Community-Based Surgery and Postoperative Survival Among Veterans Affairs Enrollees

Importance: The Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018 greatly expanded Veterans Affairs (VA) enrollees' access to non-VA (community care) services. Since then, community-based utilization has increased substantially, but the quality of noncardiac surgical procedures has not been compared in VA and community care facilities. Objective: To compare surgical outcomes among veterans at VA vs community care facilities. Design, Setting, and Participants: This retrospective cohort study used adjusted restricted mean survival time (RMST) to compare survival at 30, 90, and 365 days after carotid endarterectomy (CEA), cholecystectomy (CCY), primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA) among VA enrollees at VA and community care facilities between October 1, 2019, and July 31, 2024. Follow-up was completed July 31, 2025. Exposure: CEA, CCY, THA, and TKA performed at VA vs community care settings. Main Outcomes and Measures: Adjusted RMST at 30, 90, and 365 days. Results: A total of 215 542 unique surgical procedures-87 653 in VA-based and 127 889 in community-based facilities-were observed. The mean (SD) age of patients was 65.6 (11.7) years; 191 958 procedures (89.1%) were performed in male patients, and 94 105 (43.7%) were performed in patients who lived in rural or highly rural areas. Actuarial mortality rates were meaningfully higher for community-based CEA (30 days, 1.6% vs 0.9%; 90 days, 3.0% vs 2.0%; and 365 days, 8.5% vs 6.3%) and CCY (30 days, 1.4% vs 0.5%; 90 days, 2.6% vs 1.0%; and 365 days, 5.7% vs 2.8%) but similar for TKA (30 days, 0.1% vs 0.2%; 90 days, 0.4% vs 0.3%; and 365 days, 1.3% vs 1.2%) and THA (30 days, 0.3% vs 0.2%; 90 days, 0.7% vs 0.5%; and 365 days, 2.0% vs 1.7%). After CEA in a VA setting, adjusted survival times at 30 days increased by 0.12 (95% CI, 0.04-0.21) days; at 90 days, by 0.82 (95% CI, 0.45-1.19) days; and at 365 days, by 7.11 (95% CI, 4.71-9.51) days. After CCY in a VA setting, adjusted survival times at 30 days increased by 0.14 (95% CI, 0.11-0.18) days; at 90 days, by 0.82 (95% CI, 0.67-0.96) days; and at 365 days, by 6.20 (95% CI, 5.33-7.06) days. After THA in a VA setting, adjusted survival at 30 days increased by 0.002 (95% CI, -0.02 to 0.02) days; at 90 days, by 0.07 (95% CI, -0.02 to 0.16) days; and at 365 days, by 0.44 (95% CI, -0.17 to 1.05) days. After TKA in a VA setting, adjusted survival at 30 days increased by 0.004 (95% CI, -0.01 to 0.01) days; at 90 days, by 0.01 (95% CI, -0.04 to 0.04) days; and at 365 days, by 0.31 (95% CI, -0.03 to 0.65) days. Conclusions and Relevance: In this cohort study, veterans who underwent surgery at community care vs VA facilities had significantly decreased survival times at 30, 90, and 365 days after CEA and CCY and similar survival times after THA and TKA. The reasons for these survival differences deserve further study.