Journal of General Internal Medicine

, Volume 33, Issue 10, pp 1631–1638 | Cite as

Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings

  • Rebecca Anhang Price
  • Elizabeth M. Sloss
  • Matthew Cefalu
  • Carrie M. Farmer
  • Peter S. Hussey
Original Research



Congress, veterans’ groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.


To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.

Main Measures

We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.

Key Results

VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.


The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.


veterans Veterans Affairs Veterans Health Administration quality 



The authors gratefully acknowledge Marc N. Elliott for his statistical consultation, Chris Chan and Mike Cui for their programming support, Zachary Predmore and Clare Stevens for their research assistance, and Susan Hosek, Terri Tanielian, and Robin Weinick for their managerial support and guidance.


This work was completed under a subcontract from The MITRE Corporation for the U.S. Department of Veterans Affairs at the request of the Veterans Access, Choice, and Accountability Act of 2014 Section 201. The report was prepared under Prime Contract No. HHS-M500-2012-00008I, Prime Task Order No. VA118A14F0373.

Role of the Sponsor

The funding organization had no role in the design or conduct of the study; the collection, analysis, or interpretation of the data; or the preparation or approval of the manuscript. VA had the opportunity to review the manuscript before submission, but submission for publication was not subject to VA approval.

The analyses upon which this publication is based were performed under a contract for the Department of Veterans Affairs. The content of this publication does not necessarily reflect the views or policies of the Department of Veterans Affairs nor does the mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

Author Contributions

Drs. Anhang Price and Sloss had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design; drafting of the manuscript: RAP, ES.

Acquisition of data; analysis and interpretation of data: RAP, ES, CC, MC.

Critical revision of the manuscript for important intellectual content: RAP, ES, PH, CF.

Administrative, technical, or material support: PH, CF.

Study supervision: RAP, ES, PH, CF.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Concerned Veterans for America. How to fix the VA health care system. Arlington, VA; 2015. Available at: Accessed February 21, 2018.
  2. 2.
    Rein L. Cancer patients died waiting for care at troubled veterans hospital, probe finds. Washington Post. 2015. Available at: Accessed February 21, 2018.
  3. 3.
    Asch S, Glassman P, Matula S, Trivedi A, Miake-Lye I, Shekelle PG. Comparison of Quality of Care in VA and Non-VA Settings: a Systematic Review. VA-ESP Project #05–226; 2010.Google Scholar
  4. 4.
    Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218–2227.CrossRefGoogle Scholar
  5. 5.
    Khuri SF, Daley J, Henderson WG. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg-Chicago. 2002;137(1):20–27.CrossRefGoogle Scholar
  6. 6.
    Matula SR, Trivedi AN, Miake-Lye I, Glassman PA, Shekelle P, Asch S. Comparisons of quality of surgical care between the US Department of Veterans Affairs and the private sector. J Am Coll Surg. 2010;211(6):823–832.CrossRefGoogle Scholar
  7. 7.
    Trivedi AN, Matula S, Miake-Lye I, Glassman PA, Shekelle P, Asch S. Systematic review: comparison of the quality of medical care in Veterans Affairs and non-Veterans Affairs settings. Med Care. 2011;49(1):76–88.CrossRefGoogle Scholar
  8. 8.
    O’Hanlon C, Huang C, Sloss E, et al. Comparing VA and non-VA quality of care: a systematic review. J Gen Intern Med. 2016.Google Scholar
  9. 9.
    Blay E Jr, Delancey JE, Hewitt DB, Chung JW, Bilimoria KY. Initial public reporting of quality at Veterans Affairs vs non-Veterans Affairs hospitals. JAMA Int Med. 2017;177(6):882–3.CrossRefGoogle Scholar
  10. 10.
    National Committee for Quality Assurance. The State of Health Care Quality 2014. 2014. Available at: Accessed February 21, 2018.
  11. 11.
    Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.Google Scholar
  12. 12.
    Agency for Healthcare Research and Quality. Patient safety indicators overview. 2015. Available at: Accessed February 21, 2018.
  13. 13.
    Centers for Medicare & Medicaid Services. Outcome measures (background). 2014. Available at: Accessed February 21, 2018.
  14. 14.
    Centers for Medicare & Medicaid Services. 2014 measures updates and specifications report hospital-level 30-day risk-standardized mortality measures. 2014. Available at: Accessed February 21, 2018.
  15. 15.
    Centers for Medicare & Medicaid Services. 2014 measures updates and specifications report hospital-level 30-day risk-standardized readmission measures. 2014. Available at: Accessed February 21, 2018.
  16. 16.
    Joint Commission. Performance measurement for hospitals. 2015. Available at: Accessed February 21, 2018.
  17. 17.
    U.S. Department of Veterans Affairs. VHA facility quality and safety report. 2013. Available at: Accessed February 21, 2018.
  18. 18.
    American Hospital Association. Annual survey database fiscal year 2014 documentation manual. 2014. Available at: Accessed February 21, 2018.
  19. 19.
    Lehrman WG, Elliott MN, Goldstein E, Beckett MK, Klein DJ, Giordano LA. Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care. Med Care Res Rev. 2010;67(1):38–55.CrossRefGoogle Scholar
  20. 20.
    Centers for Medicare & Medicaid Services. Frequently asked questions, hospital value-based purchasing program, Last Updated March 9, 2012. Available at: Accessed February 21, 2018.
  21. 21.
    Quigley DD, Elliott MN, Setodji CM, & Hays RD. Quantifying Magnitude of group-level differences in patient experiences with health care. Health Serv Res. CrossRefGoogle Scholar
  22. 22.
    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.CrossRefGoogle Scholar
  23. 23.
    Maier B, Wagner K, Behrens S, et al. Comparing routine administrative data with registry data for assessing quality of hospital care in patients with myocardial infarction using deterministic record linkage. BMC Health Serv Res. 2016;16, 605. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Tang PC, Ralston M, Arrigotti M F, Qureshi L, Graham J. Comparison of methodologies for calculating quality measures based on administrative data versus clinical data from an electronic health record system: implications for performance measures. J Am Med Inform Assoc: JAMIA. 2007;14(1), 10–15. doi: CrossRefPubMedGoogle Scholar
  25. 25.
    Baker DW, Chassin MR. Holding providers accountable for health care outcomes. Ann Intern Med. 2017;167:418–423.CrossRefGoogle Scholar
  26. 26.
    Joint Commission. Performance measurement for hospitals. 2015. Available at: Accessed February 21, 2018.

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Rebecca Anhang Price
    • 1
  • Elizabeth M. Sloss
    • 1
  • Matthew Cefalu
    • 2
  • Carrie M. Farmer
    • 3
  • Peter S. Hussey
    • 4
  1. 1.RAND CorporationArlingtonUSA
  2. 2.RAND CorporationSanta MonicaUSA
  3. 3.RAND CorporationPittsburghUSA
  4. 4.RAND CorporationBostonUSA

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