ImportanceRecent legislation facilitates veterans’ ability to receive non–Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non–VA care settings are lacking.ObjectiveTo compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.Design, Setting, and ParticipantsThis coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.ExposuresSurgical care in VA or private-sector hospitals.Main Outcomes and MeasuresPostoperative 30-day mortality and failure to rescue (FTR).ResultsAmong 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.Conclusions and RelevanceAlthough women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

中文翻译：

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退伍军人事务部与非退伍军人事务部护理机构中接受非心脏手术的女性的结果比较

重要性 最近的立法提高了退伍军人接受非退伍军人事务部 (VA) 外科护理的能力。尽管退伍军人主要是男性，但在过去十年中，在 VA 内接受护理的女性人数几乎翻了一番，达到 10%，并且缺乏比较 VA 和非 VA 护理机构中女性手术护理的最新数据。设计、设置和参与者这项粗化的精确匹配队列研究涉及退伍军人事务部手术质量改进计划 (VASQIP) 和美国外科医生学会国家手术质量改进计划 (NSQIP) 中的 9 个非心脏专业）于2016年1月1日至2019年12月31日进行。具有稳健标准误的多变量泊松模型用于评估 VA 与私营部门护理机构与 30 天死亡率之间的关联。参与美国外科医师学会 NSQIP 和 VASQIP 的医院均包含在内。数据分析于 2023 年 1 月进行。参与者包括 18 岁或以上的女性患者。暴露在 VA 或私营医院的手术护理。主要结果和措施术后 30 天死亡率和抢救失败 (FTR)。结果分析了 1 913 033 例手术，VASQIP 患者更年轻（VASQIP：平均年龄，49.8 [SD，13.0] 岁；NSQIP：平均年龄，55.9 [SD，16.9] 岁；磷< .001），尽管两组中的大多数患者都是白人，但与 NSQIP 相比，VASQIP 中的黑人女性明显更多（29.6% vs 12.7%；磷< .001）。VASQIP 的平均风险分析指数得分 (13.9 [SD, 6.4]) 低于 NSQIP (16.3 [SD, 7.8]) (磷< .001 两者）。VA 患者更有可能出现术前急性严重病症（2.4% vs 1.8%：磷< .001），但 NSQIP 中的病例更常见（6.9% vs 2.6%；磷< .001）。VASQIP（n = 36 762 例手术）的 30 天死亡率、并发症和 FTR 分别为 0.2%、3.2% 和 0.1%，而 NSQIP（n = 1 876 271 例手术）的 30 天死亡率、并发症和 FTR 分别为 0.8%、5.0% 和 0.5% ）分别（所有磷< .001）。在 1 763 540 名匹配的女性中（VASQIP 中 n = 36 478 例手术；NSQIP 中 n = 1 727 062 例手术），这些比率在 NSQIP 中分别为 0.3%、3.7% 和 0.2%，在 NSQIP 中分别为 0.1%、3.4% 和 0.1%。 VASQIP（所有磷< .01）。相对于私营部门护理，VA 手术护理与较低的死亡风险相关（调整后风险比 [aRR]，0.41；95% CI，0.23-0.76）。这一发现在接受妇科手术、住院手术和低生理压力手术的女性中是强有力的。对于体弱或黑人女性以及住院和低生理应激手术，退伍军人事务部手术护理还与较低的 FTR 风险相关（aRR，0.41；95% CI，0.18-0.92）。结论和相关性尽管女性占退伍军人中接受护理的少数，但VA，在这项研究中，VA 对女性的手术护理与术后死亡和 FTR 风险的一半相关。退伍军人事务部似乎更有能力满足退伍军人独特的手术需求和风险状况，无论性别如何，包括资金在内的健康政策决策应反映这些重要的结果差异。