Expansion of the Veterans Health Administration Network and Surgical Outcomes

Abstract

ImportanceThe US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. 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.ObjectiveTo investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders.Design, Setting, and ParticipantsThis was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019.InterventionsThe VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital.Main Outcomes and MeasuresPostoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days.ResultsA total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with 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). However, there was no difference in postoperative mortality, readmissions, or emergency department visits.Conclusions and RelevanceExpanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. 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, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.

What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery

“…There is substantial evidence that patients undergoing CC surgery are systematically different than those in VHA, so to avoid biased comparisons of care quality in VHA versus CC, analyses need to account for systematic differences in patient characteristics across settings. While some prior studies found the surgical quality is better in the VHA, 7,8,10,39,40 more recent work accounting for unobservable as well as observable selection factors, as we did, found no difference in surgical outcomes between VHA and CC 41 …”

“…While some prior studies found the surgical quality is better in the VHA, 7,8,10,39,40 more recent work accounting for unobservable as well as observable selection factors, as we did, found no difference in surgical outcomes between VHA and CC. 41 Provider and facility effects were also significantly associated with CC surgery in our analysis. There is very little known about VHA provider referral decisions for CC, however, there is evidence that surgical quality is better in CC for some VHA hospitals, a difference that may affect referral decisions.…”

Growth of community‐based immunotherapy treatment in the Veterans Health Administration

“…We used data from the VA Corporate Data Warehouse from CY 2015 to 2020, including VA and community care claims. The community care claims include the PIT and Fee databases 3,9,10 . We identified immunotherapy treatment based on CPT codes and text matching in community care claims data and based on text matching in VA pharmacy data (Appendix ).…”

“…Oncologic care is a significant cost burden for the VA, driven in part by novel treatments. In 2021, total spending on oncology drugs in the United States was $75 billion 3 . Average growth in oncology drug costs was 10.5% a year from 2017 to 2021 3 .…”

“…In 2021, total spending on oncology drugs in the United States was $75 billion 3 . Average growth in oncology drug costs was 10.5% a year from 2017 to 2021 3 . The average drug costs for Nivolumab and Pembrolizumab, two commonly used immunotherapy treatments, are estimated to be approximately $75,000 and $55,000 per patient, respectively 4 …”