Background

Largest integrated delivery system in the United Launched organizational transformation in midBoth favorable and unfavorable reports of VA q

Center for the Study of Healthcare Provider Behavior 
Objective

Synthesize the totality of evidence comp

and non‐VA q y ualit of care for surg 

ic

surgical, and other medical condit

Center for the Study of Healthcare Provider Behavior 
Methods: Search Strateg

• VA Central Office b bl h i iography of artic

addressing possible VA and non‐VA

comparisons

• Medline search for similar articles• MeSH search terms included: hospital

veterans, st dd an ar s, st ti ti tatistics and num

data, and utilization

Center for the Study of Healthcare Provider Behavior 
Methods: Inclusion

• Dual screen of all articles by two traine

p yh sicians

• Inclusion criteria:

– C i ompar son of quality of care using d t a a a

January 1990

– Assessed structure, process, or outcomes 

• Included articles were categ , orized, give

quality assessment, and narratively sum

Center for the Study of Healthcare Provider Behavior 
Methods: Quality Assessm

Criteria

• C bl omparable quality measures

• Contemporaneous time frames

• Representative/national populations• Well‐established established clinical clinical outcomes outcomes or va

va

process measure

• Broad number of indicators indicators• Adequate sample size/power• Glbl o a assessment

Graded each study (A,B,C) on each do

Center for the Study of Healthcare Provider Behavior 
222 Articles Identified

175 Articles

assessed for

eligibility 47 

55

Articles Screened

122 

98 No 

55 Articles Assessed

36 Medical

98 No 

19 

4 Not i

2 A

16 Surgical

2 A

Patient 

Center for the Study of Healthcare Provider Behavior 
Results by Sub‐Topic

M di l e ca 36 S il General 9Cardiovascular 8

Surgical General Oncology 

Hospital/Nursing Home Care 9Diabetes 3

Solid Organ Transplantation Vascular 

Mental Health Care 4Other 3

Cardiac Surgery Endocrine 

Center for the Study of Healthcare Provider Behavior 
Results: General Medical Medical 

Primary prevention, multiple conditions, broad health All 9 general studies found better adherence to care p

better health outcomes in the VA

Center for the Study of Healthcare Provider Behavior 
Selected General Medical Medical St

St

• VA patients more likely to receive

recommended processes (67% vs. 51%

compared to community‐based sampet al., 2003)

• VA outperformed traditional Medicare 

of 13 quality indicators in 2000 (Jha et 

2002)

Center for the Study of Healthcare Provider Behavior 
Results: Cardiovascular (

• 5 mortality studies found no survival

difference between VA and Medicare 

• 3 studies found better evidence‐based 

therapy therapy in VA; 1 found lower use of cl

cl

appropriate angiography

Center for the Study of Healthcare Provider Behavior 
Selected Cardiovascular Stu

• VA patients with MI less likely to recei

ang g py io raphy when clinically needed (P

et al, 2003)

– 44% in VA vs. 51 %. in Medicare Medicare

• VA patient more likely to receive beta

blockers (50% vs. 42%), ACE‐inhibitors 

vs. 33%), and aspirin (77% vs. 69%) at

discharge.

Center for the Study of Healthcare Provider Behavior 
Results: Hospital/ Nursing H

(9)

• 4 found similar risk‐adjusted mortality 

VA and private sector hospitals

• Similar racial disparities in hospital mo

compared to Medicare

Center for the Study of Healthcare Provider Behavior 
Results: Diabetes (3)

• All 3 studies found better adherence t

recommended care processes in the V

• Only one study of intermediate outco

Center for the Study of Healthcare Provider Behavior 
Selected Diabetes Study

• The VA outperformed commercial ma

care plans on 7 measures of care proc

(Kerr et al. 2004)

• 92% of Veterans Veterans had A1c < 9 5%. and 8

LDL < 130 mg/dL.

• The corresponding rates were 80% an

commercial managed care plans

Center for the Study of Healthcare Provider Behavior 
Results: Mental Health (

• 4 studies of the process of care in

schizophrenia and depression found m

results

Center for the Study of Healthcare Provider Behavior 
Key Findings: Medical

• Of 14 studies studies of care processes processes, 13 favored favored VA• Of 12 studies studies of mortality mortality, 3 favored favored VA, 2 favored favored n

found no difference between VA and private sector

Center for the Study of Healthcare Provider Behavior 
Conclusions: Medical

• Studies of care processes almost alwa

demonstrated that the VA performed 

than non‐VA comparison groups.

• Studies Studies that assessed assessed risk‐adjusted adjusted mo

mo

generally found similar rates for patie

and non‐VA settings.

Center for the Study of Healthcare Provider Behavior 
Results: General Surgical Surgical 

Findings were heterogeneous

Postoperative morbidity was similar or reduced in VA, except fo

which a subset of male patients had higher adjusted rates of 

after bariatric surgery

Studies by Fink and Henderson: different types of surgeries in V

settings settings, with less common and more complex complex surgeries surgeries in V

Center for the Study of Healthcare Provider Behavior 
Results: Oncology (3)

• 2 pancreatic cancer

• 1 breast cancer

• 1 pancreatic cancer study found a sign

increase in ri ks ‐adj d uste postoperativ

morbidity and mortality rates in VA

• Other 2 studies found no significant

differences

Center for the Study of Healthcare Provider Behavior 
Results: Solid Organ

Transplantation (3)

• No significant differences in patient su

between p po ulations

• End‐stage renal disease patients in VA 

were less likely to be listed for a kidne

transplant, and less likely to receive o

listed, when compared to privately ins

patients

Center for the Study of Healthcare Provider Behavior 
Results: Vascular (3)

• VA had improved or comparable posto

morbidity

• Risk‐adjusted mortality rates were com

across populations populations in all 3 studies studies

Center for the Study of Healthcare Provider Behavior 
Results: Cardiac Surgery Surgery 

• Only one in SM publication, Rosentha

• After adjustments, adjustments, VA patients patients had hig

odds of death

Center for the Study of Healthcare Provider Behavior 
Results: Endocrine (2)

• No significant differences in postopera

morbidity or adverse events rates

Center for the Study of Healthcare Provider Behavior 
Key Findings: Surgical

• 10 of 16 articles from the Patient Safe

Surg y er Study: Oct 2001‐ Sept 2004

Center for the Study of Healthcare Provider Behavior 
Conclusions: Surgical

• Types of surgeries tend to be different 

non‐VA

• Outcomes were generally similar, with 

exceptions

• Majority of studies have data more th

years old

Center for the Study of Healthcare Provider Behavior 
Limitations

• Breadth vs. depth

• Few assessments assessments of geographic geographic or facilit

facilit

variations

• L k ac of d il d etailed cli i l n ca data for ri ks ‐adj

• Need for outcomes other than mortality

• Little recent data

Center for the Study of Healthcare Provider Behavior 
Implications

• Future VA non‐VA comparisons sh ld ou assess a b 

ro

outcome measures, national samples, recent data, more robust risk‐adjustment methods.

• Future surgical studies could address comparisons 

of care to provide information to enhance the qua

across settings

Center for the Study of Healthcare Provider Behavior 
Links and Resources

• Report

http://www.hsrd.research.va.gov/publications/esp

• VA Evidence Evidence Synthesis Synthesis Program Program

http://www.hsrd.research.va.gov/publications/esp

• Trivedi Trivedi AN, Matula S, Miake‐Lye I, Glassman Glassman P, She

She

SM. Systematic Review: Comparison of the qualit

care in VA and non VA Settings. Medical Care 2011

• Matula SR, Trivedi AN, Miake‐Lye I, Glassman PA, S

Asch S. Comparisons of quality of surgical care be

US Department Department of Veterans Veterans Affairs Affairs and the privat

privat

Am Coll Surg 2010 Dec;211(6):823‐32.

Center for the Study of Healthcare Provider Behavior 
Synthesis Team

• Paul G. Shekelle, MD, PhD

• Steven Asch, MD, MPH

• Peter Glassman, MBBS, MSc

• Sierra Matula, MD

• Amal N. Trivedi, MD, MPH

• Isomi M. Miake‐Lye, BA

Center for the Study of Healthcare Provider Behavior 
Affiliations

• VA Greater Los Angeles

– Evidence Synthesis Program & Southern California/RAND Ev

Practice Center

– Center for Surgical Outcomes and Quality

• VA Health Services Research &Development Service• Center on Systems, Outcomes and Quality in Chronic 

Rehabilitation (SOQCR), Providence VA Medical Cente

• Alpert Medical School of Brown University, Providenc

• David Geffen School of Medicine at UCLA, Los Angele

• Robert Wood Johnson Clinical Scholars Program, UCL

• University of California San Francisco

Center for the Study of Healthcare Provider Behavior

y