Steven M. Asch, MD, MPH; Elizabeth A. McGlynn, PhD; Mary M. Hogan, PhD; Rodney A. Hayward, MD; Paul Shekelle, MD, MPH; Lisa Rubenstein, MD; Joan Keesey, BA; John Adams, PhD; Eve A. Kerr, MD, MPH
Acknowledgments: The authors acknowledge the invaluable contributions of Landon Donsbach, Alison DeCristofaro, Jennifer Hicks Curtis, Liisa Hiatt, Eureka Moline, Jill Baker, Peggy Wallace, Karen Ricci, Anne Griffin, Rena Hasenfeld Garland, and the Veterans Affairs site investigators.
Grant Support: This study was funded by a Veterans Affairs Health Services Research and Development grant. Drs. Asch and Kerr were funded by Veterans Affairs Health Services Research and Development Career Development Awards. The initial development of the indicators was funded by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality (grant no. 5U18HS09463-03). The California HealthCare Foundation (grant no. 98-5005) funded development of the chart abstraction tool. The Robert Wood Johnson Foundation (grant no. 0-0192) funded work with the national sample (design, sampling, and conduct).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Steven M. Asch, MD, MPH, West Los Angeles Veterans Affairs Medical Center, Mail Code 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073; e-mail, Steven.Asch@med.va.gov.
Current Author Addresses: Dr. Asch: West Los Angeles Veterans Affairs Medical Center, Mail Code 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073
Drs. McGlynn and Shekelle: RAND, 1776 Main Street m4s, Santa Monica, CA 90407.
Drs. Hogan, Hayward, and Kerr: Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research, PO Box 130170, Ann Arbor, MI 48113.
Drs. Rubenstein and Adams and Ms. Keesey: RAND, 1776 Main Street m3s, Santa Monica, CA 90407.
The Veterans Health Administration (VHA) has introduced an integrated electronic medical record, performance measurement, and other system changes directed at improving care. Recent comparisons with other delivery systems have been limited to a small set of indicators.
To compare the quality of VHA care with that of care in a national sample by using a comprehensive quality-of-care measure.
12 VHA health care systems and 12 communities.
596 VHA patients and 992 patients identified through random-digit dialing. All were men older than 35 years of age.
Between 1997 and 2000, quality was measured by using a chart-based quality instrument consisting of 348 indicators targeting 26 conditions. Results were adjusted for clustering, age, number of visits, and medical conditions.
Patients from the VHA scored significantly higher for adjusted overall quality (67% vs. 51%; difference, 16 percentage points [95% CI, 14 to 18 percentage points]), chronic disease care (72% vs. 59%; difference, 13 percentage points [CI, 10 to 17 percentage points]), and preventive care (64% vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute care. The VHA advantage was most prominent in processes targeted by VHA performance measurement (66% vs. 43%; difference, 23 percentage points [CI, 21 to 26 percentage points]) and least prominent in areas unrelated to VHA performance measurement (55% vs. 50%; difference, 5 percentage points [CI, 0 to 10 percentage points]).
Unmeasured residual differences in patient characteristics, a lower response rate in the national sample, and differences in documentation practices could have contributed to some of the observed differences.
Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.
Table 1. Conditions and Number of Indicators Used in Comparisons
Table 2. Example Indicators of Quality of Care
Table 3. Veterans Health Administration and National Sample Characteristics
Table 4. Adjusted Adherence to Indicators by Category
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Asch SM, McGlynn EA, Hogan MM, et al. Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample. Ann Intern Med. 2004;141:938–945. doi: 10.7326/0003-4819-141-12-200412210-00010
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Published: Ann Intern Med. 2004;141(12):938-945.
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