Comparing Veterans Affairs and Private Sector Perioperative Outcomes after Noncardiac Surgery

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.