Quality of VA Care for Veterans with Newly Diagnosed Lung Cancer is Markedly Higher than Previous Studies Suggest
Lung cancer care provides an opportunity to understand the impact of patient refusals and contraindications on quality measurement, as population-based and largely administrative data-driven studies have consistently revealed that half of patients do not receive care that conforms to national guidelines. This study sought to determine the proportion of Veterans who did not receive evidence-based care who had a documented refusal or contraindication to recommended lung cancer therapy. Data for this study were obtained as part of a national evaluation of lung cancer quality of care conducted by VA in 2010. Through medical record abstraction, investigators evaluated adherence to six quality indicators addressing lung cancer-directed therapy for Veterans (n=3,927) newly diagnosed within the VA healthcare system during 2007. For each quality indicator, Veterans were categorized as receiving specified care, refusing it, having a contraindication to it, or not receiving it in the absence of documented reasons. Investigators also evaluated variables including patient demographics, extent of the disease, and medical oncology consultation within 9 months of diagnosis.
- When accounting for refusals and contraindications, this study found that quality of care for newly diagnosed lung cancer was markedly higher than previous studies suggested. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy in resected stage II/III non-small cell lung cancer (NSCLC) to 98% for curative resection of stage I/II NSCLC. However, many Veterans met quality indicator criteria without having received recommended therapy by having a refusal (0%-14%) or contraindication (1%-30%). Less than 1% refused palliative chemotherapy.
- Increasing age was associated with greater likelihood of refusing curative surgery, adjuvant therapy, and therapy for advanced disease. Black Veterans were more likely to refuse or have a contraindication to surgery even when controlling for comorbidity, but variation by race was not noted in refusals or contraindications to other treatments.
- This study was not designed to glean the specific reasons why Veterans refused care or why care was judged to be contraindicated, only whether a refusal or contraindication was documented.
Authors note that study results underscore the need for performance measurement systems that capture both patient refusals and medical contraindications. Using data that may not accurately capture quality of care may result in allocation of resources to improve quality where it is not indicated.
Dr. Asch is co-Director of VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) and is the Director of HSR&D's Center for Health Care Evaluation, Palo Alto, CA. Dr. Oishi is part of HSR&D's Center for the Study of Healthcare Provider Behavior, Sepulveda, CA.
Ryoo J, Ordin D, Antonio A, Oishi S, Gould M, Asch S, and Malin J. Patient Preference and Contraindications in Measuring Quality of Care: What Do Administrative Data Miss? Journal of Clinical Oncology June 10, 2013;e-pub ahead of print.