Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review

Abstract

Background: The Veterans Health Administration (VA) serves Veterans in the nation's largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic.

Methods: We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps.

Results: Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed.

Discussion: VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

Keywords: VA; access; community care; cost; inpatient; outpatient; patient experience; quality; safety.

Figure 1

Literature flowchart.

Figure 2

Evidence map of VA vs. non-VA clinical quality/safety. Notes: Studies are listed on the vertical axis by their qualitative results (VA care is better than community care, VA care and community care are about equal, or results are mixed, and community care is better than VA care). Study quality is depicted by bubble size, with larger bubbles being studies of better quality and representativeness than studies depicted by smaller circles. The color of the bubble indicates the type of comparison: blue for studies comparing Veterans getting care from VA to Veterans getting VA-paid care in the community; orange for studies comparing Veterans getting care from VA and non-Veterans, or a general population, getting care in the community; and, yellow for studies comparing Veterans getting care from VA to Veterans getting care in the community not paid for by VA. Beside each circle is a brief annotation of the study topic, and inside the bubble is the year of publication (’18 = 2018,’19 = 2019, etc.).

Figure 3

Evidence map of VA vs. non-VA access, patient experience, and cost/efficiency. Notes: Studies are listed by domains of care of the outcomes they report by shape: diamonds for access; squares for patient experience; and triangles for cost/efficiency. Studies are also listed on the vertical axis by their qualitative results (VA care is better than community care, VA care and community care are about equal, or results are mixed, and community care is better than VA care). Study quality is depicted by bubble size, with larger bubbles being studies of better quality and representativeness than studies depicted by smaller circles. The color of the bubble indicates the type of comparison: blue for studies comparing Veterans getting care from VA to Veterans getting VA-paid care in the community; orange for studies comparing Veterans getting care from VA and non-Veterans, or a general population, getting care in the community; and, yellow for studies comparing Veterans getting care from VA to Veterans getting care in the community not paid for by VA. Beside each circle is a brief annotation of the study topic, and inside the bubble is the year of publication (’18 = 2018,’19 = 2019, etc.).