TY - JOUR
T1 - Comparing Veterans Affairs and Private Sector Perioperative Outcomes after Noncardiac Surgery
AU - George, Elizabeth L.
AU - Massarweh, Nader N.
AU - Youk, Ada
AU - Reitz, Katherine M.
AU - Shinall, Myrick C.
AU - Chen, Rui
AU - Trickey, Amber W.
AU - Varley, Patrick R.
AU - Johanning, Jason
AU - Shireman, Paula K.
AU - Arya, Shipra
AU - Hall, Daniel E.
N1 - Funding Information:
reported receiving salary support from the Palo Alto Veterans Health Care system as part of a Veterans Affairs Center for Innovation to Implementation research fellowship during the conduct of the study. Dr Massarweh reported receiving grants from the Veterans Affairs Office of Research and Development. Dr Reitz reported grants from National Heart, Lung, and Blood Institute and the National Institute on Aging during the conduct of the study. Dr Shinall reported grants from the National Cancer Institute during the conduct of the study. Dr Johanning is managing member of and has a patent to FUTUREASSURE, which holds intellectual property for frailty assessment. Dr Shireman reported receiving grants from the National Institutes of Health and Veterans Health Administration and salary support from the University of Texas Health San Antonio and the South Texas Veterans Health Care System during the conduct of the study. Dr Arya reported receiving grants from the Veterans Affairs Office of Research and Development and Center for Innovation to Implementation during the conduct of the study. Dr Hall reported grants from Veterans Affairs Office of Research and Development and the National Institutes of Health during the conduct of the study; has a consulting agreement with FUTUREASSURE outside the submitted work. No other disclosures were reported.
Funding Information:
Funding/Support: This research was supported
Funding Information:
Funding/Support: This research was supported by the US Department of Veterans Affairs; the Veterans Health Administration; the Office of Research and Development; grants I21 HX-002345 and XVA 72-909 (Dr. Hall), grant CIN 13-413 (Dr Massarweh), and Veterans Affairs Center for Innovation to Implementation research fellowship funding (Dr George) from Health Services Research and Development; grant 5R03AG050930 (Dr Arya) from the National Institute on Aging, NIH; grant K12CA090625 (Dr Shinall) from the National Cancer Institute, NIH; and grant U01 TR002393 (Drs Hall and Shireman) from the National Center for Advancing Translational Sciences and the Office of the Director; grant 5T32HL0098036 from the National Heart, Lung, and Blood Institute (Dr Reitz), and L30 AG064730 National Institutes of Health (Dr Reitz).
Publisher Copyright:
© 2021 American Medical Association. All rights reserved.
PY - 2022/3
Y1 - 2022/3
N2 - Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures: Surgical care in either a VA or private sector setting. Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results: Of 3910752 operations (3174274 from NSQIP and 736477 from VASQIP), 1498984 (92.1%) participants in NSQIP were male vs 678382 (47.2%) in VASQIP (mean difference,-0.449 [95% CI,-0.450 to-0.448]; P <.001), and 441894 (60.0%) participants in VASQIP were frail or very frail vs 676525 (21.3%) in NSQIP (mean difference,-0.387 [95% CI,-0.388 to-0.386]; P <.001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3174274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736477) (differences in proportions,-0.003 [95% CI,-0.003 to-0.002];-0.076 [95% CI,-0.077 to-0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P <.001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P <.001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
AB - Importance: Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective: To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants: This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures: Surgical care in either a VA or private sector setting. Main Outcomes and Measures: Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results: Of 3910752 operations (3174274 from NSQIP and 736477 from VASQIP), 1498984 (92.1%) participants in NSQIP were male vs 678382 (47.2%) in VASQIP (mean difference,-0.449 [95% CI,-0.450 to-0.448]; P <.001), and 441894 (60.0%) participants in VASQIP were frail or very frail vs 676525 (21.3%) in NSQIP (mean difference,-0.387 [95% CI,-0.388 to-0.386]; P <.001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3174274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736477) (differences in proportions,-0.003 [95% CI,-0.003 to-0.002];-0.076 [95% CI,-0.077 to-0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P <.001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P <.001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance: VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
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U2 - 10.1001/jamasurg.2021.6488
DO - 10.1001/jamasurg.2021.6488
M3 - Article
C2 - 34964818
AN - SCOPUS:85122366802
SN - 2168-6254
VL - 157
SP - 231
EP - 239
JO - JAMA Surgery
JF - JAMA Surgery
IS - 3
ER -