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Date of this Version



Journal of the American College of Surgeons, Volume 211, Issue 6, December 2010, Pages 823-832; doi:10.1016/j.jamcollsurg.2010.09.001


The Department of Veterans Affairs (VA) is the largest integrated health system in the United States. Since its establishment in 1930, the VA has provided medical and surgical care to veterans of US military service. VA services are provided primarily by salaried federal employees working in government-operated facilities.

By the 1990s, the VA had developed a negative reputation, with widespread concerns about poor quality of care and systematic inefficiencies.1-3 An overhaul of the organization took place in the mid-1990s to improve both clinical care and the greater VA health system.With regard to quality of surgical care in the VA, changes began as early as 1986, when Congress passed Public Law 99-166 mandating that the VA compare its postoperative morbidity and mortality rates with the national average. Efforts to fulfill this mandate led to the establishment of the National SurgicalQuality Improvement Program (VA NSQIP) in 1994, a comprehensive program based on prospective data collection that provides hospital systems with reports of theirrisk adjusted outcomes, benchmark data, and consultation services in an effort to inform and empower local quality improvement initiatives. The VA NSQIP has been attributed with substantial reductions in postoperative morbidity and mortality. In 2001, the American College of Surgeons (ACS) partnered with the VA on the Patient Safety in Surgery Study, which ultimately led to development of the ACS NSQIP for private-sector hospitals.

Despite the profound organizational transformation that began in the VA in the 1990s, it remains unclear where the VA is in the spectrum of care currently available in the United States.During the past 2 decades, reports in the peer-reviewed literature and in the lay press have continued to provide both favorable and unfavorable perspectives on the quality of VA care. In order to gain a better understanding of the evidence, we performed a systematic review of studies that compared the quality of surgical care provided by the VA with that provided by relevant non-VA health care facilities and systems.


Data sources/study selection

We completed aMedline search of published studies between January 1990 and August 2009 using the following search terms: hospitals, veterans, hospitals, veterans/standards, hospitals, veterans/statistics and numerical data, united states department of veterans affairs, united states department of veterans affairs/ standards, united states department of veterans affairs/statistics and numerical data, and united states department of veterans affairs/utilization. Because of the focus on US health care, we searchedMedline only.

We included articles that presented a comparison of quality of care for surgical conditions in VA and US non-VA settings. Quality of care was defined using the standard Donabedian framework of quality (ie, structure, process, and outcomes)12; studies focusing solely on patient satisfactionwere excluded.A bibliographic search performed on all included articles identified additional studies.

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