New Veteran Administration Study Positive on Physical Therapy Rehabilitation

A recent meta-analysis of Veterans' Administration (VA) care compared with non-VA care found the VA performed better on process measures but about the same on patient outcomes.

Rehabilitation fared well in the Systematic Review: Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings. One of the 36 studies that passed the final cut looked at rehabilitation outcomes and assessed 60 post-stroke patients, finding good outcomes:

"...Stroke patients receiving rehabilitation in VA settings were discharged with better functional outcomes..."

Limitations of the study reported in the media were the use of self-report measures of outcome, typically questionnaires or patient interview.

Many newer data indicate that reliability of self report is superior to more traditional "objective" data but older clinicians, some physicians, politicians and the lay public may have difficulty understanding why the Oswestry Disablement Index returns "harder" data than a lumbar x-ray in the assessment of lower back pain:

"PROs are often not included in routine clinical care or quality improvement activities because some clinicians believe that PROs are not "objective" measures or that they lack precision for measuring individual patients." - Darren DeWalt, MD

Another criticism was the age of the studies - most dated from the Clinton administration and one study was from 1991.

The VA performed well on process measures such as issuing the right medication at the right time to the right patient. The VA's performance on patient outcomes, however, was not so good:

"Studies that used accepted process of care measures and intermediate outcomes measures, such as control of blood pressure or hemoglobin A1c, for quality measurements almost always found VA performed better than non-VA comparison groups.

Studies looking at risk-adjusted outcomes generally have found no differences between VA and non-VA care, with some reports of better outcomes in VA and a few reports of worse outcomes in VA, compared to non-VA care."

The media seem perplexed by these results but most physical therapists will recognize that health care, as a determinant of health, accounts only for about 10% of the causes of death and disability:

Veteran's Administration outcomes are a hot topic right now because of their own public relations campaign over the last fifteen years promoting their investment in Electronic Medical Records (EMR) and automated Clinical Decision Support (CDS) technology.

This meta-analysis may be seen by some as a testimony to the effectiveness of that investment.

“This report is strong evidence of the advancements VA continues to make in improving health care over the past 15 years,” said Secretary of Veterans Affairs Eric K. Shinseki.

“The systems and quality-improvement measures VA actively uses are second to none, and the results speak for themselves.”

Some of the reasons proposed for the VA's superior performance in processes of care include the following:

• integration of health care settings
• use of performance measures with an accountability framework
• disease-management practices and electronic medical record or health information technology.