Origins of the Veterans Health Administration Although health and social support for aged or disabled soldiers has existed in the United States since Colonial times, the spectrum of national programs for American veterans was consolidated with the establishment of the Veterans Administration in 1930. Resources for social services expanded rapidly following World War II with the Servicemen's Readjustment Act of 1944 (better known as the GI Bill of Rights), and a hospital system that specialized in meeting the rehabilitative needs of more than 1 million returning troops who had experienced physical and emotional trauma expanded and evolved. The Veterans Administration was elevated to Cabinet status and became the Department of Veterans Affairs in 1989, with financial support programs such as pensions administered under the aegis of the Veterans Benefits Administration and health services consolidated in the Veterans Health Administration (VHA). The Secretary of Veterans Affairs directs the activities of the department, and the Under Secretary for Health serves as the chief executive officer of VHA. Structural and Organizational Transformation Since 1995 Until the mid-1990s, the VA operated largely as a hospital system providing general medical and surgical services, specialized care in mental health and spinal cord
Until we can better understand what constitutes health and illness in all adult populations, we risk repeated occurrences of unexplained symptoms among veterans after each war.
ObjectiveTo determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. Summary Background DataThe Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. MethodsThe database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. ResultsTeaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. ConclusionCompared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality
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