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Publication Briefs

Increased Access to VA-Paid Community Care Resulted in Shift in Location of Surgery but No Difference in Outcomes for Veterans

VA’s Veterans Choice Program (VCP) expanded access to healthcare in community settings outside VA for eligible Veterans, but little is known about the effect of VCP on access to surgery and post-operative outcomes. Since VCP was initiated, care coordination issues – often associated with adverse post-operative outcomes – have been reported. However, research findings on the association of VCP and post-operative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding. This retrospective, quasi-experimental study explored the healthcare use of Veterans undergoing either VA-provided or VA-paid surgery (i.e., community care) between October 1, 2014, to June 1, 2019, when VCP ended. [Patients were eligible for VCP if they lived 40 or more miles from the closest VA facility with primary care capabilities at the time of surgery.] Investigators identified 615,473 unique surgical procedures among 498,427 Veterans enrolled in VA healthcare who required surgery during the study period. Main outcomes included post-operative emergency department (ED) visits, inpatient readmissions, and mortality at 30 and 90 days.


  • Expanded access to VA healthcare resulted in a shift in the location of surgical procedures but had no measurable effect on surgical outcomes. Investigators found no difference in post-operative ED visits, inpatient readmissions, or mortality between VA-provided and VA-paid surgical procedures done in a community setting.
  • Patients who underwent VA-paid vs. VA-provided procedures were significantly more likely to be female (13% vs. 9%), younger than 65 (49% vs. 46%), and White (74% vs. 73%), and they had a significantly lower comorbidity burden.
  • Overall, 15% of the procedures were VA-paid (community care), and the proportion of VA-paid procedures varied by procedure type (e.g., spinal fusion and knee prosthesis had higher proportions of VA-paid care).


  • These results emphasize the importance of access to community care and help assuage concerns of worsened outcomes due to care fragmentation. However, study results are less applicable to some select procedures (i.e., transplant, gastric bypass, or transcatheter aortic valve replacement), and VA should continue to make these decisions on a case-by-case basis.


  • Due to heterogeneity in coding across data sources, investigators were unable to look at surgery-specific outcomes, thus selected three broad outcomes of readmissions, ED visits, and mortality.
  • While quasi-experimental, this study is still an observational study design.
  • While data sources included in this study likely represent most of the Veterans’ healthcare use, other sources of healthcare (i.e., private insurance) could not be accounted for.

This study was supported by HSR&D. Drs. Graham and Rose and Ms. Schoemaker are part of HSR&D’s Health Economics Resource Center (HERC).

Graham L, Schoemaker L, Rose L, et al. Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surgery. October 12, 2022; online ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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