Systematic Review Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings

Background: The Veterans Health Administration, the nation's largest integrated delivery system, launched an organizational transformation in the mid 1990s to improve the quality of its care. Purpose: To synthesize the evidence comparing the quality of medical and other nonsurgical care in Veterans Affairs (VA) and non-VA settings. Data Sources: MEDLINE database and bibliographies of retrieved studies. Study Selection: Studies comparing the technical quality of nonsurgical care in VA and US non-VA settings published between 1990 and August 2009. Data Extraction: Two physicians independently reviewed 175 unique studies identified using the search strategy and abstracted data related to 6 domains of study quality. Data Synthesis: Thirty-six studies met the inclusion criteria. All 9 general comparative studies showed greater adherence to accepted processes of care or better health outcomes in the VA compared with care delivered outside the VA. Five studies of mortality following an acute coronary event found no clear survival differences between VA and non-VA settings. Three studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA, and 1 found lower use of clinically-appropriate angiography in the VA. Three studies of diabetes care processes demonstrated a performance advantage for the VA. Studies of hospital mortality found similar risk-adjusted mortality rates in VA and non-VA hospitals. Limitations: Most studies used decade-old data, assessed self-reported service use, or included only a few VA or non-VA sites. Conclusions: Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings.