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BACKGROUND/RATIONALE:
Cancers of the colon are the third most commonly diagnosed cancers and rank third among cancer deaths in the United States. Initial surgery and adjuvant therapy are key to disease-free and long-term survival in colon cancer, but variations in care exist. Patients using more than one healthcare system are particularly vulnerable because lack of coordination of care across systems may be lacking, resulting in delays in care and excessive healthcare use and costs.
OBJECTIVE(S):
1. Assess and compare the structure and process of colon cancer initial surgical and adjuvant treatment patterns for elderly patients across VA and Medicare systems of care. 2. Characterize and compare healthcare quality, use and costs for colon cancer care across VA and Medicare systems of care. 3. Examine factors that explain healthcare system choice, delays in colon cancer initial surgical and adjuvant treatment, healthcare use, and costs across VA and Medicare systems of care.
METHODS:
This study employs a retrospective cohort of incident colon cancer patients at least 66 years old and eligible to use both the VA and Medicare. Based on a quality of care theoretical model, the study links multiple comprehensive data sources to characterize and compare patient demographic characteristics, clinical characteristics, comorbidity, timing and type of cancer surgery and timing and type of adjuvant therapy, healthcare use and costs. Analysis focuses on treatment, healthcare use and costs for a three year period from diagnosis for each patient. Calendar years 1999-2004 comprise the study period.
To begin defining the study cohort, the sampling frame data set (a list of 3,482,654 veterans at least 66 years old and eligible to use both the VA and the Medicare program between 1999 and 2001) was submitted to each of eight participating regional tumor registries. Each registry matched and linked to the VA data set individually identifiable data on cancer cases in their registry, including staging information and first course of treatment. Preliminary analysis revealed 2,027 to be eligible for the study cohort. Colon cancer patients in the VA Central Cancer Registry (VACCR) who were age 66+ and diagnosed in 1999 through 2001 will be added to the cohort.
FINDINGS/RESULTS:
Among the 2,027 veterans in a cohort of colon cancer patients from eight regional tumor registries, 95% were male; 14% were African American; 17% were diagnosed at a VA facility; 1,788 (88%) underwent colectomy; 358 (20%) underwent colectomy at a VA facility. The one-year mortality rate was 28% overall. Among the 1,788 patients who underwent colectomy, prevalence of chemotherapy use was 9%, 27%, 58%, and 48% in stages I to IV, respectively (p-value <0.0001). Among the 1,074 stage II and III colectomy patients for whom hospital type (VA vs. non-VA) was known, a regression analysis controlling for comorbidity, stage, geographic region, and hospital type revealed that African Americans were less likely than non-African Americans (OR 0.54, CI: 0.34-0.84) and patients age 76-to-85 years and those 86 years or older were less likely than those age 66-to-75 years (OR 0.38, CI: 0.29-0.51 and OR 0.08, CI: 0.03-0.18, respectively) to receive adjuvant chemotherapy. We also found that veterans who underwent colectomy at a non-VA facility were more likely to receive adjuvant chemotherapy (OR 1.78, CI: 1.23-2.58). Adherence to adjuvant chemotherapy guidelines among patients treated in VA hospitals warrants additional research.
IMPACT:
The proposed study fills an important void by providing cancer care information specific to veterans. That this information is timely is evident from the focus on performance and results of the VHA oncology program evaluation currently being performed by the Office of Management and Budget under the Government Performance and Results Act, which requires agencies to create goals and performance measures and standards. Additionally, with renewed interest in arrangements in which Medicare would pay for some care provided in the VA, a better understanding of the dynamics of care for specific disease populations of national concern is warranted.
PUBLICATIONS:
None at this time.
DRA:
Aging and Age-Related Changes, Chronic Diseases, Health Services and Systems
DRE:
Quality of Care, Treatment
Keywords:
Cancer, Cost effectiveness, VA/non-VA comparisons
MeSH Terms:
none
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