VA Makes Significant Improvements in Surgical Care for Veterans

BACKGROUND:
In FY2015 nearly 400,000 patients underwent an operation within VA – roughly 25% of which were inpatient cases. A hallmark of VA efforts to improve the quality of cardiac and non-cardiac surgical care is the VA Surgical Quality Improvement Program (VASQIP), which continuously collects clinically rich data from all VA institutions where major surgery is performed, including information on post-operative morbidity and mortality. This retrospective cohort study used VASQIP data to examine post-operative outcomes for 704,901 Veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from FY2000 through FY2014 at 143 VA hospitals. The analysis was restricted to these specialties because they accounted for 92% of the complications and 93% of the 30-day mortality events during the study period. For patients who underwent more than one operation within a 30-day interval, only the first procedure in that time period was used for analysis. The main outcomes were hospital-level 30-day morbidity (overall and major complications), mortality, and failure to rescue (FTR – defined as mortality after one or more post-operative complications). To delineate whether any observed trends were system-wide or explained by institution-level outcome variation, hospitals were stratified into quintiles of risk-adjusted mortality.

FINDINGS:

• Over the last 15 years, there have been decreases of 25%, 54%, and 41% in morbidity, mortality, and FTR (respectively), with an ~40%-50% decrease in the odds of post-operative adverse events over that time among Veterans undergoing surgery in VA facilities. Notably, these improvements have occurred VA-wide and not only at the best-performing VA hospitals.
• In all performance quintiles there were significant improvements in complication (21%-30% decrease), major complication (23-33% decrease), and failure to rescue rates (any complication – 29%-51% decrease; major complication – 28-48% decrease) over time.

IMPLICATIONS:

• Findings suggest VA has made notable and continuous gains in the quality of surgical care provided to its beneficiaries. VA continues to be an important source of healthcare in the U.S. and provides an invaluable service with an often overlooked societal benefit – one that may be difficult to recapitulate if Veterans' care were shifted to the private sector alone.

LIMITATIONS:

• Because VASQIP is a mandatory QI program for all VA hospitals, investigators did not have a contemporaneous group of control hospitals to allow an evaluation of underlying, unmeasured factors unrelated to VASQIP that might also explain the observed system-wide improvements.
• Due to the observational nature of this study, it is not possible to directly attribute the observed improvements in post-operative outcomes to VASQIP.
• Data are collected for a systematic sample (not all) of surgical cases performed within VA. Thus, investigators were unable to evaluate changes in surgical volume or how such changes influenced findings.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Drs. Massarweh and Kougias are part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Massarweh N, Kougias P, and Wilson M. Complications and Failure to Rescue after Inpatient Non-Cardiac Surgery in the Veterans Affairs Health System. JAMA Surgery. September 21, 2016;e-pub ahead of print.