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Health Services Research & Development

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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3099 — Systematic Review: Comparison of the Quality of Medical Care in VA and Non-VA Settings

Trivedi AN (Providence VA Medical Center), Matula S (Greater Los Angeles VA Medical Center), Miake-Lye I (Greater Los Angeles VA Medical Center), Glassman P (Greater Los Angeles VA Medical Center), Shekelle P (Greater Los Angeles VA Medical Center), Asch S (Greater Los Angeles VA Medical Center)

Objectives:
Since the VA’s organizational transformation in the mid 1990s, there have been both favorable and unfavorable reports of the quality of VA care published in the peer-reviewed literature and lay media. In order to better understand the totality of the evidence, we undertook a systematic review of studies that compared quality in VA and non-VA US settings.

Methods:
We searched the MEDLINE database to identify all studies comparing the technical quality of non-surgical care in VA and US non-VA settings published between 1990 and August 2009. We used the following Medical Subject Headings (MeSH): hospitals, veterans and United States Department of Veterans Affairs. For each of these MeSH, we also included the following descriptor terms: standards, statistical and numerical data, and utilization. Two physicians independently reviewed 175 unique studies identified using the search strategy and abstracted data related to 6 domains of study quality.

Results:
Thirty-six studies met the inclusion criteria. All nine general comparative studies showed greater adherence to accepted processes of care or better health outcomes in the VA compared with care delivered outside the VA. Five studies of mortality following an acute coronary event found no clear survival differences between VA and non-VA settings. Three studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA, and one found lower use of clinically-appropriate angiography in the VA. Three studies of diabetes care processes demonstrated a performance advantage for the VA. Studies of hospital mortality found similar risk-adjusted mortality rates in VA and non-VA hospitals. Most studies used decade-old data, assessed self-reported service use, or included only a few VA or non-VA sites.

Implications:
Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings.

Impacts:
Future studies should assess why the VA has been able to produce superior care processes and compare outcomes of VA and non-VA care using a broader set of measures, national samples, recent data, and more robust risk-adjustment methods.


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