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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3100 — The Good, the Bad, and the Ugly: The Quality of VA Cancer Pain Management

Tisnado DWalling AMPantoja P, and Malin JM, COE Sepulveda; Asch SM, COE Palo Alto; Ettner SL, UCLA; Lorenz KA, COE Sepulveda;

Objectives:
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.

Methods:
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.

Results:
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.

Implications:
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.

Impacts:
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.


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