{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T16:36:38Z","timestamp":1772987798840,"version":"3.50.1"},"reference-count":46,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2025,10,17]],"date-time":"2025-10-17T00:00:00Z","timestamp":1760659200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,10,17]],"date-time":"2025-10-17T00:00:00Z","timestamp":1760659200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100007181","name":"Quality Enhancement Research Initiative","doi-asserted-by":"publisher","award":["PEC 16\u2010001"],"award-info":[{"award-number":["PEC 16\u2010001"]}],"id":[{"id":"10.13039\/100007181","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Services Research"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To investigate the relationship between community care (CC) treatment, surgical complexity, and postoperative surgical outcomes in spine surgeries among Veterans.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources and Study Setting<\/jats:title>\n                    <jats:p>Veterans Health Administration (VHA) sample with data sourced from the Corporate Data Warehouse and CC claims.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design<\/jats:title>\n                    <jats:p>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 na\u00efve logistic regression models to calculate the effect of CC on the probability of having a complex spine surgery, 30\u2010day readmission, 30\u2010day complication, and 1\u2010year reoperation. Finally, we estimated adjusted 2\u2010stage models using an instrument for primary care provider's historical CC referral rates and imaging rates as a semi\u2010parametric Newey correction for sample selection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Analytic Sample<\/jats:title>\n                    <jats:p>LSS\u2010diagnosed patients living \u2264\u200980\u2009miles from a VHA facility that performed at least one spine surgery between January 1, 2019 and December 31, 2022.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal Findings<\/jats:title>\n                    <jats:p>Of the 41,726 LSS\u2010diagnosed patients, 7496 (18.0%) had spine surgery within 1\u2009year of diagnosis. 2920 (39.0%) were VHA surgeries and 4576 (61.0%) were in CC. In the na\u00efve 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 4.31\u2009pp increase in readmission (95% CI 2.76, 5.85), and a 6.80\u2009pp 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).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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\u2010intensive procedures with no improvements in quality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1475-6773.70057","type":"journal-article","created":{"date-parts":[[2025,10,17]],"date-time":"2025-10-17T12:00:11Z","timestamp":1760702411000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Impact of Community Care on Spine Surgical Complexity and Outcomes in the Veterans Health Administration"],"prefix":"10.1111","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-0307-3853","authenticated-orcid":false,"given":"Allison","family":"Dorneo","sequence":"first","affiliation":[{"name":"Department of Health Law, Policy &amp; Management Boston University School of Public Health Boston Massachusetts USA"},{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yi\u2010Jung","family":"Shen","sequence":"additional","affiliation":[{"name":"Department of Health Law, Policy &amp; Management Boston University School of Public Health Boston Massachusetts USA"},{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aigerim","family":"Kabdiyeva","sequence":"additional","affiliation":[{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8986-8575","authenticated-orcid":false,"given":"Daniel","family":"Asfaw","sequence":"additional","affiliation":[{"name":"Department of Health Law, Policy &amp; Management Boston University School of Public Health Boston Massachusetts USA"},{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8986-3536","authenticated-orcid":false,"given":"Melissa M.","family":"Garrido","sequence":"additional","affiliation":[{"name":"Department of Health Law, Policy &amp; Management Boston University School of Public Health Boston Massachusetts USA"},{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"},{"name":"Department of Surgery Brigham and Women's Hospital Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4908-5976","authenticated-orcid":false,"given":"Steven D.","family":"Pizer","sequence":"additional","affiliation":[{"name":"Department of Health Law, Policy &amp; Management Boston University School of Public Health Boston Massachusetts USA"},{"name":"Partnered Evidence\u2010Based Policy Resource Center (PEPReC) VA Boston Healthcare System Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jacob","family":"Rachlin","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery VA Boston Healthcare System West Roxbury Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hillary J.","family":"Mull","sequence":"additional","affiliation":[{"name":"Center for Health Optimization and Implementation Research (CHOIR), VA Boston Healthcare System Boston Massachusetts USA"},{"name":"Department of Surgery Boston University Chobanian &amp; Avedisian School of Medicine Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,10,17]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.h6234"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2022.5921"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.spinee.2009.03.005"},{"key":"e_1_2_10_5_1","unstructured":"P.Sinnott S. 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