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Dual Use in Colon Cancer: What Have We Learned about Quality and Costs of Care?

Approximately 175,000 patients receive cancer care each year from the VA health care system. Among some Veterans, including those who live in urban areas with many health care options or who have a high comorbidity burden, dual use of VA and Medicare services is substantial. Several recent studies suggest that patients might receive different and possibly duplicative cancer-related services in the two settings.1

At the Center for Management of Complex Chronic Care based at the Hines VA Hospital, we have undertaken research on dual use of VA and Medicare in cancer. One study in particular focused on quality of care, survival, and costs in colon cancer (HSR&D IIR 03-196). The VA Information Resource Center (SDR-02-237) provided support for this study. We conducted a retrospective cohort study linking data from eight National Cancer Institute Surveillance, Epidemiology, End Result (SEER) programs and the VA Central Cancer Registry (VACCR) with VA and Medicare claims data on Veterans aged 66 or older with colon cancer. Forty eight percent of the cohort received their cancer care predominantly from the VA, 36 percent predominantly from Medicare, and 13 percent used both systems for substantial portions of their cancer care. Overall, we tracked care for 3,949 Veterans diagnosed with colon cancer through 2004 and examined surgery and chemotherapy use, survival, and costs.

In early work focused on colon cancer patients in California, we found similarities across those initially treated in VA settings compared to those initially treated in non- VA settings. However, we discovered that older patients were not receiving adjuvant chemotherapy at the recommended rate. The 601 Veterans with stage I to III colon cancer treated at VA and non-VA facilities experienced similar colectomy rates and stage III patients had similar odds of receiving adjuvant chemotherapy. In both settings, older patients had lower odds of receiving chemotherapy than their younger counterparts, even when race and comorbidity were considered. 2

We found differences in survival between predominantly dual users and predominantly single system users. When we compared 3-year overall and cancer event-free survival (OS, EFS) among patients with non-metastatic colon cancer who were dual users with those who were predominantly single system (VA or Medicare fee-for-service (FFS)) users, VA and non-VA users (all stages) had reduced hazard of dying compared to dual users. For EFS, we found similar stage I outcomes, whereas stage II and III VA users, but not non-VA users, had improved EFS. Improved survival among VA and non-VA users compared to dual users raises questions about coordination of care and unmet needs. 3

We found significantly higher mean colon cancer-related costs over the first year after diagnosis among those who were dual users compared to those who used predominantly VA services or Medicare services. The cost of care for dual users of colon cancer treatment in our study was 14 percent greater than the cost for predominantly VA users, and 18 percent greater than that of predominantly Medicare users. The higher costs for dual users than for single-system users could reflect higher rates of fragmented and duplicative care among dual users. Furthermore, our research indicated higher costs among patients who were African American, had more comorbidities, were older, or had more advanced-stage disease.

Although VA patients can be reassured that care is consistent with recommended guidelines, our findings signal potential concerns among patients with colon cancer who are dual users. In particular, efforts should be focused on exploring the apparent underuse of adjuvant chemotherapy among older Veterans with colon cancer. Greater understanding about the mechanisms of dual use is also important to determine causal and temporal relationships with subsequent health care use. Further research is recommended to understand the contribution of the possible causes of treatment variation: differences in unmeasured health status, patient preferences, physician communication or bias, and variations in provider or system quality. Research that seeks to explore and examine alternative care coordination options for cancer patients and that includes evaluation of VA and non-VA providers and consideration of mechanisms to facilitate improved care coordination across systems may offer potential avenues to achieve improved outcomes and costs.

  1. Keating, N.L. et al. "Quality of Care for Older Patients with Cancer in the Veterans Health Administration versus the Private Sector: a Cohort Study," Annals of Internal Medicine 2011; 154(11):727-36.
  2. Hynes, D.M. et al. "Surgery and Adjuvant Chemotherapy Use Among Veterans with Colon Cancer: Insights Using California SEER, Medicare and VA-linked Data," Journal of Clinical Oncology 2010; 28:1-9.
  3. Tarlov, E. et al. "Reduced Overall and Event-Free Survival Among Colon Cancer Patients Using Dual System Care," Cancer Epidemiology Biomarkers & Prevention 2012; published online October 11, 2012.

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