Study evaluates veterans’ care

Even though U.S. war veterans living in Connecticut may suffer more severe illness when undergoing major vascular surgery, a new Yale School of Medicine study suggests that post-recovery, they are at no greater health risk than their civilian counterparts.

Researchers at the medical school, in conjunction with the Connecticut Veterans Administration, called into question the safety of vascular surgeries in high-risk populations. They found that patients in the VA have higher rates of co-morbidity, or diseases occurring in addition to the primary problem, but do not exhibit many complications during post surgical recovery. Such diseases include hypertension, diabetes, heart disease and renal disease.

Daniel Federman, a professor at the Medical School and a primary care physician for the VA Connecticut Healthcare System said patient cases in the VA are more difficult than others. Typically, co-morbidity correlates with a worse outcome for patients during surgical procedures, but this was not the case for VA patients undergoing carotid endarterectomy, a procedure commonly used as treatment for atherosclerosis, or the clogging of the arteries due to buildup of plaque along the arterial wall. CEA involves surgically removing the plaque from the carotid artery, the main artery in the neck that brings blood to the brain.

Surgery professor Alan Dardik, another of the study’s authors, said CEA is one of the most widely studied surgical procedures, second only to heart bypass. Researchers have come to know what is expected in this type of procedure and thus have a good basis of information with which to evaluate their findings.

“It is a common perception that veterans are sicker than non-veterans, especially for vascular problems,” Dardik said. “VA cases are harder — disease [is] tougher, more inflamed, more advanced.”

Federman said veterans may be more prone to post-traumatic stress disorder and depression and thus more likely to run into problems with smoking and drinking, leaving them more prone to both atherosclerosis and associated co-morbid diseases.

Federman also points to the stigma associated with care at the VA as a reason for the increased difficulty in their cases. He said that because of misconceptions about care at the VA, which in the past has been substandard, patients who have access to health insurance and other forms of health care avoid the service.

“People who utilize the VA, we believe, are sicker than a comparably matched cohort of patients outside the VA,” he said.

Despite the prevalence of co-morbid diseases in the veteran population, the outcomes of their surgeries were not statistically different from those of non-VA patients. It is still unclear whether this is the result of veterans’ resiliency or the technical skills of surgeons performing the procedures.

“It is an indication of the quality of care that’s provided in the VA, which is a very important factor for us to be demonstrating,” said Dr. Ronnie Rosenthal, chief of surgery at the VA hospital. “In the past, there have been some questions about how good care in the VA was. If we’re demonstrating that we get as good or better results in a patient group that’s sicker, it means that the quality of care is outstanding.”

Dardik said this research has a variety of implications for the treatment of VA patients and for the future of the system’s health care.

“It clearly implies that we need to intervene earlier in veterans, be aggressive in screening for carotid disease and continue to recruit excellent surgeons to the VA system who continue to achieve excellent results” Dardik said.

Primary care physicians in the VA already account for the increased complexity of VA patients by having longer appointment times than their colleagues in private practice, Federman said.

The underlying reasons why veterans present as sicker than non-veteran patients are still unknown. The scientists said more research is needed to understand the factors contributing to severity of illness, as well as the ways in which it can be handled. It may also lead to investigation of the prevalence of co-morbidity in surgical procedures other than CEA.

This particular study looked at 7,089 CEAs performed in 37 Connecticut hospitals over a period of five years. Data was obtained from the Connecticut VA and the Connecticut Hospital Association and was derived from internal data submitted to the Veterans Health Administration’s National Surgical Quality Improvement Program.

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