3047 — Degree of Cancer Care Coordination among Primary Care, Gastroenterology, and Oncology through Service Agreements

Haggstrom DA (Indianapolis COE), Doebbeling BN (Indianapolis COE), Yano EM (Sepulveda COE)

Objectives:
Colorectal cancer screening and the follow-up of abnormal results is a national priority per VHA Directive 2007-004. The VA Office of Quality and Performance estimates that veterans fail to receive timely diagnostic colonosocopy from 30-50% of the time. Little is known about the ongoing care of cancer patients after primary treatment in the VA. The VA Clinical Practice Organizational Survey (CPOS) conducted in 2006 measured practice arrangements related to performance in VA facilities. The objective of this study of service agreement implementation was to characterize the degree of care coordination among primary care, gastroenterology, and oncology.

Methods:
This national VA organizational survey queried VA chiefs of staff regarding service agreements between primary care and subspecialty services. 111 individuals participated (response rate, 86%). Service agreements were defined as “written contracts specifying patient types that should or should not be receiving screening vs. follow-up, should or should not be referred, regarding timelines of consults, and prioritization of cases.”

Results:
Nearly all VAMCs had fully or partially implemented service agreements “between primary care and gastroenterology clinics for coordinating colorectal cancer screening and follow-up”, while about one-third of VAMCs had developed service agreements “between primary care and oncology clinics after primary cancer treatment” (90.0% vs. 36.4%, p < 0.001). Furthermore, many more VAMCs had neither implemented nor planned any agreements between primary care and oncology vs. gastroenterology (34.5% vs. 1.8%, p < 0.001).

Implications:
Coordination between primary care and gastroenterology services for colorectal cancer screening and follow-up appear to have achieved an advanced stage of implementation. On the other hand, coordination between primary care and oncology services appear to be at a very early stage of implementation. These differences likely reflect the influence of the VA national directive and priorities.

Impacts:
Local VAMCs should consider how to promote the coordination of services after primary cancer treatment. This need is driven by the potential overlap of practice scope between primary care and oncology when caring for cancer survivors, and thus, the potential for redundant care and testing. National VA research and operations should consider what actions need to be taken to explore these gaps and develop the appropriate service delivery models.