Reviewing Surgical Outcomes After VHA Health Care Expansion

According to research published in JAMA Surgery, expanded access to health care across the previously separate Veterans Health Administration (VHA) and non-VHA health care community systems was associated with a shift in the performance of surgical procedures but had no measurable association with surgical outcomes.

Laura A Graham, PhD, MPH, Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, and coresearchers investigated the impact of the US Department of Veteran Affairs (VA) Veterans Choice Program (VCP) which expanded health care access to community settings outside of the VA.

“Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported,” said Dr Graham and colleagues. “Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding.”

As part of a nonrandomized RDD study, researchers assessed outcomes of veteran patients enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019. The final sample included 615,473 unique surgical procedures among 498,427 patients, aged an average 63 years, and 90.4% male.

“Overall, 94,783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type,” found researchers.
VA-paid procedures were more commonly associated with patients identifying as women than men (12.7% vs 9.1%), White (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and aged ≤65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided). These patients also had a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]).

“The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01),” explained researchers. “However, there was no difference in postoperative mortality, readmissions, or emergency department visits.”

Dr Graham and colleagues note the VCP expansion was associated with a shift in the performance of surgical procedures in the private sector; however, no measurable association with surgical outcomes was observed.

“These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system,” concluded researchers, “although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.”

Reference:
Graham LA, Schoemaker L, Rose L, Morris A, Aouad M, Wagner TH. Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surg. Published online October 12, 2022. doi:10.1001/jamasurg.2022.4978