VA delivers high quality services for veterans
BY GALE TANG, MD, AND JASON JOHANNING, MD
Vascular surgery in the Veterans Health Administration has always been a robust service, developing into a mature specialty around the time of the Vietnam conflict. Over the years, many have called into question the quality of care within the Veterans Affairs (VA) system, even while multiple studies have recognized equivalent or better care than in the general community. And this is despite the high level of chronic conditions experienced by our veteran population.1,2 This review highlights the history of high-quality vascular surgery services delivered for common procedures in the VA system.
Peripheral arterial disease
We can assess the veteran with regards to comorbidities, medical management and outcomes compared to the community. In a comprehensive review of the epidemiology of peripheral arterial disease (PAD) in the VA, Willey et al found that compared with other non-VA studies, VA PAD patients were older (mean age: 70 years), predominantly white (68%), and male (98%), which reflects the general demographics of the veteran population.3 In the studied VA cohort, 1.3% developed chronic limb-threatening ischemia (CLTI) at one year, increasing to 2.5% at a median follow-up of 3.8 years. This is markedly higher than Medicare patients, for which the mean annual incidence of CLTI was 0.35%.4 For medical therapy, overall statin use was present in 60.8% of patients, with a high-intensity statin rate of 34.9% within the VA setting, comparing favorably to the National Health and Nutrition Examination Survey with a rate of 30.5%.
The overall rate of revascularization in the VA was low at less than 3%, while community studies suggest an exponential increase in the use of endovascular revascularization, especially endovascular stenting.5 This raises concerns about underutilization of this therapy in the VA setting; but despite the low rate of revascularization in this cohort, the overall amputation rate was 1.1%. Comparing community amputation rates is difficult due to methodology issues regarding major vs. minor amputations.
Perhaps the most studied surgical procedure in the medical literature, carotid revascularization lends itself to direct outcomes that can ensure quality vascular surgical care. Giants in our field authored “Efficacy of carotid endarterectomy [CEA] for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group” to provide a solid footing for recent studies documenting clinical equipoise with the private sector.6 Recent studies have demonstrated that both short- and long-term outcomes for carotid revascularization, primarily carotid endarterectomy, is equal to if not better than Medicare patients undergoing similar procedures.7,8
Abdominal aortic aneurysms
In contrast to CEA, the treatment of abdominal aortic aneurysms (AAAs) and performance of randomized trials do not occur with routine vigor. Performance of open vs. endovascular clinical trials have only occurred in public healthcare systems, both in the U.K. and the U.S. Just look at the results of the EVAR 1 (United Kingdom endovascular aneurysm repair 1) and DREAM (Dutch randomized endovascular aneurysm management) trials to assess quality of AAA repair in the VA. In the EVAR 1 trial, the 30-day operative mortality was 1.8% in the endovascular and 4.3% in the open repair groups. In the DREAM trial, the operative mortality rate was 4.6% in the open repair group and 1.2% for endovascular repair.9,10 With results similar to the other trials, operative mortality was lower with endovascular repair at 30 days compared to open repair but the mortality rate of veterans was markedly less in the endovascular group at 0.5%. A 3% reduction in open mortality was noted compared with other trials.11 The OVER (Open versus endovascular repair) trial is an example of research and clinical outcomes for veterans with AAAs to acknowledge the quality present within the VA system. The VA vascular surgery community can be proud of the outcomes achieved in a challenging population. Direct comparison to the community in clinical trials and real-world data suggest veterans receive care that meets or exceeds community standards
- Comparing VA and Non-VA Quality of Care: A Systematic Review. O'Hanlon C, Huang C, Sloss E, Anhang Price R, Hussey P, Farmer C, Gidengil C; J Gen Intern Med. 2017 Jan;32(1):105-121. doi: 10.1007/s11606-016-3775-2. Epub 2016 Jul 15. PMID: 27422615
- Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings. Anhang Price R, Sloss EM, Cefalu M, Farmer CM, Hussey PS; J Gen Intern Med. 2018 Oct;33(10):1631-1638. doi: 10.1007/s11606-018-4433-7. Epub 2018 Apr 25. PMID: 29696561
- Epidemiology of lower extremity peripheral artery disease in veterans. Willey J, Mentias A, Vaughan-Sarrazin M, McCoy K, Rosenthal G, Girotra S.J Vasc Surg. 2018 Aug;68(2):527-535.e5. doi: 10.1016/j.jvs.2017.11.083. Epub 2018 Mar 24. PMID: 29588132
- Nehler MR, Duval S, Diao L, Annex BH, Hiatt WR, Rogers K, et al. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg 2014;60:686–95.e2.
- Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovas- cular interventions, and major amputations. J Vasc Surg 2009;50:54–60
- Hobson RW 2nd, Weiss DG, Fields WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med. 1993;328(4):221-227. doi:10.1056/NEJM199301283280401
- Keyhani S, Madden E, Cheng EM, et al. Risk Prediction Tools to Improve Patient Selection for Carotid Endarterectomy Among Patients With Asymptomatic Carotid Stenosis. JAMA Surg. 2019;154(4):336-344. doi:10.1001/jamasurg.2018.5119
- Rothenberg KA, Arya S. Appropriateness of Carotid Endarterectomy in Asymptomatic Carotid Disease-Predicting 5-Year Survival. JAMA Surg. 2019;154(4):345. doi:10.1001/jamasurg.2018.5126
- United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362(20):1863-1871. doi:10.1056/NEJMoa0909305
- Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351(16):1607-1618. doi:10.1056/NEJMoa042002
- Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302(14):1535-1542. doi:10.1001/jama.2009.1426