The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement

Abstract

IMPORTANCE Characterizing the quality of supportive cancer care can guide quality improvement. OBJECTIVE To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans. DESIGN, SETTING, AND PARTICIPANTS Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer. MAIN OUTCOMES AND MEASURES We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived Ն30 days following diagnosis with Ն1 Veterans Affairs hospitalization or Ն2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains. RESULTS Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single-vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option. CONCLUSIONS AND RELEVANCE These care gaps reflect important targets for improving the patient and family experience of cancer care.

Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

“…Quality metrics for palliative care have also been developed and implemented in the Veterans Health Administration, but require manual chart abstraction and may be challenging to scale to other healthcare systems. 19 In the search for feasible, reliable, and valid palliative care quality metrics, automated methods of using the electronic health record (EHR) are an attractive option. However, the EHR has often not delivered on its potential.…”

Variations in Oncologist Recommendations for Chemotherapy for Stage IV Lung Cancer: What Is the Role of Performance Status?

“…Prior work has raised significant questions about oncologists' communication with patients about the goals of chemotherapy and end-of-life decision making, 33,34 and other work has underscored the potential for devastating financial impact of cancer and its treatment. 35,36 Inadequate communication about the potential physical and financial harms of chemotherapy may contribute to patterns of recommendations consistent with those we observed in this study.…”

High-Value Palliative Care for Cancer Patients

“…For example, one recent retrospective cohort study of patients with advanced solid tumors diagnosed and followed at Veterans Affairs (VA) hospitals found that study patients only received appropriate nonhospice palliative care 49.5 percent of the time, even within a health delivery system into which palliative care is deeply penetrated and well integrated [30]. Further research clarifying the barriers to appropriate implementation of high-value palliative care in health systems is imperative so that sustainable programs can develop and flourish nationally.…”