3085 — Quality of Non-Small Cell Lung Cancer (NSCLC) Care in the Veterans Health Administration (VHA)
Ryoo JJ (GLA VA, West Los Angeles), Kim B
(GLA VA, West Los Angeles), Ordin DL
(Office of Quality and Performance), Oishi SM
(GLA VA, Sepulveda), Asch SM
(GLA VA, West Los Angeles), Antonio AM
(GLA VA, West Los Angeles), He R
(GLA VA, West Los Angeles), Malin JL
(GLA VA, West Los Angeles)
Prior studies of primarily administrative data revealed areas of potential concern regarding quality of care for VHA NSCLC patients compared to non-VHA patients, including lower rates of curative resection, chemoradiation for stage III disease, and palliative chemotherapy for advanced disease. Our aim was to assess the proportion of VHA NSCLC patients who receive stage-appropriate, evidence-based treatment.
NSCLC patients diagnosed in 2007 (n = 4,369) were identified through the VA Central Cancer Registry (VACCR). Exclusion criteria included death or hospice within 30-days of diagnosis or enrollment in a clinical trial. Data were obtained from the VACCR and abstracted from patient medical records to calculate performance on quality indicators (QIs): (1) curative resection for Stage I/II disease; (2) adjuvant chemotherapy for Stage II/IIIA; (3) chemoradiation for Stage III; and (4) platinum-based chemotherapy for Stage IV. Criteria for meeting QIs included receipt of recommended care, medical record documentation of patient refusal, or documented reasons why specified care was not appropriate (e.g., severe comorbidity, poor performance status).
QI performance was as follows: Stage I/II curative resection = 98%; Stage II/IIIA adjuvant chemotherapy = 80%; unresected Stage III chemoradiotherapy = 88%; Stage IV platinum-based doublet chemotherapy = 96%. Patient refusals and documented reasons contraindicating specified care accounted for a significant proportion of patients meeting QI criteria. Among such Stage I/II patients, 7% refused surgery and 29% had a contraindication. Of Stage II/IIIA patients, 12% refused chemotherapy and 20% had a reason why it was not appropriate. Therapy was refused in 16% of Stage III patients; a contradiction to chemotherapy was documented in 20%, to radiotherapy in 15%. While only 2 (< 1%) Stage IV patients refused chemotherapy, 8% had a contraindication, and 23% had poor performance status.
VA performance on QIs for treatment of lung cancer is high, although a substantial proportion of patients do not receive treatment due to contraindications to recommended therapy or personal choice. Further investigations of patient and organizational influences on care are warranted.
Understanding the impact of treatment contraindications and patient preferences on receipt of recommended therapy is critical to ensuring Veterans receive high-quality, patient-centered care.