VA Articles of Interest
BMC Health Serv Res. 2018; 18: 171.
Published online 2018 Mar 9. doi: 10.1186/s12913-018-2975-3
Chronic disease management perspectives of colorectal cancer survivors using the Veterans Affairs healthcare system: a qualitative analysis
Leah L. Zullig,1,2 Karen M. Goldstein,1,3 Hayden B. Bosworth,1,2,4 Sara M. Andrews,1 Susanne Danus,1 George L. Jackson,1,2 Dawn Provenzale,1,3,5 Morris Weinberger,1,6 Michael J. Kelley,7,8 and Corrine I. Voils9,
Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the US. CRC survivors may have complex healthcare needs requiring care from both specialists and primary care. Our objective was to understand how CRC survivors perceive their survivorship care, especially management of their cardiovascular-related chronic diseases.
We identified patients diagnosed with non-metastatic CRC between 10/1/2007 and 12/31/2015 at Veterans Affairs Medical Centers in North Carolina or Virginia. In 2016, we conducted telephone-based, semi-structured interviews to assess survivors’ experiences with cancer survivorship and changes in health priorities. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed, and coded.
The 25 participants were, on average, 64 years old and approximately 4 years post-CRC diagnosis at the time of interview; most were white (60%), male (92%), and diagnosed with colon cancer (64%) as opposed to rectal cancer. CRC survivors reported: (1) a shift in focus from surviving cancer to reducing cardiovascular disease risk (e.g., by managing weight); (2) challenges with taking medications for CVD-related conditions; (3) new recognition of the importance of engaging with primary care providers.
Experiences with cancer shapes how survivors view their health. Management of cardiovascular-related chronic disease is important to veteran CRC survivors. There is a need to deliver cardiovascular disease risk reduction programs tailored for CRC survivors.
Semin Oncol Aug-Oct 2019;46(4-5):334-340.
doi: 10.1053/j.seminoncol.2019.09.007. Epub 2019 Oct 28.
HIV and cancer in the Veterans Health Administration System
· 1Icahn School of Medicine at Mount Sinai, NY, NY. Electronic address: email@example.com.
· 2Stanford University School of Medicine, Palo Alto, CA.
· 3VA Connecticut Healthcare System, West Haven, CT; Yale University School of Medicine.
· PMID: 31703932
· PMCID: PMC7071926
Cancer is a leading cause of death for people with HIV (PWH). The Veterans Healthcare System (VA) is the largest single institutional provider of HIV care in the United States. Cancer among Veterans with HIV is major issue and clinical research has expanded significantly during the antiretroviral therapy (ART) era providing numerous insights regarding cancer incidence, risk factors, prevention, treatment and outcomes for this unique group of patients. This work has been greatly facilitated by the availability of national VA data sources. Notably, patterns of cancer incidence have changed for Veterans with HIV during the ART era; non-AIDS defining malignancies now are the most common tumors. Despite better HIV control in the ART era, immunosuppression measured by low CD4 counts and HIV viremia have been associated with increased cancer risk. Cancer outcomes for Veterans with HIV may now be similar to uninfected Veterans, but information on outcomes and cancer treatment patterns remains limited, requiring further study to help inform prevention and treatment strategies.
Keywords: Anti-retroviral era; Cancer; HIV; Non-AIDS defining cancers; Veterans Affairs Health
JAMA Oncol. 2019 Jun 1;5(6):810-816.
Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer
Vincent Mor 1 2, Todd H Wagner 3 4 5, Cari Levy 6 7, Mary Ersek 8 9, Susan C Miller 2, Risha Gidwani-Marszowski 3 4 10, Nina Joyce 2, Katherine Faricy-Anderson 1 11, Emily A Corneau 1, Karl Lorenz 4 5, Bruce Kinosian 12, Scott Shreve 13 14
· 1Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island.
· 2Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island.
· 3Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.
· 4Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.
· 5Stanford University School of Medicine, Palo Alto, California.
· 6Eastern Colorado VA Healthcare System, Denver.
· 7University of Colorado, Division of Health Care Policy and Research, Aurora.
· 8Veteran Experience Center (formerly, the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
· 9University of Pennsylvania School of Nursing, Philadelphia.
· 10Division of Primary Care and Population Health, Stanford University, Stanford, California.
· 11Alpert Medical School of Brown University, Providence, Rhode Island.
· 12Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
· 13Hospice and Palliative Care Program, U.S. Department of Veterans Affairs.
· 14Penn State College of Medicine, Hershey, Pennsylvania.
· PMID: 30920603
· PMID: PMC6567823
· DOI: 10.1001/jamaoncol.2019.0081
Importance: Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown.
Objective: To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life.
Design, setting, and participants: A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018.
Exposures: Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability.
Main outcomes and measures: Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis.
Results: Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference.
Conclusions and relevance: Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment
Cancer Med. 2019 May;8(5):2686-2702.
doi: 10.1002/cam4.2106. Epub 2019 Apr 5.
Determinants of quality prostate cancer survivorship care across the primary and specialty care interface: Lessons from the Veterans Health Administration
· 1Division of General Medicine, University of Michigan, Ann Arbor, Michigan.
· 2VA Health Service Research & Development Center for Clinical Management Research, Ann Arbor, Michigan.
· 3Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan.
· 4Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.
· 5Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.
· 6School of Social Work, University of Michigan, Ann Arbor, Michigan.
· 7Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan.
· PMID: 30950216
· PMID: PMC6536973
· DOI: 10.1002/cam4.2106
Background: With over 3 million US prostate cancer survivors, ensuring high-quality, coordinated cancer survivorship care is important. However, implementation of recommended team-based cancer care has lagged, and determinants of quality care across primary and specialty care remain unclear. Guided by the theoretical domains framework (TDF), we explored multidisciplinary determinants of quality survivorship care in an integrated delivery system.
Methods: We conducted semistructured interviews with primary (4) and specialty (7) care providers across 6 Veterans Health Administration clinic sites. Using template analysis, we coded interview transcripts into the TDF, mapping statements to specific constructs within each domain. We assessed whether each construct was perceived a barrier or facilitator, examining results for both primary care providers (PCPs) and prostate cancer specialists.
Results: Cancer specialists and PCPs identified 2 primary TDF domains impacting their prostate cancer survivorship care: Knowledge and Environmental context and resources. Both groups noted knowledge (about survivorship care) and procedural knowledge (about how to deliver survivorship care) as positive determinants or facilitators, whereas resources/material resources (to deliver survivorship care) was noted as a negative determinant or barrier to care. Additional domains more commonly referenced by cancer specialists included Social/professional role and identity and Goals, while PCPs reported the domain Beliefs about capabilities as relevant.
Conclusions: We used the TDF to identify several behavioral domains acting as determinants of high-quality, team-based prostate cancer survivorship care. These results can inform prostate cancer survivorship care plan content, and may guide tailored, multidisciplinary implementation strategies to improve survivorship care across the primary and specialty care interface.
Keywords: behavior change; cancer specialists; implementation science; primary care; quality; survivorship; theoretical domains framework (TDF).