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Original Investigation |

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

Anne M. Walling, MD, PhD1,2,3; Diana Tisnado, PhD1,2; Steven M. Asch, MD, MPH4,5; Jennifer M. Malin, MD, PhD1,6; Philip Pantoja, MA1; Sydney M. Dy, MD7; Susan L. Ettner, PhD1,8; Ann P. Zisser, RN1; Hannah Schreibeis-Baum, MPH1; Martin Lee, PhD1; Karl A. Lorenz, MD, MSHS1,2,3
[+] Author Affiliations
1VA Greater Los Angeles Healthcare System, Los Angeles, California
2Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles
3RAND Health, Santa Monica, California
4VA Palo Alto Healthcare System, Palo Alto, California
5Stanford University School of Medicine, Stanford, California
6Jonsson Comprehensive Cancer Center, University of California, Los Angeles
7Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
8Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles
JAMA Intern Med. 2013;173(22):2071-2079. doi:10.1001/jamainternmed.2013.10797.
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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 ≥30 days following diagnosis with ≥1 Veterans Affairs hospitalization or ≥2 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.

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