VA Surgeries across Eight Specialties Result in Lower Mortality among Veterans than Comparable Private Sector Surgeries
A primary goal of the MISSION Act is to facilitate Veterans’ access to healthcare, but it is unclear that diverting care to the community/private sector completely addresses perceived issues of timeliness and/or quality. The objective of this cohort study was to compare peri-operative outcomes among Veterans treated in VA hospitals to patients treated in private-sector hospitals using VASQIP (VA Surgical Quality Improvement Program) and NSQIP (National Surgical Quality Improvement Program) as comparable, high-quality, and audited national registries. Using these data, investigators identified all Veterans who underwent a non-cardiac surgical procedure from 1/1/2015 through 12/31/2018 across 8 surgical specialties: general surgery, neurosurgery, orthopedics, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. Of nearly 4 million surgeries performed over this period, 3,174,274 were included in NSQIP data (private sector surgeries) and 736,477 were included in VASQIP data (VA surgeries). The primary outcome was 30-day post-operative mortality. The secondary outcome was ‘failure to rescue,’ defined as a post-operative death after a complication.
- Overall, unadjusted rates of 30-day mortality, complications, and failure to rescue were 0.8%, 10%, and 5% in NSQIP and 1%, 17%, and 7% in VASQIP, respectively.
- After adjusting for patient frailty and procedure-specific physiologic stress, VA surgical care was associated with lower perioperative mortality (approximately 40% lower), and this is likely due to a comparatively lower risk of failing to rescue patients from postoperative complications.
- Lower perioperative mortality in VA surgical care compared to the private sector remained robust in multiple sensitivity analyses, including among patients that were frail and non-frail, with or without complications, and those undergoing low and high physiologic stress procedures.
- Findings are relevant not only to individual Veterans choosing between VA and private-sector care, but also to stakeholders making broader health policy decisions and budgetary appropriations. Future decisions should reflect these important differences in the quality and safety of surgical care.
- Hospital factors are not included in the VASQIP or NSQIP datasets (e.g., teaching hospital status), limiting the ability to fully address the clustering effect of patients treated by the same surgeon and/or at the same hospital.
- Unmeasured confounding could account for the observed association between better outcomes and VA surgical care, but the magnitude of a confounder (present disproportionately in the private sector) would need to be very large to obviate that finding.
This study was partly funded by HSR&D. Dr. George is part of HSR&D’s Center for Innovation to Implementation, Dr. Massarweh is with HSR&D’s Center for Innovations in Quality, Effectiveness, and Safety, and Dr. Hall is part of HSR&D’s Center for Health Equity, Research and Promotion.
George E, Massarweh N, Youk A, Reitz K, Shinall M, Chen R, Trickey A, Varley P, Johanning J, Shireman P, Arya S, and Hall D. Comparing Veterans Affairs and Private-Sector Perioperative Outcomes after Non-Cardiac Surgery. JAMA Surgery. Published online: Dec 29, 2021.