The impact of community care on spine surgical complexity and outcomes in the Veterans Health Administration

Abstract:Objective: To investigate the relationship between community care (CC) treatment, surgical complexity, and postoperative surgical outcomes in spine surgeries among Veterans. Data Sources and Study Setting: Veterans Health Administration (VHA) sample with data sourced from the Corporate Data Warehouse and CC claims. Study Design: To evaluate differences in VHA and CC spine surgical complexity and outcomes, we first characterized VHA patients with lumbar spinal stenosis (LSS) who received spine surgery in the VHA or CC. Then, we estimated adjusted naïve logistic regression models to calculate the effect of CC on the probability of having a complex spine surgery, 30-day readmission, 30-day complication, and 1-year reoperation. Finally, we estimated adjusted 2-stage models using an instrument for primary care provider's historical CC referral rates and imaging rates as a semi-parametric Newey correction for sample selection. Analytic Sample: LSS-diagnosed patients living ≤ 80 miles from a VHA facility that performed at least one spine surgery between January 1, 2019 and December 31, 2022. Principal Findings: Of the 41,726 LSS-diagnosed patients, 7496 (18.0%) had spine surgery within 1 year of diagnosis. 2920 (39.0%) were VHA surgeries and 4576 (61.0%) were in CC. In the naïve model, CC surgery was associated with a 26.61 percentage point (pp) increase in the probability of having a complex surgery (95% CI 24.17, 29.05), a 4.31pp increase in readmission (95% CI 2.76, 5.85), and a 6.80pp increase in reoperation (95% CI 5.21, 8.40). After accounting for characteristics associated with the likelihood of surgery, CC, and outcomes, only the effect of CC use on the probability of a complex surgery was significant (36.48; 95% CI 22.69, 50.27). Conclusions: We found no difference in surgical outcomes between VHA and CC patients. Since CC patients were more likely to receive complex spine surgeries, the VHA paid for more costly, resource-intensive procedures with no improvements in quality.