3100 — The Good, the Bad, and the Ugly: The Quality of VA Cancer Pain Management
Tisnado D, Walling AM, Pantoja P, and Malin JM, COE Sepulveda; Asch SM, COE Palo Alto; Ettner SL, UCLA; Lorenz KA, COE Sepulveda;
The ASSIST Cancer Quality Indicator (QI) set includes 41 symptom and care planning indicators shown to be valid, reliable, and feasible in about 1000 patients at 3 VA and non-VA sites. We set out to comprehensively characterize the quality of VA cancer pain management.
We examined 9 QIs addressing pain and painful cancer complications in a national VA sample diagnosed with Stage IV colorectal, pancreatic, or lung cancer in 2008 according to the VA Comprehensive Cancer Registry. We evaluated care from diagnosis for 3 years or until death, including Veterans who lived >=30 days following diagnosis with >=1 hospitalization or >=2 VA facility outpatient visits to a VA facility during the study window.
Of 312 Veterans with advanced cancer, (31% colorectal, 31% pancreatic, 39% lung), most were older (mean age = 67) males (97%). A majority were White (67%), with 21% African-American, and 3% Latino. Of 1,052 eligible outpatient encounters and 284 inpatient days, pain screening occurred in 59% (outpatient) and 55% (inpatient) of events. When long-acting opioids were started, short-acting were used in 91% (inpatient) and 90% (outpatient) of events. Routine bowel prophylaxis with chronic opioids occurred in 51% (outpatient) and 71% (inpatient) of events. Pain follow-up occurred by the next encounter after 72% of events where pain was treated. Single vs. multiple fraction radiotherapy should have been considered in 23 evaluations of frail Veterans with bone metastasis, but none (0%) were offered it. In cases of spinal cord compression, 91% of events were managed with timely steroids, but only 72% were urgently imaged. In 50% of events, there was urgent evaluation for definitive management, and when that occurred 40% had documented follow-up.
We identified many important targets for improving Veteran quality of life and the quality of care of pain management, and of painful complications among Veterans with common advanced cancers.
Our study confirms the need for routine pain screening implementation, especially in specialty care, despite a decade-old VA national mandate, improved basic opioid practices, and opportunities for more timely management of spinal cord compression.