To the Editor: We thank Dr. Weeks for his thoughtful comments on our manuscript. Based on our review of the evidence in the published literature, we concluded that the VA often, but not always, performs better than or similarly to other systems of care with regard to safety and effectiveness. We did not conclude, or intend to imply, that we now know definitively that VA care overall is better than non-VA care, especially considering how few studies have been published on VA care with regard to the quality dimensions of timeliness, patient-centeredness, efficiency, and equity.

To address Dr. Weeks’ specific critique related to national versus non-national studies, we returned to our analysis and examined whether including only results from nationally representative studies would have changed our conclusions. We found that our conclusions would not change substantially (Table 1).

Table 1 Number of Studies Classified in Each Category According to Original Review’s Methodology
Full size table

We also disagree with Dr. Weeks’ assertion that the only relevant studies are those that measure a small set of risk-adjusted outcomes measures. Evaluations of process are critical to understanding quality of care and identifying actionable steps for providers.

Furthermore, we differ with Dr. Weeks regarding the relevance of three studies that he mentions: rates of decline of quality indicators were compared among VA and non-VA settings1; safety process measures such as infection prevention practices are critical components of quality2; and while the paper by Vaughan-Sarrazin could arguably have been excluded from this review because it compared VA-using and non-VA patients only on the non-VA care they received, omitting its finding does not change our core conclusions (Table 1).3 In addition, even if the VA is receiving “credit” for care provided by other systems, that such care is recorded in the VA’s record indicates that the process was measured, which is important.

We agree that there is geographic variation in the performance of the VA. We also agree that studies assessing the quality of all care that veterans receive, from both VA and non-VA providers, would be ideal. Similarly, we agree that studies that compare veterans who receive only VA care to veterans who receive only non-VA care over a longer period of observation would make a valuable contribution to understanding the quality of VA care. However, we are not aware of any such studies. Systematic reviews are limited to the available evidence.