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Management Brief No. 209

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Management eBriefs
Issue 209 February 2023

The report is a product of the VA/HSR Evidence Synthesis Program.

VA versus Non-VA Quality of Care: A Systematic Review

Takeaway: Regarding quality and safety, the great majority of studies found that VA care is as good as, or better than, care in the community.

Providing high-quality healthcare is a commitment VA makes to all Veterans. Comparisons of VA-delivered care to care delivered in non-VA settings are key to assessing the quality of VA care. Prior reviews comparing outcomes between VA and non-VA care included data gathered through 2014 – and found that VA care performed similarly to or better than non-VA care in most, but not all aspects of quality. Since then, concerns about access to care led to the Veteran Access, Choice, and Accountability (“Choice”) Act of 2014, which allowed some Veterans to seek medical care in the community. In 2018, this was followed by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act that further expanded eligibility for VA-reimbursed community care options. Expanding the potential for care delivered to Veterans and paid for by VA to community providers raised additional questions regarding comparing quality of care.

To address these questions, VA’s Evidence Synthesis Program (ESP) Center located at the VA Greater Los Angeles Healthcare System conducted a systematic review to compare quality and safety, access, patient experience, efficiency (cost), and equity between VA and non-VA care. PubMed was searched for relevant articles from January 1, 2015 through December 1, 2021. From 1,818 potentially relevant articles, investigators identified 47 studies: 18 studies focused on surgical care and 33 studies on non-surgical care. Four studies contributed data to both.

Summary of Findings

  • Quality and safety: The great majority of studies found that VA care is as good as, or better than, care in the community. This was the case for both surgical care and nonsurgical care - and for community care of Veterans and community care of non-Veterans.
  • Access, patient experience, and efficiency/cost: Studies were fewer in number and more mixed in results, but tended to favor VA care. Investigators did not identify any study that found that patient experience was better in community care.
  • The large majority of studies assessed quality and safety, followed by comparisons of access to care. Few studies assessed patient experience or cost/efficiency, and no studies were found that compared VA to non-VA care on equity.


In addition to the usual limitation of any systematic review, namely the quantity and quality of the original studies, an additional limitation is that the conditions and procedures for which comparisons have been published are only a small fraction of the care Veterans receive, therefore these results cannot be generalized to all kinds of care.

Implications for VA

How these findings might be used:

  • Comparisons of VA versus community care paid for by VA are critical to shaping decisions about the expansion of the program and determining whether sending Veterans out for care - in an effort to improve timeliness or convenience - comes at a cost in terms of clinical outcomes.
  • Some comparisons are useful for judging the potential advantages of VA’s national system of integrated care versus care delivery in less organized settings, i.e., delivery of preventive care and the management of chronic disease.

Future Research

No studies were identified that compared care for some conditions for which the MISSION act has resulted in increased community care, such as physical medicine and rehabilitation. Also, studies that report lower cost for purchased community care for some procedures (i.e., joint replacement, CABG) than the estimated cost for VA to deliver that care need more sophisticated analyses of what would happen if VA increased the purchase of community care. It would also greatly facilitate comparisons of VA care to non-VA care if non-VA care had the same degree of comprehensive performance data that are publicly available. Lastly, the investigators expect that comparing VA care with non-VA care is a moving target, and thus this topic needs regular updating of published studies to keep this review up to date.

Shekelle P, Maggard-Gibbons M, Blegen M, et al. VA versus Non-VA Quality of Care: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2022.

To view the full report, go to (Available on the intranet only. If you have VA network access, copy and paste the link into your browser.)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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