IIR 03-196
Quality and Costs of Colon Cancer Care in VA and Medicare
Denise M. Hynes, PhD MPH RN Edward Hines Jr. VA Hospital, Hines, IL Hines, IL Funding Period: April 2004 - September 2010 Portfolio Assignment: Quality Measurement Development |
BACKGROUND/RATIONALE:
Many VA patients use more than one healthcare system. Dual VA-Medicare use among cancer patients may lead to service redundancy, delays in care, and lack of care coordination, which may have deleterious effects on outcomes and costs of care. OBJECTIVE(S): This observational study examines the quality and cost of colon cancer care among Veterans treated in the two largest healthcare systems in the United States: VA and Medicare. Specific aims were to: 1. Assess and compare structure and process of colon cancer surgical and adjuvant treatment patterns; 2. Characterize and compare healthcare quality, use and costs for colon cancer care; 3. Examine factors that explain healthcare system choice, delays in colon cancer initial surgical and adjuvant treatment, healthcare use, and costs; and 4. Evaluate and compare survival rates for colon cancer patients treated predominantly in the VA compared to those treated outside the VA, controlling for stage and treatment regimen. METHODS: This study employs a retrospective cohort of incident Stage I-IV colon cancer patients diagnosed 1999-2001, at least 66 years old and eligible to use both VA and Medicare services. The cohort includes 3,949 Veterans diagnosed either in the VA (1,987), or outside the VA and reported to one of 8 NCI regional tumor registries (1,962). The study links multiple VA and non-VA data sources, including VA workload and pharmacy data, Medicare claims, and tumor registry records, for measurement of healthcare quality and costs. FINDINGS/RESULTS: Our cohort is 97% male and 16% African American. At diagnosis, 27%, 31%, 23%, and 19% are stage I - IV disease, respectively. Twenty-eight percent died within 12 months of diagnosis. Forty-eight percent of the cohort receives their cancer care predominantly from the VA, 36% predominantly from Medicare and 13% use both systems for substantial portions of their cancer care. Odds of receiving cancer-directed surgery and chemotherapy are similar in both systems. However, compared to patients aged 66-72 years old, the adjusted likelihood of receiving adjuvant chemotherapy among those 73-78 years and 79 years and older is reduced by 34 percent (HR: 0.66, CI95%: 0.54 - 0.80) and 60 percent (HR: 0.40, CI95%: 0.31 - 0.50), respectively. African American patients are equally as likely as non-African Americans to receive adjuvant chemotherapy (HR: 0.88, CI95%: 0.67 - 1.16). Stage II patients outside the VA are over twice as likely as their VA counterparts to receive chemotherapy (IRR: 2.64, CI95%: 1.06 - 6.61), despite no convincing evidence of a survival benefit of chemotherapy for that group. Cox proportional hazards ratios for Stage II and III reveal that Stage I dual users are twice as likely to experience a cancer relapse/progression (HR: 2.01, CI95%: 1.40 - 2.87), even after adjustment for confounders. Of the 3842 cases for the cost analysis cohort, initial analyses suggest that dual users of Medicare and VA healthcare are more likely to incur greater healthcare costs. IMPACT: As policymakers consider ways to improve colon cancer care, and with renewed policy interest in the quality of cancer care across the VA and Medicare systems in particular, results to date from this study show that efforts to identify patients who are dual users may yield opportunities to coordinate care across providers/systems. Care coordination may lead to improved quality and reduced costs for cancer care. In addition, care coordination efforts across VA and Medicare providers may reduce use of treatments of uncertain benefits. However, any care coordination across VA and non-VA providers will also need to be balanced with patients' ability to choose their own providers and care options. We are sharing results with our clinical advisory committee, including VA Hematology/Oncology Service. We are also sharing our improved methodologies for comorbidity assessment and ascertainment of colon cancer care specific costs. External Links for this ProjectDimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Health Systems Science, Aging, Older Veterans' Health and Care
DRE: Epidemiology, Treatment - Observational Keywords: Cancer, Cost effectiveness, VA/non-VA comparisons MeSH Terms: none |