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Quality of Care for Older Patients With Cancer in the Veterans Health Administration Versus the Private Sector: A Cohort Study

Nancy L. Keating, MD, MPH; Mary Beth Landrum, PhD; Elizabeth B. Lamont, MD, MS; Samuel R. Bozeman, MPH; Steven H. Krasnow, MD; Lawrence N. Shulman, MD; Jennifer R. Brown, MD, PhD; Craig C. Earle, MD; William K. Oh, MD; Michael Rabin, MD; and Barbara J. McNeil, MD, PhD
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Medical School, Massachusetts General Hospital Cancer Center, and Dana-Farber Cancer Institute, Boston, Massachusetts; Abt Associates, Cambridge, Massachusetts; Veterans Affairs Medical Center, Washington, DC; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; and Mount Sinai Medical Center, New York, New York.

Disclaimer: The views reflect those of the authors and not the Department of Veterans Affairs. This study used the linked SEER–Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. Dr. Keating had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgment: The authors thank Rose Zummo, MS; Elena Kouri, PhD; Jeffrey Souza; Stephanie Segers; Larry Zaborski; Garrett Kirk; Albert Muhleman, MD; Nirmala Bhoopalam, MD; Dawn Provenzale, MD; Michael Kelley, MD; Robert Kerns, MD; Raye Anne Dorn; Marshall Amesquita; Barbara Stephens; Stanlie Daniels; Heidi Martin; Paulette Mehta, MD; Diana Ordin; Karen Pane; Archna Sharma, MD; Anecia Thibodeau; and Patricia Vandenberg. They also acknowledge the efforts of the Applied Research Program of the National Cancer Institute; the Office of Research, Development, and Information of the Centers for Medicare & Medicaid Services; Information Management Services; and the SEER Program tumor registries in the creation of the SEER–Medicare database.

Grant Support: By contract 101-35-04 from the Department of Veterans Affairs through the Office of Policy and Planning.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2217.

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Nancy L. Keating, MD, MPH, Department of Health Care Policy; Harvard Medical School, Boston, MA 02115; e-mail, keating@hcp.med.harvard.edu.

Current Author Addresses: Drs. Keating, Landrum, Lamont, and McNeil: Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115.

Mr. Bozeman: Abt Associates, 55 Wheeler Street, Cambridge, MA 02138-1168.

Dr. Krasnow: Veterans Affairs Medical Center, 50 Irving Street NW, Washington, DC 20422.

Dr. Shulman: Dana-Farber Cancer Institute, 44 Binney Street, Dana 1608, Boston, MA 02115.

Dr. Brown: Dana-Farber Cancer Institute, 44 Binney Street, Dana Building D1B30, Boston, MA 02115.

Dr. Earle: Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, G-Wing Room 106, Toronto, Ontario M4N 3M5, Canada.

Dr. Oh: Mount Sinai School of Medicine, The Tisch Cancer Institute, One Gustave L. Levy Place, Box 1079, New York, NY 10029.

Dr. Rabin: Dana-Farber Cancer Institute, 44 Binney Street, Dana D-1234, Boston, MA 02115.

Author Contributions: Conception and design: N.L. Keating, M.B. Landrum, S.R. Bozeman, S.H. Krasnow, L.N. Schulman, W.K. Oh, M. Rabin.

Analysis and interpretation of the data: N.L. Keating, M.B. Landrum, S.H. Krasnow, L.N. Schulman, J.R. Brown, C.C. Earle, W.K. Oh, M. Rabin.

Drafting of the article: N.L. Keating, M.B. Landrum, L.N. Schulman, J.R. Brown, W.K. Oh, M. Rabin.

Critical revision of the article for important intellectual content: N.L. Keating, L.N. Schulman, J.R. Brown.

Final approval of the article: N.L. Keating, M.B. Landrum, S.R. Bozeman, L.N. Schulman, J.R. Brown, C.C. Earle, W.K. Oh, M. Rabin.

Provision of study materials or patients: S.R. Bozeman.

Statistical expertise: N.L. Keating, M.B. Landrum.

Obtaining of funding: N.L. Keating, S.R. Bozeman.

Administrative, technical, or logistic support: N.L. Keating.

Collection and assembly of data: N.L. Keating, M.B. Landrum, S.R. Bozeman.

Ann Intern Med. 2011;154(11):727-736. doi:10.7326/0003-4819-154-11-201106070-00004
Text Size: A A A

Background: The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. Studies suggest that the VHA provides better preventive care and care for some chronic illnesses than does the private sector.

Objective: To assess the quality of cancer care for older patients provided by the VHA versus fee-for-service Medicare.

Design: Observational study of patients with cancer that was diagnosed between 2001 and 2004 who were followed through 2005.

Setting: VHA and non-VHA hospitals and office-based practices.

Patients: Men older than 65 years with incident colorectal, lung, or prostate cancer; lymphoma; or multiple myeloma.

Measurements: Rates of processes of care for colorectal, lung, or prostate cancer; lymphoma; or multiple myeloma. Rates were adjusted by using propensity score weighting.

Results: Compared with the fee-for-service Medicare population, the VHA population received diagnoses of colon (P < 0.001) and rectal (P = 0.007) cancer at earlier stages and had higher adjusted rates of curative surgery for colon cancer (92.7% vs. 90.5%; P < 0.010), standard chemotherapy for diffuse large B-cell non-Hodgkin lymphoma (71.1% vs. 59.3%; P < 0.001), and bisphosphonate therapy for multiple myeloma (62.1% vs. 50.4%; P < 0.001). The VHA population had lower adjusted rates of 3-dimensional conformal or intensity-modulated radiation therapy for prostate cancer treated with external-beam radiation therapy (61.6% vs. 86.0%; P < 0.001). Adjusted rates were similar for 9 other measures. Sensitivity analyses suggest that if patients with cancer in the VHA system have more severe comorbid illness than other patients, rates for most indicators would be higher in the VHA population than in the fee-for-service Medicare population.

Limitation: This study included only older men and did not include information about performance status, severity of comorbid illness, or patient preferences.

Conclusion: Care for older men with cancer in the VHA system was generally similar to or better than care for fee-for-service Medicare beneficiaries, although adoption of some expensive new technologies may be delayed in the VHA system.

Primary Funding Source: Department of Veterans Affairs.





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Submit a Comment/Letter
Intensity of care does not equal quality of care, especially not in older patients
Posted on June 17, 2011
Marcel GM Olde Rikkert
Depts. of Geriatrics, Radiation Oncology and Epidemiology, Biostatistics and HTA, Radboud University
Conflict of Interest: None Declared

In an extensive study, Keating et al. demonstrate that, for older cancer patients, the Veterans Health Administration (VHA) provides similar care intensity as the private sector (1). It is highly relevant to know that for older patients, state of the art cancer interventions for colon cancer, lung cancer, non-Hodgkin lymphomas, and multiple myeloma in the VHA do not differ from fee-for-service private sector care. The VHA patients received only less of the most modern radiotherapeutic interventions for prostate cancer; other quality indicators, based on the intensity of treatment given, were similar or even better for the VHA. The authors correctly conclude that there were no limitations based on age or comorbidity for expensive cancer treatments in their integrated care system. This evidences absence of ageism. As such, these data evidence availability of care, which is impressive as the VHA is not paid per service but per patient, which might have been an incentive for offering less expensive care.

However, the study of Keating et al. starts from a questionable assumption, as it considers intensity of care to be equal to quality of care. In the Dartmouth Atlas of Health Care, Wennberg proved that this assumption does not hold true for many patients; on the contrary, mortality in high intensity of care regions was even higher for several chronic diseases, as well as for colon cancer (2). High prevalence of high intensity treatments is very likely to be caused by supply driven health care, and insufficient responsiveness to the patients'preferences. Several studies showed that older patients often prefer lower intensity treatment options, and that physicians have problems in predicting the preferences of patients empowered with a decision aid. For example 71% of 150 older patients with prostate cancer preferred lower dose radiation, while physicians' own preference favored the lower dose in only 20% of the patients (3). Similarly, 20-40% of patients with breast and lung cancer, or benign prostate hypertrophy preferred low intensity therapy after having been informed with several decision aids (2,4). When comparing quality of care for older patients, the presence and quality of shared decision making, as well as the application of decision aids should best be included in quality indicators and combined with data of care consumption (5). Addition of such patient centered quality indicators is necessary to really guide older patients to the best quality of care and to lead professionals to the best care system.


1.Keating NL, Landrum MB, Lamont EB, Bozeman SR, Krasnow SH, Shulman LN et al. Quality of care for older patients with cancer in the Veterans Health Administration versus the private sector. Ann Int Med 2011;154:727- 36

2.Wennberg JE.Tracking Medicine. Oxford: Oxford University Press; 2010.

3.Stalmeier PF, van Tol-Geerdink JJ, van Lin EN, Schimmel E, Huizenga H, van Daal WA, Leer JW. Doctors' and patients' preferences for participation and treatment in curative prostate cancer radiotherapy. J Clin Oncol 2007;25:3096-100.

4.Vinod SK, Sidhom MA, Gabriel GS, Lee MT, Delaney GP. Why do some lung cancer patients receive no anticancer treatment? J Thorac Oncol 2010;5:1025-1032.

5.Feinstein AR. Is "quality of care" being mislabeled or mismeasured? Am J Med 2002;112:472-478

Conflict of Interest:

None declared

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