Study Identifies Gaps in Quality of Supportive VA Cancer Care for Veterans
The VA healthcare system strives to provide palliative care and hospice programs that address the needs of Veterans and their families. Recent studies found that VA provides at least equivalent cancer care compared to fee-for-service Medicare using the standard metrics of guideline-concordant treatment and survival. However, there is sparse data on supportive care for patients with advanced cancer in VA. Using VA data, this retrospective cohort study evaluated non-hospice supportive VA cancer care in a nationally representative sample of 719 Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008. Medical record abstraction from diagnosis for up to three years – or until death – was used to measure quality of care based on the Cancer Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST) quality indicators. The indicators used in this study covered three main domains: Pain, Non-Pain Symptoms (e.g., depression, vomiting, fatigue, dyspnea), and Information and Care Planning (e.g., discussion of prognosis, documentation of advance care planning).
- Overall, Veterans received only about half (49%) of recommended care as measured by ASSIST quality indicators.
- Gaps in quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals following intensive care unit (ICU) admission.
- Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
- Because this study's remote medical record retrieval system did not allow investigators to review actual advance directives, they relied upon clinical note documentation and possibly under-estimated quality in that area.
- Findings may have over-estimated VA performance if non-VA care affected it favorably (e.g., prognostic communication outside VA could facilitate transition to hospice within VA); however, most indicators (e.g., symptom-related) directly reflected processes at the point of care.
The ASSIST study used evidence-based, actionable metrics, and thus points the way directly to specific, system improvement strategies such as initiatives integrating oncology and palliative care and efforts to increase pain screening in outpatient oncology settings.
This study was funded by HSR&D (IIR 09-097). Drs. Walling, Tisnado, and Lorenz are part of the VA Greater Los Angeles Healthcare System. Dr. Asch is part of HSR&D's Center for Health Care Evaluation, Palo Alto, CA.
Walling A, Tisnado D, Asch S, et al. The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement. JAMA Internal Medicine December 9, 2013;173(22):2071-79.