Our study has several limitations. The scope of the national evaluation did not include indicators for all aspects of supportive care, including care for dyspnea, depression, and psychosocial distress; support for care givers; and care planning assistance. Small numbers of eligible events per facility for some indicators limit interpretation, particularly in the palliative treatment domain, where the largest range was 1-15 eligible events per facility. Facility characteristics used for analyses were identified from a surveyand may be subject to respondent error. Potentially useful processes, such as a midlevel practitioner monitored tracking system were identified as “present” at the facility, but use for cohort patients was not possible to confirm, limiting direct linkage with better care. Some facility-level results may be influenced by errors in VACCR attribution to a facility that was not directly involved with the patient’s care, specialty service receipt at multiple VAMCs, or through contract care at non-VHA facilities. Quality-of-care coordination between different VHA and non-VHA facilities for services not provided at the diagnosing facility, or to reduce travel burden if the VAMC was far from the patient’s home may be associated with better or worse care quality and should be evaluated in future work.
In conclusion, use of quality indicators to evaluate quality of supportive lung cancer care in a large integrated health care system proved feasible, confirmed
provision of overall high-quality supportive care, but identified a high degree of variability across individual facilities in the system. Facility characteristics examined did not explain this variation; however, the data suggested that, while not accounting for the overall variation, having professionals providing cancer-specific psychological support and care-tracking may contribute to better quality of care in some domains. Difficulties in identifying predictors of quality suggest that future research should include qualitative comparisons of facilities with varying rates of providing recommended supportive care to identify potentially impactful organizational factors not examined in this study.
Disclaimer and Disclosures
Accepted for publication February 24, 2014. Correspondence: Sabine Oishi, PhD, MSPH; sabine.oishi@va.gov. Disclosures: Dr Ryoo was supported in part by the Robert Wood Johnson Foundation Clinical Scholars Program and by the UCLA Jonsson Comprehensive Cancer Center R25 grant. The authors have no direct conflicts of interest to disclose. Dr Karl Lorenz is a consultant as a member of the Data Monitoring Committee for a Phase II trial of Sativex being conducted by Otsuka Pharmaceuticals. The current study has no direct financial implications related to his participation and was conducted entirely outside of the timeframe of his consultancy; however, it may be perceived as indirectly related. The views and opinions of authors expressed herein do not necessarily state or reflect that of the Department of Veterans Affairs, the United States Government, Kaiser Permanente, Stanford University, or the University of California.