Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA

Harris, Alex H. S.; Beilstein‐Wedel, Erin; Rosen, Amy K.; Shwartz, Michael; Wagner, Todd H.; Vanneman, Megan E.; Giori, Nicholas J.

doi:10.1377/hlthaff.2020.01679

Cited by 12 publications

(25 citation statements)

References 16 publications

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“…We interpreted effect sizes as small if they were greater than 0.20 and medium if they were greater than 0.50. 16 We used a mixed-effects logistic regression model with dependent variable presence or absence of a complication, as described in Harris et al 9 Whereas Harris' findings were based on analysis of the random effects (ie, conditional estimates), we calculated marginal results (relevant for conclusions about subgroups or populations) using an extension of the approach used by CMS in hospital profiling. Specifically, we calculated risk-standardized complication rates and used bootstrapping to evaluate statistical significance (see eAppendix in the Supplement for further details and Krumholz et al 17 ).…”

Section: Discussionmentioning

confidence: 99%

“…11 The primary outcome was any surgical complication (no or yes). 9 Sociodemographic variables included age, sex, race, marital status, rurality, priority level, and Nosos risk score. Race information was originally self-reported by the veteran and was obtained from the electronic health record.…”

Section: Variables In Risk-adjustment Modelmentioning

confidence: 99%

“…[4][5][6][7] VA-performed surgical procedures, such as total knee arthroplasties (TKAs), have comparable or lower overall rates of complications and readmissions than VA-purchased surgical procedures. [8][9][10] However, these findings may obscure quality differences across VA facilities and across community health care facilities from whom the VA purchases care.…”

Section: Introductionmentioning

confidence: 99%

“…The lack of meaningful VA and community quality data are a problem that should be rectified if these data could help veterans make better choices about where to receive care. To investigate this, we built on prior work by Harris et al (2021) 9 to evaluate, at the facility level, whether the proportion of veterans having VA-performed (vs VA-purchased) TKAs was associated with the quality of TKAs (as measured by standardized short-term complication rates) performed or purchased by that VA facility. If veterans selected high-quality care without access to meaningful comparative quality information, then there is no need to develop and publish such metrics.…”

Section: Introductionmentioning

confidence: 99%

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Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

et al. 2022

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ImportanceRecent legislation expanded veterans’ access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance.ObjectiveTo determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates).Design, Setting, and ParticipantsThis 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA’s Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services’ methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period.ExposuresOf the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased.Main Outcomes and MeasuresThe primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility’s TKAs.ResultsAmong the study sample’s 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs.Conclusions and RelevanceIn this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans’ decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.

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Section: Discussionmentioning

confidence: 99%

Section: Variables In Risk-adjustment Modelmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

et al. 2022

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“…2,3 The few studies comparing VA and CC quality show similar or better quality of care at the national level for VA-delivered versus VA-purchased care. [4][5][6][7][8] One study comparing Veterans who underwent cataract surgery in the VA and CC found no significant differences in 90-day complication rates between the 2 care settings. 7 Another study by Harris et al 6 found that adjusted complication rates were significantly lower for total knee arthroplasties (TKAs) delivered in the VA compared with VA-purchased TKAs.…”

mentioning

confidence: 99%

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care

et al. 2021

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Background: There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care.Objective: We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels.Methods: Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics.Principal Findings: Nationally, the odds of experiencing an allcause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers.Conclusions: Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

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Location and Types of Treatment for Prostate Cancer After the Veterans Choice Program Implementation

Erickson,

Hoffman,

Wachsmuth

et al. 2023

JAMA Netw Open

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ImportanceThe Veterans Choice Program (VCP) was implemented in 2014 to help veterans gain broader access to specialized care outside of the Veterans Health Administration (VHA) facilities by providing them with purchased community care (CC).ObjectiveTo describe the prevalence and patterns in VCP-funded purchased CC after the implementation of the VCP among veterans with prostate cancer.Design, Setting, and ParticipantsThis cohort study used VHA administrative data on veterans with prostate cancer diagnosed between January 1, 2015, and December 31, 2018. These veterans were regular VHA primary care users. Analyses were performed from March to July 2023.ExposuresDriving distance (in miles) from residence to nearest VHA tertiary care facility. The location (VHA or purchased CC) in which treatment decisions were made was ascertained by considering 3 factors: (1) location of the diagnostic biopsy, (2) location of most of the postdiagnostic prostate-specific antigen laboratory testing, and (3) location of most of the postdiagnostic urological care encounters.Main Outcomes and MeasuresThe main outcome was receipt of definitive treatment and proportion of purchased CC by treatment type (radical prostatectomy [RP], radiotherapy [RT], or active surveillance) and by distance to nearest VHA tertiary care facility. Quality was evaluated based on receipt of definitive treatment for Gleason grade group 1 prostate cancer (low risk/limited treatment benefit by guidelines).ResultsThe cohort included 45 029 veterans (mean [SD] age, 67.1 [6.9] years) with newly diagnosed prostate cancer; of these patients, 28 866 (64.1%) underwent definitive treatment. Overall, 56.8% of patients received definitive treatment from the purchased CC setting, representing 37.5% of all RP care and 66.7% of all RT care received during the study period. Most patients who received active surveillance management (92.5%) remained within the VHA. Receipt of definitive treatment increased over the study period (from 5830 patients in 2015 to 9304 in 2018), with increased purchased CC for patients living farthest from VHA tertiary care facilities. The likelihood of receiving definitive treatment of Gleason grade group 1 prostate cancer was higher in the purchased CC setting (adjusted relative risk ratio, 1.79; 95% CI, 1.65-1.93).Conclusions and RelevanceThis cohort study found that the percentage of veterans receiving definitive treatment in VCP-funded purchased CC settings increased significantly over the study period. Increased access, however, may come at the cost of low care quality (overtreatment) for low-risk prostate cancer.

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Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA

Cited by 12 publications

References 16 publications

Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care

Location and Types of Treatment for Prostate Cancer After the Veterans Choice Program Implementation

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