The president’s 2013§ budget included more than $53.3 billion for the Veterans Health Administration (VHA)1; this outlay constituted nearly 40 percent of the Department of Veterans Affairs (VA) budget. The VHA houses what is considered to be the largest integrated health care system in the United States, serving 8.8 million veteransλ in 2012.2 The VA health care facilities include 152 hospitals and 827 community-based outpatient clinics.3 An estimated 130 of the VA hospitals provide acute medical and surgical services, and these hospitals accounted for approximately 703,500 inpatient admissions in 2012.2 The VA assigned an inpatient surgical complexity level of “complex” (versus “intermediate” or “standard”) to more than half of its medical centers that perform surgery, indicating that they have special facilities, equipment and staff for difficult operations such as cardiac surgery and craniotomies.4
In comparison, HCA Healthcare (HCA) is the largest non-governmental health system in the United States with calendar year (CY) 2012 net revenues of more than $33 billion. At the end of CY 2012, HCA comprised 162 hospitals and 112 freestanding surgery centers. Interestingly, the HCA hospitals reported 1,740,700 admissions in CY 2012, almost 2.5 times the number in 2012 for the VA medical centers.5
Despite the resources within the VA health system, most veterans do not use VA health care service providers. According to the 2001 National Survey of Veterans, more than three-fourths (76.6 percent) received care exclusively from non-VA service providers compared to 7.4 percent who relied exclusively on the VA and 16 percent who relied on both.6 A similar survey in 2010 reported that 71.6 percent of veterans had never used VA health care benefits and 58.1 percent of those not using the VA benefits agreed with the statement, “I would only use VA if I did not have access to any other source of health care.” Additionally, only 16.2 percent of the veterans indicated they would use VA health care in the future as their “primary source of health care.”7
Veterans 65 years and older also relied primarily on non-VA facilities for surgical care. A 2009 Congressional Budget Office (CBO) paper reported that in 2005, 87 percent of these elderly veterans used only non-VA facilities for inpatient surgical care and 13 percent used only VA providers; less than 1 percent used both VA and non-VA facilities. For outpatient surgery, 73 percent used non-VA providers, 19 percent used VA only and 8 percent used both.8
Several studies have found that veterans who use the VA health system were substantially more likely to have poor health status and multiple morbidities than found in the general population; and these differences are especially significant among the oldest veterans.9-12 Some of the most prevalent conditions among veterans are hypertension, angina, diabetes, chronic lung disease, depression and alcohol-related problems. These conditions subject the patient to increased risk of complications and pose significant challenges for the anesthesiologist throughout the perioperative period.
VA Quality Initiatives, Data and Research Opportunities
As noted by the CBO, “Two decades ago, VHA had a poor reputation for quality. Beginning in the mid-1990s …VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients.”8 One of many VHA quality initiatives was the National Surgical Quality Improvement Program (NSQIP).8 From this beginning in VA hospitals, the program was piloted in non-VA hospitals in 1999. In 2001, the American College of Surgeons (ACS) launched a program funded by the Agency for Healthcare Research and Quality to demonstrate that the NSQIP also reduced morbidity and mortality in private sector hospitals. In 2004, ACS began enrolling additional private sector hospitals into what is now known as ACS NSQIP®.13 Today, the VA program is referred to as VASQIP. There are hundreds of peer-reviewed health services research publications using ACS NSQIP® and VASQIP data.
Implementing VASQIP was facilitated by the VA’s comprehensive electronic medical record (EMR) infrastructure called VistA (Veterans Health Information Systems & Technology Architecture). VistA’s origin traces back to 1969 with the first clinical computer use in the VA. Its development was accelerated in 1982 when Congress endorsed development of a VA patient computer system.14 It incorporates extensive administrative and clinical capabilities to facilitate, track and monitor patient care. Many of the VA hospitals have implemented anesthesia information management systems (AIMS) as part of VistA, from a small number of approved vendors. All VA hospitals are expected to have fully electronic records within the next few years.
By the mid-2000s, the VA’s EMR system was widely praised for its crucial role in substantially improving the quality of patient care throughout the VA.15 Although some in the health information technology arena are concerned that development of the VA’s EMR has stagnated in the last 15-20 years,16 the VA is generally regarded as a high-performing health system.17
The VA health system also employs a comprehensive Decision Support System, an activity-based cost-allocation system that generates estimates of the cost of health care services provided within VA hospitals.18 The combination of robust clinical and administrative data offers unique research opportunities relevant to anesthesiology and surgical specialties and health services research at large. For example, in a study of 2006 inpatient surgeries at VA hospitals, researchers found that 20 percent of patients developed postoperative surgical complications, and the presence of any complication significantly increased unadjusted costs. After adjusting for differences in patient severity, costs for patients with any complication were 1.89 times greater compared to costs for patients with no complications. Adjusted costs were significantly greater for patients with respiratory, cardiac, central nervous system, urinary, wound or other complications.19
Other studies within VA hospitals provide evidence that perioperative team training and coordinated care may reduce surgical mortality and morbidity.20-21 Although these retrospective studies are not conclusive, they demonstrate “provocative and clinically relevant results”22 and suggest that initiatives such as the Perioperative Surgical Home (PSH) envisioned by ASA may be especially beneficial within the VA health care system.
The VA’s robust data motivate many research questions; however, the VA has strict privacy and security requirements for its data. In general, only VA employees (including researchers at academic centers with part-time appointments at a local VA hospital) can request and access the EMR and Decision Support System data, and the data must remain on the VA’s computer servers.¥ Even the VA’s AIMS data are restricted in use. The VA will not allow the transfer of individual case data to the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry, although VA anesthesia leaders have agreed to follow similar outcome definitions and exchange benchmarking data at the national level.
Through the VA’s Health Services Research & Development Service (HSR&D)23 and other researchers aligned with VA medical centers, there has been substantial health services and policy research focused on the VA health system. The HSR&D alone has funded more than 1,300 studies. Unfortunately, none of these has the word “anesthesia” or “anesthesiology” in its title.24 Even a PubMed search of anesthesia-related articles based on VA health system data produces only a handful of relevant references. Although the current HSR&D priorities for investigator-initiated research do not include perioperative care, researchers are encouraged to submit proposals that address potential quality improvements in the medical services for veterans.25
The VA health care system and affiliated researchers have access to robust clinical and administrative data for an important and relatively vulnerable population of veterans. In general, little anesthesia-related health services and policy research has been conducted with these data. In addition, there has been limited qualitative and primary research relevant to anesthesiology undertaken in VA medical centers.
Anesthesiologists and other researchers interested in health services and health policy research should reach out and collaborate with VA researchers to submit grant applications and conduct studies on anesthesia and perioperative services within VA medical centers.
The proposed research should include retrospective studies using the robust clinical and administrative data within VA hospitals and primary and qualitative research on key aspects of perioperative practices and outcomes.
Anesthesiologists who work within VA hospitals should be proactive in leading development of PSH-like initiatives and in publishing the results.
Thomas R. Miller, Ph.D., M.B.A.is ASA Director of Health Policy Research.
Nick Halzack, M.P.H. is ASA Health Policy Research Analyst.
1. Panangala SV. Veterans’ Medical Care: FY 2013 Appropriations (R42518). Washington, DC: Congressional Research Service; June 13, 2013.
2. Selected Veterans Health Administration characteristics: FY2002 to FY2012. U.S. Department of Veterans Affairs website. http://www.va.gov/vetdata/docs/Utilization/VHAStats.xls. Accessed October 9, 2013.
3. National Center for Veterans Analysis and Statistics. U.S. Department of Veterans Affairs website. http://www.va.gov/vetdata/. Accessed October 9, 2013.
4. VA Medical Centers designated for surgical complexity. U.S. Department of Veterans Affairs website. http://www.patientcare.va.gov/20100518a1.asp. Accessed October 9, 2013.
5. SEC Filings: 10-K, HCA Holdings, Inc., page 17, 60. HCA: Hospital Corporation of America website. http://phx.corporate-ir.net/phoenix.zhtml?c=63489&p=irol-sec&control_selectgroup=Annual%20Filings. Document date December 31, 2012. Accessed October 9, 2013.
6. 2001 National Survey of Veterans (NSV): Final Report. Washington, DC: National Center for Veterans Analysis and Statistics; 2001.
7. Westat. National Survey of Veterans, Active Duty Service Members, Demobilized National Guard and Reserve Members, Family Members, and Surviving Spouses: Final Report. Washington, DC: U.S. Department of Veterans Affairs; October 18, 2010.
8. Quality Initiatives Undertaken by the Veterans Health Administration. Washington, DC: Congressional Budget Office; August, 2009:2-3.
9. Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998;158(6):626-632.
10. Kramarow EA, Pastor PN. The health of male veterans and nonveterans aged 25-64: United States, 2007-2010. NCHS Data Brief. August, 2012;(101):1-8.
11. Selim AJ, Berlowitz DR, Fincke G, et al. The health status of elderly veteran enrollees in the Veterans Health Administration. J Am Geriatr Soc. 2004;52(8):1271-1276.
12. Wilmoth JM, London AS, Parker WM. Military service and men’s health trajectories in later life. J Gerontol B Psychol Sci Soc Sci. 2010;65(6):744-755.
13. NSQIP history. American College of Surgeons website. http://site.acsnsqip.org/programspecifics/nsqip-history/. Accessed October 9, 2013.
14. Eisen S. VA EMR: VistA [presentation slides]. National Committee on Vital and Health Statistics website. http://ncvhs.hhs.gov/070619p5.pdf. Accessed October 9, 2013.
15. Sao D, Gupta A, Gantz DA. Interoperable electronic health care record: a case for adoption of a national standard to stem the ongoing health care crisis. J Leg Med. 2013;34(1):55-90.
16. Trotter F. OSEHRA and the future of VA VistA. O’Reilly Radar website. http://radar.oreilly.com/2011/10/osehra-and-the-future-of-va-vi.html. Accessed October 9, 2013.
17. Klein S. The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nation’s Largest Integrated Delivery System. New York: The Commonwealth Fund; September, 2011.
18. Decision support system (DSS). U.S. Department of Veterans Affairs website. http://www.herc.research.va.gov/data/dss.asp. Accessed October 9, 2013.
19. Vaughan-Sarrazin M, Bayman L, Rosenthal G, Henderson W, Hendricks A, Cullen JJ. The business case for the reduction of surgical complications in VA hospitals. Surgery. 2011;149(4):474-483.
20. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700.
21. Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368-1373.
22. Pawlik TM, Urbach DR, Halverson AL; Evidence-Based Reviews in Surgery Group. Is there an association between implementation of a medical team training program and surgical mortality? Can J Surg. 2013;56(1):65-68.
23. VA HSR&D centers. U.S. Department of Veterans Affairs website. http://www.hsrd.research.va.gov/centers/#.UlH2aqzD_cc. Accessed October 9, 2013.
24. HSR&D research studies and implementation projects. U.S. Department of Veterans Affairs website. http://www.hsrd.research.va.gov/research/default.cfm#.UlIY143D_cc. Accessed October 9, 2013.
25. Program announcement: HSR&D priorities for investigator-initiated research. U.S. Department of Veterans Affairs. http://www.research.va.gov/funding/solicitations/docs/hsrd-iir-priorities.pdf. Updated September 29, 2010. Accessed October 9, 2013.
§ Unless otherwise specified, all years refer to the federal fiscal year ending September 30.
λ Includes a small number of non-veteran patients.
¥ There are possible exceptions to this policy.
If you have any questions about Health Policy Research, available information or activities within the department, please visit our webpages on the ASA website or send an email to ask.HPR@asahq.org.