About 8% of patients were diagnosed at a VAMC different from the VACCR attribution. Six percent received specialty service consultations or treatment at multiple VAMCs, and about 25% received at least one specialty service consultation or treatment at a non-VHA facility.
Quality Indicator Eligibility and Rates of Receiving Recommended Care
Patient eligibility for the quality indicators (Table 3) ranged from 1% (treatment of spinal cord compression) to 68% (prevention of chemotherapy-related nausea and vomiting). Few patients were eligible for palliative treatment indicators (palliative radiation therapy and treatment of spinal cord compression), with only 2% of patients (50 individuals) eligible for the imaging indicator. Eligibility for the two indicators related to use of shortacting opioids for break-through pain was also low (2%-4%).
Mean national rates for recommended support ive care were generally high (above 85% for 8 of the 12 indicators), ranging from 98% for outpatient pain screening to a low of 60% for spine MRI or myelography within 24 hours for suspected spinal cord compression (Table 3). There was pronounced variability across facilities, with facility rates in every domain ranging from 0%-100% (Figure 1). Many facilities scored 100% in at least 1 domain (eg, 44 of 109 facilities for pain screening; 51 of 94 for palliative cancer therapy). Eight (of 111) facilities did not provide recommended care in 1 domain and 1 did not provide recommended care in 2 domains (ie, 0% of recommended care).
In bivariate analyses (data not shown), referral to palliative care was associated with better care for treatment toxicity (P = .04) but not the other domains. Patients with poor performance status were more likely to be referred to hospice (81% vs 74% for those with good performance status, P = .005) as were patients who lived in an urban zip code area (77% vs 71% for rural zip code, P = .03). In multivariate analyses (Table 4), small-cell cancer type, though not significant in the bivariate analyses, was associated with a higher odds of receiving recommended care [OR, 2.71; 95% CI, 1.89-3.86)] in the
treatment toxicity domain and lower odds in the pain domain [OR, 0.50; 95% CI, 0.33-0.77)]; and poor performance remained associated with higher odds of referral to hospice [OR, 1.49; 95% CI, 1.12-1.99)] after adjusting for other patient and facility characteristics.
In multivariate analysis, moderate facility complexity was associated with lower quality in the toxicity domain than was low facility complexity [OR, 0.28; 95% CI, 0.18-0.44)]; however there was no such difference between the low- and high-complexity facilities. The presence of a patient tracking method appeared to be associated with better quality of care in the treatment toxicity domain [OR, 3.38; 95% CI, 1.87-6.10)] and a higher likelihood of referral to hospice [OR, 1.60; 95% CI, 1.22-2.28)] when the method was monitored by a midlevel practitioner (nurse practitioner or physician assistant), but no association was found for methods monitored by other types of staff. In the pain domain, having a psychologist specializing in cancer was associated with a higher odds of receiving recommended care [OR, 1.76; 95% CI, 1.16-2.66)]. No patient or facility characteristics were associated with receiving recommended palliative cancer therapy, although statistical power was limited by the small numbers of eligible events.
