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Table 1.  
Outcomes at VA vs Non-VA Hospitals
Outcomes at VA vs Non-VA Hospitals
Table 2.  
Patient Experience and Behavioral Health Measures at VA vs Non-VA Hospitals
Patient Experience and Behavioral Health Measures at VA vs Non-VA Hospitals
1.
Centers for Medicare & Medicaid Services. Hospital Compare is updated with Veterans Health Administration (VHA) Hospital Data. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-10-21.html. Accessed November 9, 2016.
2.
Nuti  SV, Qin  L, Rumsfeld  JS,  et al.  Association of admission to Veterans Affairs hospitals vs non–Veterans Affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia.  JAMA. 2016;315(6):582-592.PubMedGoogle ScholarCrossref
3.
O’Hanlon  C, Huang  C, Sloss  E,  et al.  Comparing VA and non-VA quality of care: a systematic review.  J Gen Intern Med. 2017;32(1):105-121.PubMedGoogle ScholarCrossref
4.
Government Accountability Office. High Risk: Managing Risks and Improving VA Health Care. 2015. http://www.gao.gov/highrisk/managing_risks_improving_va_health_care/why_did_study. Accessed January 30, 2016.
5.
Rajaram  R, Barnard  C, Bilimoria  KY.  Concerns about using the patient safety indicator-90 composite in pay-for-performance programs.  JAMA. 2015;313(9):897-898.PubMedGoogle ScholarCrossref
6.
Bilimoria  KY, Chung  J, Ju  MH,  et al.  Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure.  JAMA. 2013;310(14):1482-1489.PubMedGoogle ScholarCrossref
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Research Letter
June 2017

Initial Public Reporting of Quality at Veterans Affairs vs Non–Veterans Affairs Hospitals

Author Affiliations
  • 1Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Intern Med. 2017;177(6):882-885. doi:10.1001/jamainternmed.2017.0605

Recently, the Centers for Medicare and Medicaid (CMS) announced the inclusion of Veterans Affairs (VA) hospital performance data on its Hospital Compare website.1 Prior to this release, comparisons of quality at VA vs non-VA hospitals were inconclusive and had methodological limitations.2,3 Given longstanding concerns about care at VA hospitals,4 our objective was to compare available outcome, patient experience, and behavioral health measures between VA and non-VA hospitals.

Methods

Hospital-level data were obtained for 129 VA and 4010 non-VA hospitals through the CMS Hospital Compare website (reporting period spanned July 2012-March 2015) and were merged with 2014 American Hospital Association Annual Survey data. Non-VA hospitals were classified as major teaching (based on Council of Teaching Hospitals membership), other teaching, community, specialty, and critical access hospitals. t Tests with and without Bonferroni correction for multiple comparisons were used to evaluate pairwise comparisons between VA and non-VA hospitals for risk-adjusted rates of 17 outcome measures (9 Agency for Healthcare Research and Quality Patient Safety Indicators [PSIs], 4 mortality measures, 4 readmissions measures), 10 patient experience measures, and 9 behavioral health measures.

Results

Veterans Affairs hospitals had better outcomes than non-VA hospitals for 6 of 9 PSIs. There were no significant differences for the other 3 PSIs (Table 1). In addition, VA hospitals had better outcomes for all the mortality and readmissions metrics (Table 1). However, on the patient experience measures, non-VA hospitals scored better overall than VA hospitals for nursing and physician communication, responsiveness, quietness, pain management, and on whether the patient would recommend the hospital to others (Table 2). For behavioral health measures, non-VA hospitals did better on 4 of 9 measures, while VA hospitals did better on 1 of 9 measures (Table 2).

Discussion

In this evaluation of the most recent, comprehensive public reporting of VA hospital quality that can be compared with non-VA hospitals, we found that VA hospitals performed better than non-VA hospitals for most outcome measures, but VA hospitals performed worse on certain patient experience measures and behavioral health measures. A recent systematic review was inconclusive about the quality of care provided at VA hospitals vs non-VA hospitals.3 In that analysis, VA hospitals generally performed better than non-VA hospitals with respect to safety and effectiveness of care; however, most of the studies in this review examined only a subset of patients, had a smaller sample size of non-VA Hospitals, used older data, and/or did not examine PSIs or the current patient experience metrics used by CMS.3

There are several possible explanations for the findings in our study. First, the VA may have invested considerable efforts in quality improvement and care coordination over the last 3 decades. Second, they may also have better documentation of comorbidities that are used in the risk adjustment, as a result of the VA unified electronic health record system and because patients have their health care mostly within 1 system.3 Third, while the mortality and readmission measures are thought to be indicative of quality, many of the Agency for Healthcare Research and Quality PSIs have been questioned due to the validity of the data (ie, complications are coded inconsistently, data are not audited) and due to ascertainment bias.5 In fact, when ascertainment bias occurs, quality measures may reflect the inverse of quality, where hospitals performing worse may be the ones providing higher-quality care (eg, PS1-12 venous thromboembolism outcome measure).6

While concerns remain about the validity of some of the measures used in current public reporting of health quality, the available data suggests that VA hospitals have a similar or more favorable quality compared with non-VA hospitals. On the other hand, these results suggest that VA hospitals should focus on improving certain aspects of patient experience and behavioral health. Hospitals can use these data to identify opportunities for quality improvement.

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Article Information

Corresponding Author: Karl Y. Bilimoria, MD, MS, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL 60611 (k-bilimoria@northwestern.edu).

Accepted for Publication: February 16, 2017.

Published Online: April 17, 2017. doi:10.1001/jamainternmed.2017.0605

Author Contributions: Dr Bilimoria had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Blay, Chung, Bilimoria.

Acquisition, analysis, or interpretation of data: Blay, DeLancey, Hewitt, Bilimoria.

Drafting of the manuscript: Blay, Hewitt, Bilimoria.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Blay, DeLancey, Bilimoria.

Obtained funding: Bilimoria.

Study supervision: Chung, Bilimoria.

Conflict of Interest Disclosures: Dr Bilimoria has received support from the National Institutes of Health, Agency for Healthcare Research and Quality, American Board of Surgery, American College of Surgeons, Accreditation Council for Graduate Medical Education, Health Care Services Corporation, Mallinkrodt, Northwestern University Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Foundation, and Northwestern Memorial Hospital. No other conflicts were reported.

Funding/Support: This research was supported by the National Institutes of Health (grant No. T32HL094293 to Dr Blay).

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Centers for Medicare & Medicaid Services. Hospital Compare is updated with Veterans Health Administration (VHA) Hospital Data. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-10-21.html. Accessed November 9, 2016.
2.
Nuti  SV, Qin  L, Rumsfeld  JS,  et al.  Association of admission to Veterans Affairs hospitals vs non–Veterans Affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia.  JAMA. 2016;315(6):582-592.PubMedGoogle ScholarCrossref
3.
O’Hanlon  C, Huang  C, Sloss  E,  et al.  Comparing VA and non-VA quality of care: a systematic review.  J Gen Intern Med. 2017;32(1):105-121.PubMedGoogle ScholarCrossref
4.
Government Accountability Office. High Risk: Managing Risks and Improving VA Health Care. 2015. http://www.gao.gov/highrisk/managing_risks_improving_va_health_care/why_did_study. Accessed January 30, 2016.
5.
Rajaram  R, Barnard  C, Bilimoria  KY.  Concerns about using the patient safety indicator-90 composite in pay-for-performance programs.  JAMA. 2015;313(9):897-898.PubMedGoogle ScholarCrossref
6.
Bilimoria  KY, Chung  J, Ju  MH,  et al.  Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure.  JAMA. 2013;310(14):1482-1489.PubMedGoogle ScholarCrossref
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