Discussion
Use of evidence-based measures to assess care quality proved feasible in this evaluation of supportive care for advanced lung cancer in a large national integrated health care system and confirmed that gaps found in smaller studies represent critical unmet needs for patients. The methods permitted individualized feedback to facilities, accompanied by support for quality improvement efforts. The effectiveness of providing facility feedback with quality improvement strategies will be evaluated in follow-up studies.
Although quality of supportive care as measured by this specific set of indicators was quite high compared to previous reports, 10,13,15 substantial variation across facilities was observed even for measures with high overall performance. Comparatively high levels of supportive care may reflect greater emphasis on supportive measures for advanced lung cancer patients whose expectation of cure is low (other studies evaluated cohorts with mixed cancer types), or the fact that previous studies did not account for documentation of a reason for forgoing indicated care. Tough high quality of supportive care for lung cancer in VHA nationally is encouraging, variability across individual facilities is of concern. Such variation may well exist in any large health care system, with patients potentially experiencing different standards of care depending on where they live.
In this study, facilities located in the South, treating 45% of advanced lung cancer patients in the cohort, were associated with worse care in the treatment toxicity and hospice domains, and those in the Northeast appeared to generally have worse care for pain. Although reasons for these differences are unclear, geographic variation in Medicare hospice use has been related to a variety of determinants, 20-23 some of which may also apply to VHA. Referral to palliative care or hospice was among the lowest scoring quality indicators in the evaluation, with a 75% national rate and 43% of facilities documenting referral for less than 75% of eligible cases. Although our measures determined only referral to palliative care or hospice (versus actual receipt of services), low rates may in part reflect provider anticipation of low local availability of hospice. Although the VHA Hospice and Palliative Care program has made progress in reducing variability in hospice access for Veterans, surveys conducted by Hospice-Veteran Partnerships showed lack of shared knowledge about the different systems of benefits and health care available for veterans, misunderstandings about referral processes among health care providers and payment for hospice services, and difficulties in caring for veterans across multiple care settings to be barriers to Veteran access to community services. 24 Targeted inquiry at lowreferral facilities may elucidate which of these and other possible challenges may suggest points of intervention for improvement in hospice referral patterns and support of appropriate hospice use.
Attempting to identify facility-related explanations for overall variability, we explored the potential role of a number of structural variables, including presence of a tumor board, a palliative care unit, outpatient palliative care services, chaplain services, presence of a cancer care tracking system, and presence of a case manager. Tough facilities with a psychologist specializing in cancer provided better care for pain, and those with midlevel practitioners (nurse practitioner or physician assistant) monitoring patient tracking through care were more likely to appropriately refer to hospice and have better care for treatment toxicity, many facilities without such designated professionals also provided quality care in these domains. Because of limited methodological feasibility of demonstrating patient receipt of psychosocial/spiritual support and care tracking using medical record review, the final set of quality indicators did not include measures for these forms of care; however, psychosocial care is considered integral to supportive care in cancer 25 and care tracking has been associated with improved cancer care in non-VA settings. 26 The presence of appropriate professionals providing cancer-specific psychological support and tracking may be directly associated with improved care, not only in the domains noted above, but also in the important domain of existential and emotional well-being not evaluated here. These services may also be part of larger facility-level quality improvement mechanisms contributing to cancer care quality that are worth identifying in future research. Lack of consistent explanations for the overall facility-level variation in this study suggests the need to identify data sources that can be used to measure additional organizational characteristics in future research.
