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