patients (9.2% vs. 7.5% HR 1.363 (95%CI 1.275-1.458). The adjusted 

probability of being alive with the same or better physical health after 2 years was similar in 

both systems. However, the VA cohort had a slightly higher adjusted probability of being alive 

with the same or better mental health score at 2 years (71.8% in the VA vs. 70.1% in MA). Using 

similar methods, another study by these authors extended the analysis to an approximately five 

year time frame, with similar results41. They found that risk-adjusted mortality rates over an 

approximately five year period was 26.0% for male VA patients and 28.8% for male Medicare 

Advantage patients (HR 1.404; 95% CI 1.383–1.426). Among female patients, the unadjusted 

mortality rates were 20.2% for the VA and 23.4% for the Medicare Advantage program (HR 

1.244; 95%CI 1.168–1.324). In a separate analysis, the adjusted rate of 3 year mortality was 

higher for MA enrollees eligible for Medicaid than in VA enrollees eligible for Medicaid (HR, 

1.260 [95% CI, 1.044–1.520])46.

Harada et al. examined patient satisfaction with outpatient care among VA users compared 

to non-users in southern California and southern Nevada45. VA users were 2 to 8 times more 

satisfied than VA non-users on 5 of 10 measures of satisfaction. VA users were less satisfied than 

non-VA users on one measure: the number of days waited for an appointment. 

Summary: Of 10 general comparative studies assessing use of preventive services, acute and 

chronic care for multiple medical acute and chronic medical conditions, changes in broad 

health status including risk-adjusted morality, and patient satisfaction, each showed superior 

performance, as measured by greater adherence to accepted processes of care, better health 

outcomes or improved patient ratings of care, for care delivered in the VA compared with care 

delivered outside the VA. The studies used data from 1995 to 2004.

Cardiovascular

We identified 8 studies that assessed quality of care for cardiovascular conditions24, 34-36, 38, 

47-49. Three studies by Petersen et al. assessed risk-adjusted mortality rates, use of clinicallyappropriate coronary angiography, and receipt of effective cardiovascular medications following 

an acute myocardial infarction among male enrollees in the Medicare fee-for-service program 

compared to elderly male veterans treated in VA facilities during 1994 and 199535, 47. The 

authors studied 19,305 male Medicare beneficiaries hospitalized in 1530 nonfederal acute care 

hospitals for myocardial infarction and 1665 elderly male veterans with myocardial infarction 

who were treated in 81 VA medical centers. In analyses adjusting for demographic and clinical 

characteristics, the authors found no difference in mortality for Medicare patients compared with 

the VA at 30 days (OR 0.94, 95% CI 0.82-1.07) and at one year (OR 0.94, 95% CI 0.84-1.05). 

Patients in the VA were less likely to receive angiography when clinically needed (43.9 percent 

vs. 51.0 percent; odds ratio, 0.75; 95% CI, 0.57 to 0.96). After controlling for the availability of 

on-site cardiac procedures, there was no difference in the rate of angiography36. 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Of the patients who survived their hospitalization, more VA patients than Medicare patients 

received beta-blockers (49.7 percent vs. 41.6 percent, P<0.001), angiotensin-converting-enzyme 

inhibitors (44.6 percent vs. 32.5 percent, P<0.001), or aspirin (77.2 percent vs. 68.6 percent, 

P<0.001) at discharge. Among a subset of patients deemed to be ideal recipients of these 

medications, VA patients were more likely than Medicare patients to undergo thrombolytic 

therapy at arrival (OR 1.40 [1.05, 1.74]) or to receive ACE inhibitors (OR 1.67 [1.12, 2.45]) or 

aspirin (OR 2.32 [1.81, 3.01]) at discharge and equally likely to receive beta-blockers (OR 1.09 

[1.03, 1.40]) at discharge47.

Landrum et al. studied mortality following acute myocardial infarction for elderly male veterans 

hospitalized in the VA and a matched set of male Medicare beneficiaries treated in non-VA 

hospitals between 1996 and 199934. The study found that in 1999 there were no significant 

differences in adjusted 30 day and one year mortality following myocardial infarction between 

the VA and Medicare. However, in earlier years of the study (1997 and 1998) there were higher 

adjusted mortality rates in the VA compared to Medicare. 

Ritchie et al. compared 10 and 30 day mortality rates and use of cardiac bypass surgery among 

patients receiving percutaneous coronary angioplasties in a national sample of VA medical centers 

and a sample of private sector hospitals in the state of Washington48. In this study, mortality and 

bypass surgery rates were largely similar for patients treated in the VA and private sector. 

Wright et al. examined mortality rates following an acute myocardial infarction for Medicareeligible VA-users initially admitted to a VA medical center compared with VA users initially 

admitted to a Medicare-financed hospital49. There were no significant differences in 30 day and 1 

year mortality rates for VA users initially admitted to VA medical centers compared to Medicare 

hospitals.

Another study by Bansal et al. of quality of care for acute myocardial infarction compared use of 

aspirin, beta-blockers, ace-inhibitors, heparin, and other specified anti-thrombotic agents among 

patients with an acute myocardial infraction in the Little Rock VA (n=117) compared to patients 

with acute myocardial infarction in a national sample derived from the National Registry of 

Myocardial Infarction 24. The study found higher use of all of these agents in patients at the Little 

Rock VA compared to those obtaining care elsewhere in Arkansas and to those in the national 

sample. 

Finally, Rehman et al. studied rates of blood pressure control in VA compared to non-VA setting 

using data from the National Health and Nutrition Examination Survey (NHANES) from 1999 

to 200038. The NHANES is a survey of a nationally-representative sample of 5000 persons that is 

administered by the Centers for Disease Control and Prevention. The survey combines detailed 

demographic, socioeconomic, nutrition, and health-related questions with a physical examination 

and laboratory testing by trained medical personnel. The authors found that while blood pressure 

control to below 140/90 mmHg was comparable among white hypertensive men at VA (55.6%) 

and non-VA (54.2%) settings (P=.12), blood pressure control was higher among African 

American hypertensive men at VA (49.4%) compared with non-VA (44.0%) settings (P< 0.01), 

even after controlling for age, numerous co-morbid conditions, and rural-urban classification. 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Summary: Of the 6 studies that assessed cardiovascular outcomes, 5 studies of mortality 

following an acute myocardial infarction or percutaneous coronary transluminal angioplasty 

found no clear survival differences between VA and non-VA settings and one study found greater 

control of blood pressure in the VA. Of the 3 studies that assessed use of processes of care 

following an acute myocardial infarction, all three found greater rates of evidence-based drug 

therapy in VA, and one study found lower use of clinically-appropriate angiography in the VA. 

Of note, all of these cardiovascular studies use data that are between 7 to 18 years old.

Diabetes

We identified 4 studies that focused exclusively on comparing quality of care for diabetes in 

the VA and outside the VA31, 39, 50, 51. Kerr et al. compared clinical performance on 7 diabetes 

care processes, 3 diabetes intermediate outcomes, and 4 measure of patient satisfaction in 5 

VA medical centers and in 8 commercial managed care organizations in matched geographic 

regions31. The study sample included 1285 patients in the VA and 6920 patients in commercial 

managed care plans. The VA outperformed commercial managed care plans on all measures of 

care processes. Intermediate outcome of blood pressure control was comparable between the 

two cohorts; however, the VA cohort had a significantly greater percentage of patients with tight 

blood sugar and cholesterol control. Patients reported similar overall satisfaction in the two 

cohorts, though there was significantly greater satisfaction with diabetes care in the VA. 

Reiber et al. assessed use of preventive services among veterans with self-reported diabetes using 

the VA compared with diabetic veterans and non-veterans receiving care outside the VA39. The 

study sample included 535 veterans using VA care, 1848 veterans using non VA care and 9055 

nonveterans responding to the 2000 BRFSS. The study found that veterans who used the VA had 

higher rates of foot exams, diabetes education, and sigmoidoscopy and a lower rate of a1c testing 

compared to veterans who did not use the VA. There were non-significant differences between 

these two groups in the receipt of eye exams, blood pressure measurements, cholesterol testing 

and fecal occult blood testing.

Nelson also examined 2000 BRFSS data and compared use of preventive services among VA 

enrollees with diabetes compared to persons with diabetes with other sources of insurance 

coverage50. The authors found that persons who received care through the VA were more likely 

to report taking a diabetes education class than those covered by private insurance The adjusted 

odds ratio for receipt of diabetes education among persons receiving all of their care through the 

VA was 3.5 (95% CI 1.6-7.8).

Piette studied satisfaction with care among patient with diabetes treated in 4 VA outpatient clinics 

compared with patients with diabetes receiving care in a 2 county-funded clinics51. The authors 

found that VA patients were more satisfied than were county patients overall and with 5 of 6 

dimensions of their care. These dimensions include access, technical quality, communication, 

interpersonal care, and quality of outcomes.

Summary: Four studies of the quality of diabetes care demonstrate a performance advantage 

on some measures for the VA compared with commercial managed care and other non-VA 

populations.
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Hospital and Nursing Home Care

We identified 8 studies that compared the quality of hospital care in the VA with care outside the 

VA33, 37, 43, 44, 53, 54, 60, 61. 

Polsky et al. examined racial differences in 30 day mortality for patients in VA and non-VA 

hospitals who were hospitalized for one of six conditions (pneumonia, congestive heart failure, 

gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction)37. The data were 

derived from hospital discharge abstracts from California and Pennsylvania. The study found 

that among patients less than age 65 years, black patients in VA and non-VA hospitals had similar 

30 day mortality rates to whites for gastrointestinal bleeding, hip fracture, and stroke. Among 

patients 65 years and older, blacks patients in VA and non-VA hospitals had significantly lower 

odds of 30 day mortality compared to white patients for all conditions except pneumonia. Racial 

mortality differences for these conditions were similar in VA and non-VA settings. 

Weeks et al. compared readmission rates for hospitalized VA enrollees who received care in a VA 

hospital compared with rates for VA enrollees who were hospitalized in non-VA hospitals43. The 

study included 111,854 patients residing in New York State. Among persons less than age 65, there 

were no significant differences in 30 day readmission rates for veterans admitted to a VA hospital 

compared with veterans initially admitted to a non-VA hospital. However, for veterans 65 and older, 

persons initially admitted to a VA hospital had a significantly higher odds of readmission within 

30 days than persons not initially admitted to a VA hospital (OR 2.79, 95%CI 1.4-5.6). In another 

similar study, Weeks et al. assessed 15 indicators of patient safety for inpatient care provided in VA 

hospitals compared to care provided outside the VA system44. The study found lower risk-adjusted 

rates of decubitus ulcer, postoperative sepsis, nosocomial infection, postoperative respiratory 

failure, and postoperative metabolic derangement for VA enrollees hospitalized in VA hospitals 

compared with rates among VA enrollees treated in hospitals outside the VA. The VA performed 

worse on one patient safety indicator: mortality rates for low-risk diagnoses. For 9 of the 15 patient 

safety indicators, there were no significant differences in rates between VA and non-VA hospitals.

Krein et al. assessed the use of central venous catheter bloodstream infection prevention 

practices in VA and non-VA hospitals using data from survey of a random sample of infection 

control coordinators in 516 hospitals33. The study found that compared with non-VA hospitals, 

VA hospitals reported greater use of maximal sterile barrier precautions, chlorhexidine gluconate 

for insertion site antisepsis, and a composite approach using multiple safety practices. 

Three similar studies compared hospital mortality rates in a single VA medical center with 

moratlity rates in different samples of private sector hospitals53, 54, 61. Gordon et al. found no 

significant difference in adjusted mortality rates for the VA medical center compared to a national 

sample of non-VA hospitals53. The actual in-hospital mortality rate was 4.0%, compared with the 

predicted mortality rate based on the private sector sample of 4.4% (95%CI 4.0% – 4.9%) 

Rosenthal also found that risk-adjusted in-hospital mortality was similar in the VA medical center 

compared with private sector hospitals in the same metropolitan area (OR 1.07 95%CI 0.74-

1.54)60. Mortality among patients admitted to an intensive care unit was also similar in the VA 

medical center compared with hospitals in the same metropolitan area61. 
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Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Finally, Berlowitz examined risk-adjusted rates of pressure ulcer development, functional 

decline, behavioral decline, and mortality in VA nursing homes compared with community 

nursing homes54. Veterans in VA nursing homes were less likely to develop a pressure ulcer (OR 

0.62 95%CI 0.47-0.83) but more likely to experience functional decline (OR 1.6 95%CI 1.2-

2.1) compared to veterans in community nursing homes. Risk-adjusted mortality and rates of 

behavioral decline were not different for veterans in VA and community nursing homes.

Summary: Studies of the quality of hospital and nursing home care demonstrate similar riskadjusted mortality rates in VA facilities compared with non-VA facilities. VA hospitals had 

somewhat better patient safety outcomes compared with non-VA hospitals. Veterans in VA nursing 

homes were less likely to develop a pressure ulcer but more likely to experience functional decline 

compared to veterans in community nursing homes. In addition, the VA had higher use of infection 

control practices, but greater readmission rates and equivalent mortality rates for racial minorities.

Mental Health

We identified 4 studies assessing the quality of mental health care in VA and non-VA settings26, 

55-57. Busch et al. compared the quality of antidepressant pharmacotherapy in the VA and private 

sector using identical performance indicators26. The authors determined the proportion of 

patients with a new diagnosis of depression who received a prescription for an antidepressant 

and remained on antidepressant therapy for the first 84 days following the diagnosis (known 

as the acute phase of treatment) and for the first 181 days following the diagnosis (known as 

the maintenance phase of treatment). The VA slightly outperformed the private sector in the 

prescription of antidepressants during the acute phase of treatment (84.7 compared with 81 

percent; p<0.001) and during the maintenance phase of treatment (53.9 compared with 50.9 

percent; p<0.001). The findings persisted when assessed by age and gender.

Leslie et al. compared care for hospitalized patients with schizophrenia in the VA and private 

sector55. Rates of readmission were lower and rates of timely follow-up visits after discharge 

were higher in the private sector compared to the VA. The VA had better continuity of care, 

defined as the number of two-month periods in which the patient had two or more outpatient 

visits in the six months after discharge. In an analysis of the quality of antipsychotic prescribing 

among patients with schizophrenia, Leslie et al. found that VA patients were more likely to 

receive a prescription for an antipsychotic and equally likely to be dosed in accordance with 

accepted clinical guidelines compared to private sector patients with schizophrenia56.

Finally, Rosenheck examined adherence to 26 treatment guidelines recommended by the Patient 

Outcomes Research Team (PORT) for patients with schizophrenia57. In an analysis of care 

for patients with schizophrenia in two states in the southeast and Midwest, the study found 

non-significant differences in adherence to PORT recommendations between VA and non-VA 

patients for 21 of the 26 measures. Significant differences were found in the following areas: VA 

outpatients were less likely to receive an antipsychotic medication and to be taking doses outside 

of the recommended range; VA inpatients were less likely to receive treatment that addressed 

psychosocial issues than non-VA inpatients; VA outpatients were less likely to participate in work 

therapy or job training than non-VA outpatients, and both VA inpatients and outpatients were less 

likely to receive case management services than non-VA patients.
20

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Summary: 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. One 

study of national data found VA patients with schizophrenia were more likely to receive an 

antipsychotic medication in the outpatient setting, but a study of data from two states found VA 

outpatients were less likely to receive an antipsychotic medication and psychosocial services. 

Among patients discharged after a hospitalization for schizophrenia, readmission and timely 

outpatient visit follow-up rates after discharge were worse in the VA, but continuity of care in the 

outpatient setting was better compared to the private sector. 

Other studies

We classified 4 additional studies into an ‘other’ category25, 27, 58, 59. 

Barnett et al. compared the use of potentially inappropriate medications among elderly patients 

in the VA and Medicare managed plans and 10 distinct geographic regions25. The authors 

identified 33 medications that in previously published studies have been generally considered 

inappropriate when given to the elderly because these medications may pose more risk than 

benefit. The 33 medications were classified into the following 3 categories: “always avoid”, 

“rarely appropriate” and “some indications’. Compared with Medicare managed care patients, 

VA patients were less likely to receive any inappropriate medication (21% vs. 29%, P <0.001), 

and in each classification: always avoid (2% vs. 5%, P <0.001), rarely appropriate (8% vs. 13%, 

P<0.001), and some indications (15% vs. 17%, P <0.001). The rate of inappropriate drug use was 

lower in the VA compared with the private sector for both males (21% vs. 24%, P <0.001) and 

females (28% vs. 32%, P <0.001). Differences were consistent when stratified by age.

Campling et al. examined the survival of Pennsylvania patients diagnosed with lung carcinoma 

between 1995 and 1999 who were treated in VA medical centers compared to patients treated 

in other medical centers in the state27. The median survival was 6.3 months for VA patients 

compared with 7.9 months for patients in the rest of the state, and the 5-year overall survival rate 

was 12% for VA patients compared with 15% for patients in the rest of the state. The Cox model 

showed a hazard ratio for VA patients compared with non-VA patients of 1.22 (P< 0.001) after 

adjusting for age, disease stage, and race, meaning that VA patients had a 22% greater odds of 

dying over the same time period.

Stineman studied functional outcomes following a stroke for patients admitted to 60 VA and 

467 non-VA rehabilitation facilities58. Across 20 different types of functional impairments, VA 

patients had significantly better motor outcomes on 8 impairments and worse outcomes for 2 

impairments compared to non-VA patients.

Cox et al. compared satisfaction with hearing aid fittings and perceived benefit from hearing aid 

placement among VA and non-VA patients59. VA patients reported greater satisfaction with the 

fitting of the hearing aid. Using three survey instruments to assess the perceived benefit of using 

the hearing aid in comparison to unaided hearing, VA patients reported greater benefit on all 

three instruments. In multivariate analysis of variance adjusting for baseline level of hearing loss, 

VA had significantly greater benefit from hearing aid placement on a composite measure of all 

three instruments. When the instruments were examined separately, VA patients reported greater 
21

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

benefit on one instrument but not the other two.

Summary: Elderly VA patients were less likely to be prescribed potentially inappropriate 

medications than elderly patients in Medicare managed care plans. A study of survival following 

a diagnosis of lung carcinoma in Pennsylvania found worse survival for VA patients in that state. 

Stroke patients receiving rehabilitation in VA settings were discharged with better functional 

outcomes. VA patients had greater satisfaction with hearing aid fittings and somewhat greater 

self-reported benefit from hearing aid placement.
22

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

SUMMARY AND DISCUSSION

Limitations

Publication Bias

Publication bias refers to the lack of publication of studies based on their findings. In its 

traditional sense, it refers to lack of publication of studies failing to show a statistically 

significant benefit for an intervention, either because authors feel such results are not newsworthy 

or because journals are less likely to publish studies that reach null results. In this context, it is 

not clear whether the specific directionality of a comparison of quality of care between VA and 

non-VA facilities would lead authors or journal editors to not publish a study. So the potential for 

publication bias, while always a concern in any systematic review, is not qualitatively the same 

for this review as in reviews of medical interventions.

However, there is still concern that we identified all published studies of VA care compared 

to non-VA care. We searched broadly using a literature search strategy designed to identify 

such articles, but there is never any guarantee that all relevant studies have been found. The 

consistency of our findings, though, means that any studies that are unpublished would have to 

be both numerous and have results contrary to the published studies in order to substantively 

influence our conclusions.

Study Quality

An important limitation common to systematic reviews is the quality of the original studies. We 

defined a minimum threshold of design and execution that must have been present for inclusion 

in our review. Criteria considered included the time frames of the quality measurement in VA and 

non-VA samples, the similarity of the measures of quality in both samples, the types of measures 

used, and the statistical methods. Above this threshold, we distinguished between studies 

based on a global assessment of quality. However, other factors not considered may also have 

influenced the results of studies in ways we cannot account for.

Ten of the seventeen articles included from the surgical literature were part of the Patient Safety in 

Surgery Study briefly described previously that used NSQIP methodology to compare care that was 

provided in the VA setting with that provided in 14 private sector, university hospitals9, 11-17, 19, 21. The 

NSQIP is the first validated, risk adjusted program evaluating outcomes and allowing for measurement of quality of care across surgical settings62. However, there are some potential limitations to 

the Patient Safety in Surgery Study that should be acknowledged. The 14 private sector hospitals 

in this study may not be generalizable to the private sector at large. Risk adjusted outcomes were 

assessed in most cases with stepwise logistic regression evaluating the impact of all variables collected on postoperative morbidity and mortality. A potential limitation includes omitted variable 

bias. For example, risk adjustment models were not able to account for stage of disease in the oncology studies or for indications for surgery in a number of other studies such as those evaluating 

outcomes after hepatectomy, adrenalectomy, thyroidectomy or parathyroidectomy. The omission of 

cases may have affected the findings in some studies, as well. For example, in the vascular surgery 

analyses, endovascular procedures performed outside of the operating room, such as in a radiology 
23

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

suite, were not accounted for. Additionally, in Hall et al’s study on thyroidectomies and parathyroidectomies, surgeries performed by otolaryngologists were not captured in the private sector data 

although they accounted for up to 50% of the operations in the VA12. Another limitation was inability to account for specific structural components of the care delivery system. For example, in the 

Lancaster paper assessing hepatectomy outcomes, the data did not take into account if the hospital 

had a transplant program, if they were able to perform veno-veno bypass, whether or not specialists 

in hepatology were on staff and available, ability to perform radiofrequency ablation or the quality 

of the intensive care units16. Finally, morbidity analyses across these studies were based on standard 

NSQIP assessment of morbidity. Disease and procedure specific outcomes could not be assessed 

with this data in some instances such as leak rate after pancreatectomy11, nerve injury after thyroidectomy or parathyroidectomy12, or disease recurrence after oncologic surgery11, 19.

An additional limitation is that all but one of the studies was either supported by VA research 

funding or had VA investigators performing some or all of the work. This may be natural as the 

VA has more interest than non-VA systems in comparing VA care with non-VA care. However, 

the possibility of bias must still be kept in mind.

Yet an additional limitation of the non-surgical comparisons is that they are either a narrow set of 

quality measures applied to a broad set of patients, or a broad set of quality measures applied to a 

limited sample of patients. In other words, for medical conditions, there is no study that assesses 

a broad set of quality measures on a national sample of patients. However, the results from the 

narrow-measures-broad-sample studies and the broad-measures-narrow-sample studies support 

each other, lessening the likelihood that a broad set of measures applied to a national sample of 

patients would yield results different from what we report here. Other limitations include lack of 

comparisons using data collected within the past five years, the use of self-reported data which 

may be subject to recall error, and the potential for inadequate assessment of clinical risk in 

studies comparing patient outcomes.

Conclusions

With the above caveats in mind, we reached the following conclusions for the fifty five articles 

included in our synthesis. The seventeen surgery articles addressed a variety of conditions and 

procedures. Primary measures of quality tended to be outcomes measures such as morbidity, 

mortality, graft survival and occurrence of adverse events. The findings among these seventeen 

studies were heterogeneous with nine studies reporting no significant difference in quality 

outcomes, three studies reporting improved quality in the VA compared with the non-VA setting 

and five reporting improved quality in the non-VA setting. The majority of the surgical studies 

were based on the Patient Safety in Surgery Study. 

 Of four general surgery studies, three revealed no significant difference in adjusted postoperative 

morbidity rates; one found significantly lower rates of postoperative morbidity in the VA setting 

compared with the private sector. Only 3 of the 4 studies assessed risk adjusted mortality rates; 

of these two found no significant difference across settings and one found significantly higher 

risk adjusted rates of postoperative mortality among male patients at the VA compared with the 

private sector. 
24

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Of three solid organ transplant articles, two found no significant difference in patient survival 

when comparing VA patients with non-VA patients. Additionally, one of these found no 

significant different in graft survival between these two groups. This study also included a subanalysis of HRQOL among heart and liver transplant recipients and found no significant different 

in functional status or mental component scoring, but noted a trend toward lower physical 

component scores among VA patients after 7 years post-transplant. One study found that VA 

patients with end-stage renal disease were both less likely to be listed for a kidney transplant and 

less likely to receive a transplant when listed compared with privately insured patients. 

Two of the three vascular surgery studies found significantly lower risk adjusted rates of 

postoperative morbidity; the final vascular surgery study found no significant difference in 

morbidity rates. There were no significant differences in risk adjusted mortality rates throughout 

these three studies. 

The studies pertaining to surgical oncology consisted of two that focused on pancreatic cancer 

and one that focused on breast cancer. One of the pancreatic cancer studies based on the NCDB 

found no significant difference in postoperative mortality. The other study on pancreatic cancer 

based on the Patient Safety in Surgery Study found increased risk adjusted postoperative rates of 

morbidity and mortality. The breast cancer study found no significant difference in risk adjusted 

postoperative morbidity. 

Of the two studies that addressed quality of care related to CABG in VA and non-VA hospitals, 

one found that, after risk adjustment, VA patients were more likely than non-VA patients to 

report a problem with patient care. This was based on self-reported data about many aspects of 

patient care. The second study focused on mortality and found that the odds of death was higher 

in VA patients relative to private sector patients after accounting for patient level predictors and 

hospital volume.

In both of the endocrine studies, there were no significant differences in postoperative morbidity 

or adverse events.

Of 10 general comparative studies assessing use of preventive services, acute and chronic 

care for multiple medical acute and chronic medical conditions, changes in broad health status 

including risk-adjusted morality, and patient satisfaction, each showed superior performance, as 

measured by greater adherence to accepted processes of care, better health outcomes or improved 

patient ratings of care, for care delivered in the VA compared with care delivered outside the 

VA. Of the 6 studies that assessed cardiovascular outcomes, 5 studies of mortality following an 

acute myocardial infarction or percutaneous coronary transluminal angioplasty found no clear 

survival differences between VA and non-VA settings and one study found greater control of 

blood pressure in the VA. Of the 3 studies that assessed use of processes of care following an 

acute myocardial infarction, all three found greater rates of evidence-based drug therapy in VA, 

but one study found lower use of clinically-appropriate angiography in the VA. Four studies of 

the quality of diabetes care demonstrate a performance advantage on some measures for the VA 

compared with commercial managed care and other non-VA populations.
25

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

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. Veterans in VA nursing 

homes were less likely to develop a pressure ulcer but more likely to experience functional 

decline compared to veterans in community nursing homes. In addition, the VA had higher 

use of infection control practices, but greater readmission rates and equivalent mortality rates 

across racial groups. 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. One 

study of national data found VA patients with schizophrenia were more likely to receive an 

antipsychotic medication in the outpatient setting, but a study of data from two states found VA 

outpatients were less likely to receive an antipsychotic medication and psychosocial services. 

Among patients discharged after a hospitalization for schizophrenia, readmission and outpatient 

visit follow-up rates were worse in the VA, but continuity of care was better compared to the 

private sector. 

Elderly VA patients are less likely to be prescribed potentially inappropriate medications than 

elderly patients in Medicare managed care plans. A study of survival following a diagnosis 

of lung carcinoma in Pennsylvania found worse survival for VA patients in that state. Stroke 

patients receiving rehabilitation in VA settings were discharged with better functional outcomes. 

VA patients had greater satisfaction with hearing aid fittings and somewhat greater self-reported 

benefit from hearing aid placement.

Of note, some of the studies compare a narrow band of practice(s), such as vaccinations or a 

specific type of surgery, across a broader population and other studies compare a wide spectrum 

of practices in a smaller sample (e.g., Asch et al.)23. Moreover, many of the studies are quite 

dated, with 16 articles using data prior to 2000, and more than likely practices have changed over 

time inside and outside of the VA.

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 outcome 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.

Future Research

Going forward, further research should be considered to address contemporary comparisons 

in the quality of care between the VA and the private sector. For example, most of the studies 

that compared the quality of surgical care in the VA with that in non-VA settings are based on 

data that is over five years old. The ACS-NSQIP has grown substantially from the original 
26

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

demonstration group of 14 university hospitals in the Patient Safety in Surgery Study to over 

180 non-VA hospitals today. The data management for the ACS-NSQIP program has advanced, 

as well, with more surgical specialties being evaluated and with continually evolving data-fields 

for collection allowing for more detailed analysis. To further address the quality of care in the 

VA and non-VA settings, it may be worthwhile to repeat some of these studies using this larger 

sample; and consideration could be given to merging the VA and ACS NSQIP systems to allow 

for ongoing comparisons at the institutional and systems level. In areas of medical care, many 

studies are, as noted with the surgical literature, limited by their age, and newer projects would 

be worthwhile if benchmarking is considered important. If so, consideration should also be given 

to determining which healthcare systems the VA should benchmark against (e.g., other managed 

care organizations, local centers of excellence).
27

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

REFERENCE LIST

1. Longman, P., Best Care Anywhere: Why VA Health Care Is Better Than Yours. 2007, 

Sausalito: PoliPointPress.

2. Ashton, C. M., et al., Hospital use and survival among Veterans Affairs beneficiaries. N 

Engl J Med, 2003. 349(17): p. 1637-46.

3. Maslin, J. (March 13, 1992) Article 99: Idealism Meets Iodine and Illogic in a Veterans 

Hospital. New York Times, 99.

4. Canby, V. (December 20, 1989) Born on the Fourth of July: How an All-American Boy 

Went to War and Lost His Faith. New York Times.

5. Bogdanich, W. (June 29, 2009) Oncologist Defends His Work at a V.A. Hospital. New 

York Times.

6. Austin, G. L., et al., Comparative analysis of outcome following liver transplantation in 

US veterans. Am J Transplant, 2004. 4(5): p. 788-95.

7. Bilimoria, K. Y., et al., Quality of pancreatic cancer care at Veterans Administration compared with non-Veterans Administration hospitals. Am J Surg, 2007. 194(5): p. 588-93.

8. Feria, M. I., M. V. Sarrazin and G. E. Rosenthal, Perceptions of care of patients undergoing coronary artery bypass surgery in Veterans Health Administration and private sector 

hospitals. Am J Med Qual, 2003. 18(6): p. 242-50.

9. Fink, A. S., et al., Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in women. J Am Coll Surg, 2007. 204(6): p. 1127-36.

10. Gill, J. S., et al., Access to kidney transplantation among patients insured by the United 

States Department of Veterans Affairs. J Am Soc Nephrol, 2007. 18(9): p. 2592-9.

11. Glasgow, R. E., et al., Pancreatic resection in Veterans Affairs and selected university 

medical centers: results of the patient safety in surgery study. J Am Coll Surg, 2007. 

204(6): p. 1252-60.

12. Hall, B. L., et al., Thyroid and parathyroid operations in veterans affairs and selected 

university medical centers: results of the patient safety in surgery study. J Am Coll Surg, 

2007. 204(6): p. 1222-34.

13. Henderson, W. G., et al., Comparison of risk-adjusted 30-day postoperative mortality and 

morbidity in Department of Veterans Affairs hospitals and selected university medical 

centers: general surgical operations in men. J Am Coll Surg, 2007. 204(6): p. 1103-14.

14. Hutter, M. M., et al., Comparison of risk-adjusted 30-day postoperative mortality and 

morbidity in Department of Veterans Affairs hospitals and selected university medical 

centers: vascular surgical operations in men. J Am Coll Surg, 2007. 204(6): p. 1115-26.
28

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

15. Johnson, R. G., et al., Comparison of risk-adjusted 30-day postoperative mortality and 

morbidity in Department of Veterans Affairs hospitals and selected university medical 

centers: vascular surgical operations in women. J Am Coll Surg, 2007. 204(6): p. 1137-

46.

16. Lancaster, R. T., et al., Liver resection in veterans affairs and selected university medical 

centers: results of the patient safety in surgery study. J Am Coll Surg, 2007. 204(6): p. 

1242-51.

17. Lautz, D. B., et al., Bariatric operations in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg, 2007. 204(6): p. 

1261-72.

18. Moore, D., et al., Survival and quality of life after organ transplantation in veterans and 

nonveterans. Am J Surg, 2003. 186(5): p. 476-80.

19. Neumayer, L., et al., Breast cancer surgery in Veterans Affairs and selected university 

medical centers: results of the patient safety in surgery study. J Am Coll Surg, 2007. 

204(6): p. 1235-41.

20. Rosenthal, G. E., M. Vaughan Sarrazin and E. L. Hannan, In-hospital mortality following 

coronary artery bypass graft surgery in Veterans Health Administration and private sector 

hospitals. Med Care, 2003. 41(4): p. 522-35.

21. Turrentine, F. E., et al., Adrenalectomy in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg, 2007. 204(6): p. 

1273-83.

22. Weiss, J. S., et al., Safety of carotid endarterectomy in a high-risk population: lessons 

from the VA and Connecticut. J Am Coll Surg, 2006. 203(3): p. 277-82.

23. Asch, S. M., et al., Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med, 2004. 141(12): p. 938-45.

24. Bansal, D., et al., Trends in the care of patients with acute myocardial infarction at a 

university-affiliated Veterans Affairs Medical Center. J Cardiovasc Pharmacol Ther, 2005. 

10(1): p. 39-44.

25. Barnett, M. J., et al., Comparison of rates of potentially inappropriate medication use according to the Zhan criteria for VA versus private sector medicare HMOs. J Manag Care 

Pharm, 2006. 12(5): p. 362-70.

26. Busch, S. H., D. L. Leslie and R. A. Rosenheck, Comparing the quality of antidepressant 

pharmacotherapy in the Department of Veterans Affairs and the private sector. Psychiatr 

Serv, 2004. 55(12): p. 1386-91.

27. Campling, B. G., et al., A population-based study of lung carcinoma in Pennsylvania: 

comparison of Veterans Administration and civilian populations. Cancer, 2005. 104(4): p. 

833-40.
29

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

28. Chi, R. C., G. E. Reiber and K. M. Neuzil, Influenza and pneumococcal vaccination in 

older veterans: results from the behavioral risk factor surveillance system. J Am Geriatr 

Soc, 2006. 54(2): p. 217-23.

29. Jha, A. K., et al., Effect of the transformation of the Veterans Affairs Health Care System 

on the quality of care. N Engl J Med, 2003. 348(22): p. 2218-27.

30. Jha, A. K., S. M. Wright and J. B. Perlin, Performance measures, vaccinations, and pneumonia rates among high-risk patients in Veterans Administration health care. Am J Public 

Health, 2007. 97(12): p. 2167-72.

31. Kerr, E. A., et al., Diabetes care quality in the Veterans Affairs Health Care System and 

commercial managed care: the TRIAD study. Ann Intern Med, 2004. 141(4): p. 272-81.

32. Keyhani, S., et al., Use of preventive care by elderly male veterans receiving care through 

the Veterans Health Administration, Medicare fee-for-service, and Medicare HMO plans. 

Am J Public Health, 2007. 97(12): p. 2179-85.

33. Krein, S. L., et al., Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc, 2007. 82(6): p. 672-8.

34. Landrum, M. B., et al., Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare. Health Serv Res, 2004. 39(6 

Pt 1): p. 1773-92.

35. Petersen, L. A., et al., Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients. N Engl J Med, 2000. 343(26): p. 1934-

41.

36. Petersen, L. A., et al., Regionalization and the underuse of angiography in the Veterans 

Affairs Health Care System as compared with a fee-for-service system. N Engl J Med, 

2003. 348(22): p. 2209-17.

37. Polsky, D., et al., Is lower 30-day mortality posthospital admission among blacks unique 

to the Veterans Affairs health care system? Med Care, 2007. 45(11): p. 1083-9.

38. Rehman, S. U., et al., Ethnic differences in blood pressure control among men at Veterans 

Affairs clinics and other health care sites. Arch Intern Med, 2005. 165(9): p. 1041-7.

39. Reiber, G. E., et al., Diabetes in nonveterans, veterans, and veterans receiving Department of Veterans Affairs health care. Diabetes Care, 2004. 27 Suppl 2: p. B3-9.

40. Ross, J. S., et al., Use of recommended ambulatory care services: is the Veterans Affairs 

quality gap narrowing? Arch Intern Med, 2008. 168(9): p. 950-8.

41. Selim, A. J., et al., Risk-adjusted mortality as an indicator of outcomes: comparison of the 

Medicare Advantage Program with the Veterans’ Health Administration. Med Care, 2006. 

44(4): p. 359-65.
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42. Selim, A. J., et al., Change in health status and mortality as indicators of outcomes: comparison between the Medicare Advantage Program and the Veterans Health Administration. Qual Life Res, 2007. 16(7): p. 1179-91.

43. Weeks, W. B., et al., Comparing the characteristics, utilization, efficiency, and outcomes 

of VA and non-VA inpatient care provided to VA enrollees: a case study in New York. 

Med Care, 2008. 46(8): p. 863-71.

44. Weeks, W. B., et al., Comparing measures of patient safety for inpatient care provided 

to veterans within and outside the VA system in New York. Qual Saf Health Care, 2008. 

17(1): p. 58-64.

45. Harada, N. D., V. M. Villa and R. Andersen, Satisfaction with VA and non-VA outpatient 

care among veterans. Am J Med Qual, 2002. 17(4): p. 155-64.

46. Selim, A. J., et al., Differences in risk-adjusted mortality between medicaid-eligible 

patients enrolled in medicare advantage plans and those enrolled in the veterans health 

administration. J Ambul Care Manage, 2009. 32(3): p. 232-40.

47. Petersen, L. A., et al., Comparison of use of medications after acute myocardial infarction 

in the Veterans Health Administration and Medicare. Circulation, 2001. 104(24): p. 2898-

904.

48. Ritchie, J. L., et al., A comparison of percutaneous transluminal coronary angioplasty in 

the Department of Veterans Affairs and in the private sector in the State of Washington. 

Am J Cardiol, 1998. 81(9): p. 1094-9.

49. Wright, S. M., et al., Increasing use of Medicare services by veterans with acute myocardial infarction. Med Care, 1999. 37(6): p. 529-37.

50. Nelson, K. M., et al., The association between health insurance coverage and diabetes 

care; data from the 2000 Behavioral Risk Factor Surveillance System. Health Serv Res, 

2005. 40(2): p. 361-72.

51. Piette, J. D., Satisfaction with care among patients with diabetes in two public health care 

systems. Med Care, 1999. 37(6): p. 538-46.

52. Weeks, W. B., et al., Veterans Health Administration and Medicare outpatient health care 

utilization by older rural and urban New England veterans. J Rural Health, 2005. 21(2): p. 

167-71.

53. Gordon, H. S., et al., Using severity-adjusted mortality to compare performance in a 

Veterans Affairs hospital and in private-sector hospitals. Am J Med Qual, 2000. 15(5): p. 

207-11.

54. Berlowitz, D. R., et al., Purchasing or providing nursing home care: can quality of care 

data provide guidance. J Am Geriatr Soc, 2005. 53(4): p. 603-8.

55. Leslie, D. L. and R. A. Rosenheck, Comparing quality of mental health care for publicsector and privately insured populations. Psychiatr Serv, 2000. 51(5): p. 650-5.
31

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

56. Leslie, D. L. and R. A. Rosenheck, Benchmarking the quality of schizophrenia pharmacotherapy: a comparison of the Department of Veterans Affairs and the private sector. J 

Ment Health Policy Econ, 2003. 6(3): p. 113-21.

57. Rosenheck, R. A., et al., Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers. J Nerv Ment 

Dis, 2000. 188(4): p. 209-16.

58. Stineman, M. G., et al., Inpatient rehabilitation after stroke: a comparison of lengths of 

stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system. 

Med Care, 2001. 39(2): p. 123-37.

59. Cox, R. M., G. C. Alexander and G. A. Gray, Hearing aid patients in private practice and 

public health (Veterans Affairs) clinics: are they different? Ear Hear, 2005. 26(6): p. 513-

28.

60. Rosenthal, G. E., et al., Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market. J Gen Intern Med, 2003. 18(8): p. 601-8.

61. Kaboli, P. J., et al., Length of stay as a source of bias in comparing performance in VA 

and private sector facilities: lessons learned from a regional evaluation of intensive care 

outcomes. Med Care, 2001. 39(9): p. 1014-24.

62. Khuri, S. F., et al., The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and 

enhancement of the quality of surgical care. National VA Surgical Quality Improvement 

Program. Ann Surg, 1998. 228(4): p. 491-5. 
32

VA and Non-VA Settings Evidence-based Synthesis Program

Table of Surgical Studies

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

e 

149 1991-2000 Single med ctr 285 1991-2000 Other Surgical mortality at 1,3,5 years

VA patients had increased 

mortality rates as assessed 

by Kaplan-Meier curves. 

However after adjusting for 

gender, donor age, recipient 

age, etiology of liver disease 

and MELD score, hospital 

status was not a significant 

predictor of mortality RR 

1.15 (95% CI 0.94-1.43) A

513 1985-2004 Nat’l

12,756/

18,299 1985-2004

General 

surgical, 

Surgical 

Oncology

60 day and 3 

year mortality

Unadjusted and adjusted 

mortality rates at 60days and 

3 years were comparable 

between VA, academic and 

community hospital settings 

for resection of stage I and II 

pancreatic cancer. B

808 1995-1998

Mult 

ctrs 18,299 1996-1998

IHD, Cardiothoracic

perceptions 

of various 

dimensions of 

care

VA patients were more likely 

than non-VA patients to note 

a problem with patient care; 

when analysis limited to 

teaching hospital settings, 

VA patients remained more 

likely to note a problem with 

care in 5 dimensions. B
33

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

5157 2001-2004

Mult. 

Ctrs 27467 2001-2004

General 

surgical

30 day 

postoperative 

morbidity and 

mortality

Risk adjusted mortality rates 

are comparable between PS 

and VA patients, although 

setting of care did not enter 

the mortality regression 

model. Risk adjusted 

morbidity was higher in the 

PS compared with the VA 

OR 0.8 (CI 0.71-0.90) B

7395 1995-2004 Nat’l 144651/ 357345 1995-2004 Other surgical time to treatment

Both VA-insured and 

Medicare/Medicaid-insured 

patients were approximately 

35% less likely to receive 

transplants than patients with 

private insurance (hazard 

ratio [HR] 0.65; 95% CI 

0.60 to 0.70; P _ 0.0001). 

Most of this difference was 

explained by the fact that VA 

patients were less likely to be 

placed on the wait-list (HR 

0.71; 95% CI 0.67 to 0.76), 

but even listed VA patients 

received transplants less 

frequently than those insured 

privately (HR 0.89; 95% CI 

0.82 to 0.96). A

377 2001-2004

Mult. 

Ctrs 692 2001-2004

Other 

surgical

postoperative 

outcomes 

(primarily 

morbidity and 

mortality)

Adjusting for case mix 

differences, postoperative 

morbidity and mortality rates 

for pancreatectomy were 

higher in the VA compared 

with the PS (OR 1.581, 

95% CI 1.084-2.307 and 

2.533 95% CI 1.020– 6.290 

respectively). A/B
34

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

2814 2001-2004

Mult. 

Ctrs 357345 2001-2004

General 

surgical, 

head and 

neck

30 day 

morbidity 

and mortality; 

specific adverse 

event rates, 

LOS

Overall 30day morbidity 

and mortality do not differ 

significantly in the VA vs 

PS in risk adjusted model. 

Mortality event rate is too 

low to accurately evaluate, 

odds ratio for morbidity 

associated with VA care is 

1.25 ( 95% CI 0.87-1.78) B

9409818 2001-2004

Mult. 

Ctrs 18399 2001-2004

General 

surgical

30 day 

postoperative 

morbidity and 

mortality

After risk adjustment for 

patient comorbidities and 

severity of illness, the odds 

of mortality at 30days were 

higher in the VA compared 

with the PS (OR 1.23, 

95% CI ). There was no 

significant difference in 

morbidity at 30days among 

the sites. A/B

5174 2001-2004

Mult. 

Ctrs 30058 2001-2004 Vascular

30 day 

postoperative 

morbidity and 

mortality

Risk adjusted mortality was 

comparable among the two 

groups, although hospital 

site/type did not enter the 

stepwise regression model. 

Accounting for comorbidities 

and severity of illness, 

postoperative morbidity 

rates were lower in the VA 

population, OR 0.84 (95% 

CI 0.78-0.92) A/B
35

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

458 2001-2004

Mult. 

Ctrs 3535 2001-2004 Vascular

30 day 

postoperative 

morbidity and 

mortality

After risk adjustment, no 

significant difference in 30 

day mortality rates among 

VA and PS female vascular 

patients. After adjusting for 

severity of illness, 30 day 

complication/morbidity rates 

were significantly lower in 

the VA compared with the PS 

(OR 0.60, 95% CI 0.44-0.81) B

237 2001-2004

Mult. 

Ctrs 783 2001-2004

General 

surgical

post-operative 

morbidity and 

mortality at 

30 days; also 

evaluated LOS, 

need for reoperation and 

occurrence 

of 18 specific postoperative 

events

Risk adjusted outcomes 

suggest that 30day postoperative morbidity and 

mortality rates in the VA 

compared with the PS for 

hepatic resections do not 

vary significantly. (after 

risk adjustment, morbidity 

rates and mortality were 

comparable in VA and PS. 

Comparing Morbidity of VA 

w/ PS OR was 0.94 (95% 

CI 0.62-1.42) and Mortality 

OR was 1.623 (95% CI 0.61-

4.32)) A/B
36

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

374 2001-2004

Mult. 

Ctrs 2064 2001-2004

Other 

surgical

30 day 

postoperative 

outcomes: 

morbidity 

(overall, 

specific adverse 

events, # 

complications), 

mortality, LOS

No significant difference 

in postop morbidity or 

mortality among women 

in the VA versus non-VA 

settings (16.07 vs 12.02 % 

p =0.21 and 0.89 vs 0.42%, 

p=0.47). Unadjusted and 

adjusted morbidity rates 

were higher among men 

treated at the VA versus 

non-VA (OR 2.77, 95% CI 

1.78-4.31 unadjusted and 

OR 2.29, 95% CI 1.28-

4.10 adjusted). Unadjusted 

mortality rates significantly 

higher among men treated at 

VAversus non-VA((1.91% vs 

0.25% p=0.03). A/B

e 

380 1990-2002 Single med ctr 1429 1990-2002 Other surgical

graft survival; 

patient survival, 

Karnofsky 

score, SF36

No significant difference in graft or patient survival in liver, heart, or kidney between veteran and nonveteran patients, and survival statistics were consistent with recently published national data A

644 2001-2004

Mult. 

Ctrs 3179 2001-2004

General 

surgical

30day 

postoperative 

morbidity and 

mortality, LOS

After adjusting for 

comorbidities and 

preoperative factors, there 

was no significant difference 

in 30day morbidity or 

mortality in female patients 

at the VA compared with 

the PS (OR 1.404, 95% CI 

0.894-2.204). B
37

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

 

l

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

19266 1993-1996

Lrg geo 

area

44247/ 

9696 1993-1996

Cardiothoracic in hospital mortality

Adjusting for patient-level 

predictors and volume, the 

odds of death was higher 

in VA patients, relative to 

private sector patients (OR, 

1.34; 95% CI, 1.11-1.63; P 

<0.001). A

178 2001-2004

Mult. 

Ctrs 371 2001-2004

Other 

surgical

30 day 

morbidity and 

mortality

Unadjusted morbidity 

and mortality rates were 

higher in VA compared 

with PS (16.3% vs 6.7%, 

p=0.003 and 2.8% vs. 

0.4%, p=0.0074). Mortality 

event rate was too low for 

adjustment. Adjusting for 

comorbidities, the 30day 

postoperative morbidity 

ratio in the VA versus the 

PS was no longer significant 

(adjusted OR1.33, 95%CI 

0.49-3.6 compared with 

unadjusted OR 2.75, 95% 

CI: 1.55-4.91). B

 

N 140 1997-2002 Lrg geo 6949 1997-2002 Vascular

perioperative 

mortality, 

stroke and 

cardiac 

complications

After risk adjustment, having 

surgery at the VA was not 

a significant predictor of 

death (OR 2.98, 95% CI 

0.51-17.6), stroke (OR .95, 

95% CI 0.3-3.4 ) or cardiac 

complications(OR 1.07 95% 

CI 0.37-3.1) B
38

VA and Non-VA Settings Evidence-based Synthesis Program

Table of Medical and Non-surgical Studies

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

t. 

Ns 596 1997-1999 Nat’l 992 1996-2000

CHF, DM, 

IHD, HTN, 

Pulmonary 

Disease, 

Preventive 

Care, 

Cancer, 

Osteoarthritis, 

Depression, 

TIA/Stroke

adherence to 

348 indicators 

targeting 26 

conditions

VA scored better on adjusted 

overall quality 67% vs 51%; 

chronic disease care (72 vs 59) 

and preventive care (64 vs 44), 

but not acute care. A

le 

92/117 2002 Nat’l not described 2002 IHD

use of aspirin, 

betablockers, 

aceinhibitors, 

heparin, gp2a3b 

inhibitors 

among pts with 

MI

Use of all these agents were 

higher in the Little Rock 

VA compared to the rest of 

Arkansas and the entire US B

’l 123633 2002-2003 Nat’l 157517 2000-2001 Other safety

use of 

potentially 

inappropriate 

medications 

among the 

elderly

Compared with private sector 

patients, VA patients were 

less likely to receive any 

inappropriate medication 

(21% vs. 29%, P <0.001), and 

in each classification: always 

avoid (2% vs. 5%, P <0.001), 

rarely appropriate (8% vs. 

13%, P<0.001), and some 

indications (15% vs. 17%, P 

<0.001). B
39

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

e 

N 3802/961 1997-1999

Lrg geo 

area

52986/

142452 1997-1999

Other 

medical/

nonsurgical 

condition

Risk-adjusted 

rates of 

pressure ulcer

development, 

functional 

decline, 

behavioral 

decline, and

mortality.

Veterans in VA nursing homes 

were significantly

(Po.05) less likely to develop 

a pressure ulcer (odds ratio 

(OR)50.63) but more likely to 

experience functional decline 

(OR51.6) than veterans in 

community nursing homes. 

Veterans in VA nursing homes 

were also less likely to die 

but more likely to experience 

behavioral decline, but these 

differences did not achieve 

statistical significance

after risk adjustment. A

’l 27713 2000-2001 Nat’l 4852 2000-2001 Depression

Receipt of 84, 

140, and 181 of 

antidepressant 

therapy among 

patients with 

initial diagnosis 

of depression

The VA slightly outperformed 

the private sector in the 

prescription of antidepressants 

during the acute phase 

of treatment, the first 84 

days (84.7 compared with 

81 percent) and during 

the maintenance phase of 

treatment, the first 181 

days (53.9 compared with 

50.9 percent). The findings 

persisted after adjustment 

for age and sex but lost 

significance after adjustment 

for comorbid conditions. A
40

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

e 

N 862 1995-1999 Lrg geo 27936 1995-1999 Cancer

survival 

following 

diagnosis of 

lung cancer

The median survival was 

6.3 months for VA patients 

compared with 7.9 months 

for patients in the rest of the 

state, and the 5-year overall 

survival rate was 12% for 

VA patients compared with 

15% for patients in the rest 

of the state. The Cox model 

showed a hazard ratio for VA 

patients compared with nonVA patients of 1.22 (P_ 0.001) 

after adjusting for age, disease 

stage, and race. B

’l 3265 2003 Nat’l

10677/

40331 2003

Preventive 

Care

Influenza and 

pneumococcal 

vaccination

Among veterans, Influenza 

and vccinatin rates highers for 

VA users compared to nonusers. For veterans, VA care 

was independently associated 

with influenza vaccination 

(adjusted OR 1.8; 95%CI 

1-5-2.2) and pneumococcal 

vaccionation (adjusted OR 

2.4; 95%CI 2.0-2.9). A

lt 

Ns 151 2000-2003

Mult 

ctrs 79 2000-2003

Other 

medical/

nonsurgical 

condition

satisfaction 

with hearing 

aid fitting

Three weeks after the

fitting, VA patients reported 

more satisfaction with

their hearing aids. On some 

measures VA patients

reported more benefit, but 

different measures of

benefit did not give completely 

consistent results. B
41

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

le 

5016 1993 Nat’l 850000 1991

Other 

medical/

nonsurgical 

condition

hospital 

mortality

Adjusted death rates were 

similar in the VA and a private 

sector sample B

e 

N

1262/ 840 

dual 2000

Lrg geo 

areao 550 2000

Other 

medical/

nonsurgical 

condition

patient 

satisfaction 

with outpatient 

care

VA users were 2-8 times 

more satisfied than va nonusers on 5 of 10 measures 

of satisfaction. VA users 

were less satified than nonVA users on one measure – 

number of days waited for an 

appointment. B

’l

48505-

84503 1994-2000 Nat’l

diff. to 

ascertain 1997-2001

CHF, 

DM, IHD, 

Preventive 

care

3 preventive 

measures, 

3 diabetes 

measures, 5 

ami measures, 

2 chf measures

The VA outperformed the 

Medicare fee-for-service 

program on all 11 similar 

indicators from 1997 to 1999 

and of 12 of 13 indicators in 

2000. A

’l

48505-

84503 1994-2000 Nat’l

diff. to 

ascertain 1997-2001

Preventive 

Care

3 preventive 

measures, 

3 diabetes 

measures, 5 

ami measures, 

2 chf measures

The VA outperformed the 

Medicare fee-for-service 

program on all 11 similar 

indicators from 1997 to 1999 

and of 12 of 13 indicators in 

2000. A

le 

1142 1994-1995

Mult 

ctrs 51249 1994-1995

Other 

medical/

nonsurgical 

condition

risk adjusted 

mortality

Using logistic regression to 

adjust for severity, the odds 

of death was similar in VA 

patients, relative to private 

sector patients (OR 1.16, 

95% CI 0.93-1.44; P = 0.18). 

Using proportional hazards 

regression and censoring 

patients at hospital discharge, 

the risk for death was lower in 

VA patients (hazard ratio 0.70; 

95% CI 0.59-0.82; P <0.001). B
42

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

t. 

Ns 1285 2000-2001

Mult. 

Ctrs 6616 2001-2002 DM

Process of 

care measures 

of quality as 

derived from 

the Diabetes 

Quality 

Improvement, 

Project 

accountability 

and 

measurement 

set, 

Intermediate 

outcomes, 

Patient 

satisfaction 

with care

After adjustment, VA 

significantly outperformed 

mgd care on all process of 

care measures. Intermediate 

outcome of blood pressure 

control was comparable 

between the two cohorts, 

however the VA cohort 

had significantly greater 

percentage of patients tight 

HgbA1C and LDL control. 

Patients reported similar 

overall satisfaction in the 

two cohorts, though there 

was significantly greater 

satisfaction with diabetes care 

in the VA. A

’l

171/

1009/145 2000-2003 Nat’l 3552/576 2000-2003

Preventive 

Care

self-reported 

use of influenza 

vaccination, 

pneumonia 

vaccianation, 

serum 

cholesterol 

screening

Veterans receiving care 

through VA reported 10% 

greater use of influenza 

vaccination (P<.05), 14% 

greater use of pneumococcal 

vaccination (P<.01), 

And a nonsignificant 

6% greater use of serum 

cholesterol screening (P=.1), 

than did veterans receiving 

care through Medicare 

HMOs. Veterans receiving 

care through Medicare FFS 

reported less use of all 4 

preventive measures (P<.01) 

than did veterans receiving 

care through Medicare HMOs. B
43

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l

95 

hospitals 2005 Nat’l

421 

hospitals 2005

Other 

medical/

nonsurgical 

condition

regular use 

of specific 

prevention 

modalities 

(maximum 

sterile barrier 

precautions, 

use of 

chlorhexadine 

gluconate 

for insertion 

site and 

antimicrobial 

CV catheters, 

routine change 

of catheters, 

use of 

antimicrobial 

impreganated 

dressing); also 

a composite 

measure of max 

sterile barrier, 

chlorhexadine 

and avoidance 

of routine 

changes.

Adjusted findings revealed 

that VA hospitals were 

significantly more likely to use 

chlorhexadine gluconate (OR 

4.8, 95%CI 1.6-15.0) and/or 

to use a composite approach 

(OR 2.1, 95%CI 1.0-4.2) 

as compared with non-VA 

hospitals. B

’l 15259/ 13129 1996-1999 Nat’l 447445/ 384470 1996-1999 IHD

mortality (30 

day and one 

year)

VA pts had significantly 

higher one year mortality rates 

across all years studied; 30day 

mortality rates were higher in 

VA in 1997 however 30day 

mortality rates decreased 

overtime and were comparable 

between the two sites by 1999. B
44

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 181132 1993-1997 Nat’l 12163 1993-1995

Depression, 

Psychosis/

schizophrenia, 

other 

medical/

nonsurgical 

condition

Readmission 

rates and 

outpatient 

follow-up 

care following 

hospitalization 

for a 

psychiatric or 

substance abuse 

disorder

This study found that, overall, 

private-sector mental health 

inpatients had shorter lengths 

of stay, more days to the 

next inpatient readmission, 

and lower readmission rates 

within 14, 30, or 180 days of 

discharge compared with VA 

mental

health inpatients. Although 

VA patients had higher 

continuity-of-care scores, 

moderately higher proportions 

of private-sector patients had 

an outpatient visit within 30 

and 180 days after discharge. 

Private-sector patients also 

had fewer days to the first 

outpatient visit and more 

outpatient visits in the six 

months after discharge. B

’l 2636 2000 Nat’l 1318 2000

Psychosis/

schizophrenia

adherence 

to treatment 

guidelines for 

antipsychotic 

prescribing

Patients in the VA and private 

sector were equally likely 

to receive an antipsychotic 

regimen that complied with 

PORT guidelines. B

’l 254/281 2000 Nat’l 10632 2000 DM

They studied 

five selfreported 

measures of 

diabetes selfmanagement 

and preventive 

care practices

Persons who received care 

through the VA were more 

likely to report taking a 

diabetes education class and 

HbA1c testing than those 

covered by private insurance. B
45

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 2486/ 13310 1994-1995 Nat’l 29249/ 41754 1994-1995 IHD

comparison 

of coexisting 

conditions, 

severity of AMI 

and mortality at 

30days & one 

year

Adjusted rates of mortality at 

30days and one year were not 

significantly different among 

VA and Medicare patients 

after AMI (OR 0.94, 95% CI 

0.82-1.07 and OR 0.94, 95% 

CI 0.84-1.05 respectively). B

’l 2486 1994-1995 Nat’l 29249 1994-1995 IHD

use of 

thrombolytics, 

_-blockers, 

ACE inhibitors, 

or aspirin 

among ideal 

candidates 

following 

an acute 

myocardial 

infarction

Ideal VA candidates were 

more likely to undergo 

thrombolytic therapy at arrival 

(OR [VA relative to Medicare] 

1.40 [1.05, 1.74]) or to receive 

ACE inhibitors (OR 1.67 

[1.12, 2.45]) or aspirin (OR 

2.32 [1.81, 3.01]) at discharge 

and equally likely to receive 

_-blockers (OR 1.09 [1.03, 

1.40]) at discharge. A

’l 1665/ 2486 1994-1995 Nat’l 19305/ 29249 1994-1995 IHD

use of 

angiography 

(appropriate 

use) and 

mortality

After accounting for patient 

characteristics and need for 

angiography, VA pts were 

significantly less likely to 

receive angiography (43.9 

vs 51%, OR 0.75, 95% CI 

0.57-0.96). After accounting 

for hospital and capability 

of cardiac interventions, 

underuse of angiography 

and mortality did not differ 

significantly between patient 

groups. A

lt 

s 310 1996-1997

Mults 

ctrs 228 1996-1997 DM

Six dimensions 

of patient 

satisfaction

VA patients were more 

satisfied than were county 

patients overall and with 5 of 

6 dimensions of their care. B
46

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l

369155/

427367 1995-2001 Lrg geo

1509891/

3861953 1995-2001

CHF, IHD, 

Pulmonary 

Disease, 

TIA/Stroke

30 day 

mortality (for 

white and 

black males 

after hospital 

admission 

for any of 

the above 

conditions)

After risk adjustment, racial 

(black vs white) differences 

in 30 day mortality rates 

after admission for 6 medical 

conditions were similar among 

VA and non-VA care settings. B

e 

N 12366 2001-2003 Lrg geo 7734 2001-2003 HTN

control of 

blood pressure 

below 140/90

Blood pressure control to 

below 140/90 

mmHg was comparable 

among white hypertensive 

men at VA (55.6%) and nonVA (54.2%) settings (P=.12). 

In contrast, BP control 

was higher among African 

American hypertensive men 

at VA (49.4%) compared 

with non-VA (44.0%) settings 

(P_.01), even after controlling 

for age, numerous comorbid 

conditions, and ruralurban 

classification. Being in a 

non-VA site was negatively 

associated with blood control 

adjusted OR 0.839 (0.742-

0.949) A
47

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 535 2000 Nat’l

1848/

9055 2000

DM, 

Preventive 

care

a1c testings 

foot exam, 

diabetes 

education, bp 

measurement, 

cholesterol 

measurement, 

sigmoidoscop, 

fotb testing 

among patients 

with diabetes

Veterans who use VA have 

higher rates of foot exams, 

diabetes education, and 

sigmoidoscopy an da lower 

rate of a1c testing compared to 

veterans who did not use the 

VA. There were non-signifcatn 

difference for eye exams, bp 

measurements, cholestestorol 

testing and fobt screening. A

e 

N 8326 1993-1994 Lrg geo area 6666 1993-1994 IHD

10 and 30 day 

mortality, 10 

and 30 day 

use of cardiac 

bypass surgery

Overall mortality and sameadmission bypass surgery 

rates were similar for patients 

undergoing PTCA in the 

VA and Washington State 

hospitals. B

lt 

s 192/274 1994-1996

Mult 

ctrs 96/184 1994-1996

Psychosis/

schizophrenia

adherence to 

port recommendations

On 5 of 26 Schizophrenic 

Patient Outcomes 

Research Team treatment 

recommendations, a smaller 

proportion of VA than non-VA 

patients adhered to standards. 

Four of these reflected reduced 

access among VA patients to 

psychosocial services such as 

work therapy, job training, or 

case management services. B

le 

1960 1994-1995

Mult 

ctrs 157147 1994-1995

Other 

medical/

nonsurgical 

condition mortality

Risk adjusted inhospital 

mortality was similar for VA 

and private sector patients OR 

1.07 95%CI 0.74-1.54. B
48

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 10007 2000-2004 Nat’l 393873 2000-2004

DM, IHD, 

HTN, 

Preventive 

Care

self reported 

use of 17 

recommended 

health care 

services 

including 

cancer 

prevention, 

cardiovascular 

risk reduction, 

diabetes 

management 

and infection 

prevention.

VAMC care was associated 

with greater use of 

recommended services in both 

years of study (6/17 services 

more used in 2000, 12/17 

more used in 2004) B

’l

420514/

1.5m 1999-2004 Nat’l

584294/

879202 1998-2004

Other 

medical/

nonsurgical 

condition

Risk adjusted 

mortality

After adjusting for casemix, the HR for mortality in 

the MAP was significantly 

higher than that in the VA 

(HR, 1.404; 95% CI _ 1.383–

1.426). B

’l

12177/

16725 1998-2000 Nat’l

26225/

62614 1998-2000 None

Risk-adjusted 2 

year mortality, 

change in 

physical and 

mental health 

status

Higher risk-adjusted mortality 

in the VA compared to 

Medicare Advantage (2 year 

mortality 7.6% in VA vs. 

9.2% in MA); There were no 

significant differences in the 

probability of being alive with 

the same or better PCS except 

for the South (VA 65.8% vs. 

MAP 62.5%, P = .0014).VA 

patients had a slightly higher 

probability than MAP patients 

of being alive with the same or 

better MCS (71.8% vs. 70.1%, 

P = .002) B
49

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 2361 1999-2000 Nat’l 1912 1999-2000

Other 

medical/

nonsurgical 

condition

3 year risk 

adjusted 

mortality rate

The adjusted HR of mortality 

in the MA dual enrollees was 

significantly higher than in 

the VHA dual enrollees (HR, 

1.260 [95% CI, 1.044–1.520]). B

’l 3056 1994-1995 Nat’l 52382 1995 TIA/Stroke

functional 

independence

Stroke patients receiving 

rehabil- itation in the VA 

setting were discharged with 

slightly better functional 

outcomes. B

e 

N 105026 1998-2000 Lrg geo 163853 1998-2000 None

length of stay, 

readmission 

within 30 days

Across conditions, the length 

of stay was longer for VA 

patients compared with 

non-VA patients. In logistic 

regression, VA care was not a 

significant predictor of 30day 

readmission for veterans 

<65years old, however for 

veterans >=65 years of age 

initial VA admission was 

associated with a significantly 

higher odds of readmission 

within 30 days than non-VA 

index admission (OR2.79, 

95%CI 1.4-5.6) B

e 

N 50429 1998-2000 Lrg geo 74017 1998-2000

Patient 

Safety 

Indicators

Risk adjusted 

rates of nonobsteric 

patient safety 

indicators

Rates similar for 9 of 15 

PSIs, ulcer, sepsis, iatrogenic 

infection, postop resp 

failure, post op metabolic 

derangement lower in VA, 

mortality higher in VA for 

low-risk DRGs B
50

VA and Non-VA Settings Evidence-based Synthesis Program

VA Sample Non-VA Sample

Conditions Outcomes Primary Findings

Final 

Grade

a 

el

Sample 

Size

Years 

Collected

Data 

Level

Sample 

Size

Years 

Collected

’l 14853 1992-1995 Nat’l 32745 1992-1995 IHD

30 day and 1 

year adjusted 

mortality rates

After adjusting for patient 

characteristics, the odds of 

30-day mortality were not 

significantly different between 

patients admitted to VA basic 

service hospitals (reference) 

and patients admitted to any 

other type of hospital within 

either system of care. The 

odds of 1-year mortality were 

significantly lower in patients 

admitted to Medi- care cardiac 

surgery hospitals (OR 0.88, 

95% CI 0.79-0.98) compared 

to patients admitted to VA 

basic service hospitals B
51

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Appendix 3. Screener Form

Article ID: ________________ Reviewer:

First Author:

 (Last Name Only)

Study Number: ___of____ Description: 

(Enter ‘1of 1’ if only one) (if more than one study)

1. Does the paper present a comparison of quality of clinical data in VA and US non-VA settings?

Yes..................................................................

No...................................................................

If No Stop

[NB: exclude the following: pure utilization rates, rates of disease, efficiency, recruitment techniques, and lack of 

direct comparisons] 

2. Are the data for the comparison sufficiently contemporaneous (within 1 to 2 years)?

Yes..................................................................

No...................................................................

3. How are the VA data assembled (within sites)? 

Random/representative sampling...................

Convenience sampling...................................

Other (specify__________________) ...........

4. How are the non-VA data assembled (within sites)? 

Random/representative sampling...................

Convenience sampling...................................

Other (specify__________________) ...........

5. At what level do the VA data come from?

National or sufficiently multisite 

to represent national data ...............................

Multiple VISNs..............................................

One VISN (or state) .......................................

Multiple medical centers or clinics................

Single medical center or clinic.......................

Unknown........................................................

6. At what level do the non-VA data come from?

National or sufficiently

representative .................................................

Large geographic area like a state..................

Multiple centers or clinics..............................

Single medical center or clinic.......................
52

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

7. What conditions are covered by the quality assessment (check all that apply)

Medical and Non-Surgical Quality Areas

CHF................................................................

DM.................................................................

IHD ................................................................

HTN ...............................................................

Pulmonary Disease....................................

Preventive Care........................................

Cancer (list type)......................................

Osteoarthritis...........................................

Depression.............................................

Psychosis/schizophrenia............. ................

PTSD...................................................

TIA/Stroke........................ .....................

Other (specify__________) ...........................

Surgical Quality Areas

General.................................................

Cardiothoracic.........................................

Head and Neck.........................................

Orthopedic..............................................

Surgical Oncology.....................................

Urology............................... ..................

Vascular.................................................

Other surgical..........................................

Other (specify__________) ...........................

Safety Areas

Patient Safety Indicators...................... ...

Other (specify__________) ...........................

8. What features of quality are measured?

Structure.........................................................

Process ...........................................................

Outcomes .......................................................

Structure includes presence/absence of facilities

Process includes overuse, underuse, misuse

Outcomes includes intermediate outcomes

9. How did the specifications for the quality assessments compare in VA and non VA samples?

Identical..........................................................

Sufficiently similar for valid comparison... ..

Sufficiently dissimilar to present a 

threat to valid comparison..............................

Unclear...........................................................
53

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Appendix 4. Data Abstraction Form

Data Abstraction Form: Round Two

Article ID: <<Pre-filled from database>>

Reviewer: <<Pre-filled from database>>

Author/ Year: <<Pre-filled from database>>

VA sample: <<Pre-filled from database>> (random/rep, convenience AND national, multisite, 

etc.)

Non-VA sample: <<Pre-filled from database>> (same two sets of information)

Conditions: <<Pre-filled from database>>

Sample size used

VA:

Non-VA:

Years of data collection covered

VA:

Non-VA:

Control variables:

Primary outcomes:

Findings (adjusted if possible):

Secondary/associated findings (optional):

Assessment (grade each of the following with A/B/C scale):

___1. Time frames

___2. Samples (both VA and non-VA) 

___3. Quality measurements 

___4. Outcomes 

___5. Importance of measures 

___6. Statistical methods

Other/notes:

Overall assessment/assignment of level:

Rejected (Graded C or lower, or failed to meet prior criteria):
54

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Appendix 5. Data Abstraction Grading Guidelines

Assessment (grade levels detailed below):

1. Time frames

A. Contemporaneous time frames

B. All between A and C

C. non-contemporaneous

2. Samples (both VA and non-VA) 

A. representative or national samples (both VA and non-VA)

B. All between A and C

C. small, limited, unequal or non-representative samples

3. Quality measurements 

A. specified and identical measures with a similar assessment format for those 

 measures

B. All between A and C

C. dissimilar measures and/or dissimilar assessment methods

4. Outcomes 

A. outcomes are either well established clinical endpoints or processes strongly 

 associated with well-established clinical endpoints 

B. All between A and C

C. outcomes are structures, processes or clinical endpoints that are not well- 

 established or are indirect measures of quality

5. Importance of measures (e.g. number of clinically relevant indicators, potential impact 

 of indicators)

A. High

B. Medium

C. Low

6. Statistical methods

A. Sufficient sample size and/or methods appropriate to address hypothesis(ses)

B. All between A and C

C. Insufficient sample size and/or methods questionable to address hypothesis(ses)

Overall assessment/assignment of level: Measured as an average of grades assigned above
55

Comparison of Quality of Care in VA and Non-VA Settings Evidence-based Synthesis Program

Appendix 6. Search Strategy

TOPIC: Veterans Hospitals and Non-Veterans Hospitals Quality of Care –

 Search Methodology

NOTE: Search strategy was derived from subject terms used in 34 articles provided by the 

project

Database: PubMed

Years Covered: 1996- 2009 (August)

Number of results: 432

Search Strategy:

hospitals, veterans[MeSH Terms] OR hospitals, veterans[majr] OR hospitals, veterans/standards 

OR hospitals, veterans/statistics and numerical data OR united states department of veterans 

affairs OR united states department of veterans affairs/standards OR united states department 

of veterans affairs/statistics and numerical data OR united states department of veterans affairs/

utilization 

Appendix 7. Peer Review Comments Table

Location Comment Change

Executive Summary, 

Background 

I am curious about why you do not 

mention the “Best Care Anywhere” book 

and others, and only focus upon negative?

Background updated to 

incorporate suggested 

citation.

Executive Summary, 

Conclusion

Might clarify that medication process of 

care showed VA was better, but procedural 

process of care not uniformly better (ie 

angiography).

“...and interventional 

procedures” added for 

clarification.

Hospital and Nursing Home 

Care, Summary

“Racial mortality differences” to “mortality 

rates for racial minorities”

Change incorporated

Mental Health, Summary It wasn’t clear in the summary how 

outpatient follow-up rates could be worse 

when outpatient continuity was better, so I 

tried to clarify: “...and [timely] outpatient 

visit follow-up rates [after discharge] were 

worse in the VA, but continuity of care [in 

the outpatient setting]...”

Change incorporated

Conclusions, paragraph 9 Same comments as in the mental health 

section above: “...equivalent racial 

mortality differences...” to “equivalent 

mortality rates across racial groups”

Change incorporated