Deaths and complications after surgery decline at VA hospitals

Surgery patients in Veterans Affairs (VA) hospitals are much less likely to die or suffer postoperative complications today than they were 15 years ago, a U.S. study suggests.

Researchers examined data on more than 700,000 mostly male patients who had surgery at 143 VA hospitals nationwide from 1999 through 2014.

The proportion of patients who had major complications dropped from 10 percent to 7 percent during the study period. Among patients who did have major complications, the proportion that died as a result declined from 24 percent to 15 percent.

"Our data in many ways mirror trends that we find in the private sector as well," said lead study author Dr. Nader Massarweh, a researcher at Baylor College of Medicine and the Michael E. DeBakey VA Medical Center in Houston.

"Some of what we are seeing is probably the end result of underlying trends that have been occurring over time across all of healthcare relating to our ability to simply provide better care," Massarweh added by email.

At the VA in particular, surgical care may have also improved as a result of a quality initiative started in the 1990s to track surgical outcomes, identify problems and evaluate fixes, Massarweh said.

One focus of this effort was to minimize the potential for patients to die after complications develop following surgery, a situation known in the healthcare industry as "failure to rescue."

This might happen, for example, when a patient undergoes a colon operation, develops pneumonia after surgery, ends up in the intensive care unit on a ventilator and then dies, Massarweh said.

"Our goal is to minimize the number of patients who experience complications and in those who do to treat them as quickly and definitively as possible," Massarweh said. "This is one of the reasons failure to rescue has gained traction as measure of quality - it acknowledges that complications do occur, but that timely recognition and treatment are really the things we can control to minimize their impact on patients."

To assess how quality improvement efforts have influenced surgical outcomes at the VA, researchers analyzed data on patients having inpatient surgery or operations for vascular, spinal, orthopedic, neurological, thoracic, genital or urinary issues. They excluded cardiac surgeries from the analysis.

Overall, patients were about 64 years old on average and 96 percent were men.

During the entire study period, almost 98,000 patients (14 percent) had complications after surgery, and failure to rescue occurred for about 13,000 of them.

Roughly 67,000 patients (9.5 percent) had major complications during the study, and failure to rescue happened in about 12,000 cases.

The odds of postoperative death or failure to rescue were about 40 to 50 percent lower by the end of the study than at the start, researchers report in JAMA Surgery.

Researchers received funding for the study from the VA.

Limitations of the study include the lack of a comparison group of hospitals that didn't implement the VA's quality control initiative because it was done systemwide, the authors note. The findings also don't prove what caused any improvements in outcomes.

Researchers also lacked data on surgical volume, which can influence the outcome of quality improvement efforts because surgeons are thought to be better at procedures they do more frequently, the authors note.

The study doesn't examine access to care issues including long waits for appointments that have been raised at the VA in recent years.

"I think we have to separate out access and quality of care as the current paper does not specifically address surgical access," said Dr. Jason Johanning, cao-author of an accompanying editorial and researcher at the Nebraska Western Iowa VA Health System in Omaha.

"The paper does confirm once again that VA surgical outcomes are comparable to private sector data and that the VA's quality reporting which has been adopted and replicated in the private sector can provide a robust look at the quality of surgical programs in the nation's largest integrated healthcare system," Johanning said by email.