The Cancer Quality ASSIST National Study evaluated the quality of supportive care (2008-11) using 41 process indicators that comprehensively assess HRQOL domains among a nationally representative cohort of Veterans with metastatic colorectal, pancreatic, and lung cancers diagnosed in 2008.
a. Describe veterans' overall quality of supportive cancer care
b .Evaluate the association of veterans' characteristics with the overall quality of supportive cancer care.
c. Evaluate the impact of VA palliative care services on the overall quality of supportive cancer care and healthcare use
We identified a sampling frame of 424 Veterans with pancreatic, 3,184 with lung, and 628 with colorectal cancers diagnosed in 2008 from the VA Comprehensive Cancer Registry (VA-CCR). We randomly sampled from each cancer type in equal proportions and confirmed eligibility on the basis of advanced stage and documentation that the Veteran was alive for greater than 30 days with more than one VA facility hospitalization greater than two days, or at least two VA encounters of any type (e.g., emergency room visit, outpatient visit).
a.The overall adherence to quality of supportive care measures in the VA was 49%, with better care for pain (69%) compared to non-pain symptoms (37%), and information and care planning (46%) domains.
b.Quality of information and care planning lagged among rural vs. urban Veterans, and there was a marginally non-significant trend for lower communication and care planning quality among non-white vs. white Veterans. The trend was notable among Hispanic Veterans although our sample of Hispanic Veterans was very small.
c.Veterans used inappropriate end-of-life care interventions at low rates compared to reported rates in Medicare. Lower rates of inappropriate end-of-life hospitalization were associated with improved early communication about goals for care in the month following a metastatic diagnosis
d.Palliative care and/or hospice referrals were made for 86% of eligible Veterans overall. In this national cohort, 43% of Veterans received at least one palliative care consultation. Average numbers of palliative care consultations per Veteran were 1.2 for those with lung or pancreatic cancer and 1.3 for those with colorectal cancer. The use of palliative care services was associated with a 6 percentage point improvement in overall quality and an 11 percentage point improved communication and care planning quality score vs. those Veterans who did not receive palliative consultations.
In summary, the VA National ASSIST Study found areas of moderate to good quality of care corresponding to previous policy emphases in VA (e.g., pain management), but heterogeneous supportive care quality overall, with many important targets for improvement. ASSIST suggests that early supportive intervention including palliative care is an important facilitator of better health-related quality of life (HRQOL), as well as more appropriate system resource use.
a.The National Quality Forum is issuing a call for additional measures in palliative care and based on the VA's support of this work and our findings, we expect to submit several of the most relevant measures, if not the measure set.
b.Dr. Lorenz will serve on the American Academy of Hospice and Palliative Medicine's technical panel for measures in 2013-2014 to represent the ASSIST measures.
c.VA currently lacks specific strategies and interventions for improving end of life communication to Hispanic and minority Veterans. A follow-up proposal to expand our analyses of these populations and to qualitatively develop a roadmap of intervention is underway.
d.The ASSIST measure for early communication in cancer is a candidate for routine cancer measurement in VA HPC program which is emphasizing the timing of palliative care consultation in FY 2014 in its programmatic measurement goals. .
- Walling AM, Tisnado D, Asch SM, Malin JM, Pantoja P, Dy SM, Ettner SL, Zisser AP, Schreibeis-Baum H, Lee M, Lorenz KA. The quality of supportive cancer care in the veterans affairs health system and targets for improvement. JAMA internal medicine. 2013 Dec 1; 173(22):2071-9.
- Tisando D, Walling AM, Pantoja P, Malin JL, Asch SM, Ettner SL, Lorenz KA. The Good, the Bad, and the Ugly: The Quality of VA Cancer Pain Management. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.