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Quality and Equity of Care in the Veterans Affairs Health-Care System and in Medicare Advantage Health Plans

Trivedi, Amal N. MD, MPH*,†; Grebla, Regina C. MGA, MPH*,†

doi: 10.1097/MLR.0b013e31820fb0f6
Original Articles

Background After an organizational transformation in the mid-1990s, the quality of care in the Veterans Affairs health-care system (VA) compared favorably with the quality of care in some private-sector settings. Whether this performance advantage has persisted, and also its relation to geographic and socioeconomic variations in care, is unknown.

Objective We compared the quality and equity of care for older adults in the VA with that delivered in Medicare Advantage (MA) health plans using the same performance measures.

Research Design Cross-sectional comparison.

Subjects A total of 293,554 observations from enrollees in 142 VA medical centers (VAMCs) and 5,768,573 observations from enrollees in 305 MA plans.

Measurements Adherence to quality measures assessing diabetes, cardiovascular, and cancer screening care from 2000 to 2007.

Results The VA outperformed MA plans on 10 of 11 quality measures in the initial study year, and on all 12 measures in the final year. In 2006 and 2007, adjusted differences between the VA and MA ranged from 4.3 percentage points (95% CI, 3.2-5.4) for cholesterol testing in coronary heart disease to 30.8 percentage points (95% CI, 28.1-33.5) for colorectal cancer screening. For 9 of 12 measures, socioeconomic disparities (defined as the difference in performance rates between persons in the highest and lowest quartiles of area-level income and education) were lower in the VA than in MA. Across all measures, the mean interquartile range of performance was 6.7 percentage points for VAMCs and 14.5 percentage points for MA plans.

Conclusions Among persons aged 65 years or older, the VA health-care system significantly outperformed private-sector MA plans and delivered care that was less variable by site, geographic region, and socioeconomic status.

Supplemental Digital Content is available in the text.

*Center on Systems, Outcomes & Quality in Chronic Disease & Disability, Providence VA Medical Center

Department of Community Health, Alpert Medical School of Brown University, Providence, RI

Reprints: Amal N. Trivedi, MD, MPH, Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908. E-mail:

Supported by a Career Development Award (CDA-2) from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research & Development (HSR&D) Service, and a Robert Wood Johnson Physician VA Faculty Scholar Award to Dr Trivedi. Resources and support were also provided by the Center on Systems, Outcomes & Quality in Chronic Disease & Rehabilitation, Research Enhancement Award Program (HSR&D REA 08-263).

The views expressed in this study are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Vincent Mor, Peter Friedmann, Donna Washington, Kenneth Kizer, Steven Wright, Peter Glassman, and Paul Shekelle received no financial compensation for their assistance.

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

© 2011 Lippincott Williams & Wilkins, Inc.