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Publication Briefs

Total Knee Arthroplasties have Significantly Lower Complication Rates when Performed in VA vs. Community Care Facilities

Since the passage of the Choice Act, VA has evolved from a healthcare delivery system to both delivering care and purchasing care in the community. Currently, 22% of VA's FY2021 healthcare funds are spent on purchasing community care, an amount that is increasing with VA's MISSION Act, which provides community care to even more Veterans via less restrictive criteria. The Choice and MISSION Acts improve Veterans' access to timely and convenient healthcare, but also introduce questions about the quality of VA-delivered vs. VA-purchased care. This study compared risk-adjusted post-operative complication rates for elective total knee arthroplasties (TKAs) that were delivered vs. purchased by VA. Using VA data, investigators identified elective primary (vs. revision) TKAs delivered in VA hospitals or purchased by VA from community providers from FY2017 through FY2019 (41,775 Veterans received 43,371 unilateral TKAs). Post-TKA complications were identified according to the specifications of the 2019 Centers for Medicare and Medicaid Services "TKA Complication Measure," including complications related to acute myocardial infarction (AMI), joint/wound infection, pneumonia, pulmonary embolism, sepsis/septic shock, bleeding, and mechanical complications.


  • Overall, adjusted complication rates were significantly lower for VA-delivered vs. VA-purchased TKAs. Those TKAs delivered in VA had significantly lower risk-adjusted odds of individual complications (AMI, mechanical, joint/wound, pneumonia, and sepsis/septic shock) compared to those performed in the community. The exceptions were pulmonary embolisms (not significantly different between settings) and bleeding complications (numbers too low to calculate).
  • Hospital-level comparisons revealed five locations where VA-purchased care out-performed VA-delivered care. These five VA locations had significantly higher complications compared to relatively low community complication rates.


  • As the amount of VA-purchased care continues to increase under the MISSION Act, these results support VA monitoring of overall and local comparative hospital performance, in order to improve the quality of care VA delivers while ensuring optimal outcomes in VA-purchased care.


  • Elective TKA is only one procedure and short-term complications are only one aspect of quality.

This study was funded by HSR&D (SDR 18-318). Drs. Harris, Rosen, and Wagner are supported by HSR&D Research Career Scientist awards; and Dr. Vanneman is supported by an HSR&D Career Development Award. Drs. Harris, Wagner, and Giori are part of HSR&D’s Center for Innovation to Implementation; Drs. Beilstein-Wedel, Rosen, and Shwartz are part of HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR); and Dr. Vanneman is with HSR&D’s Informatics, Decision-Enhancement and Analytic Services Center (IDEAS).

Harris A, Beilstein-Wedel E, Rosen A, Shwartz M, Wagner T, Vanneman M, and Giori N. Comparing Complication Rates after Elective Total Knee Arthroplasty Delivered or Purchased by the VA. Health Affairs. August 2021;40(8):1312-20.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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