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Treatment Patterns and Outcomes of Older (Age ≥ 80) Veterans With Newly Diagnosed Diffuse Large B-Cell Lymphoma (DLBCL)
Background
Over one-third of newly diagnosed Diffuse Large B-Cell Lymphoma (DLBCL) cases are in people age ≥75. Although a potentially curable malignancy, older adults have a comparatively lower survival rate. This may be due to multiple factors including suboptimal management. In one study, up to 23% of patients age ≥80 did not receive any therapy for DLBCL. This age-related survival disparity is potentially magnified in patients who reside in rural areas. As there is no standard of care for this population, we speculate that there is wide variation in treatment practices which may influence outcomes. The purpose of this study is to describe treatment patterns and outcomes in in veterans age ≥80 with DLBCL by area of residence.
Methods
We conducted a retrospective study of veterans age ≥80 newly diagnosed with Stage II-IV DLBCL between 2006-2023 using the Veterans Affairs (VA) Cancer Registry System (VACRS). Patient, disease, and treatment variables were extracted from the VA Corporate Data Warehouse (CDW) and via chart review. Variables were compared amongst Veterans residing at urban vs. rural addresses.
Results
We evaluated a total of 181 Veterans. Most veterans resided in an urban area (60.2%). At least 18.8% of veterans failed to start lymphoma-directed therapy, but only 6.6% of veterans were not explicitly offered treatment per documentation. In total, 68.5% of veterans were offered a curative treatment regimen by their provider; curative treatment was more likely to be offered to urban patients (68.8% vs 61.5%, p=0.86). Pre-phase steroids and geriatric assessments prior to treatment were severely underutilized (2.8% and 0.6%). More urban veterans started treatment (75.2% vs 65.4%, p=0.38) and 40.9% started an anthracyclinecontaining regimen. Only 27.6% of veterans completed 6 total cycles of treatment. Only 37.6% of veterans achieved a complete response at end of treatment, although response was not reported in 46.4% of patients.
Conclusions
Most elderly veterans with DLBCL are being offered and started on a curative treatment regimen; however, most do not complete a full course of treatment. Although not statistically significant, more urban veterans were offered a curative regimen and received treatment. Wider adoption of pre-phase steroids and geriatric assessments could improve response outcomes.
Background
Over one-third of newly diagnosed Diffuse Large B-Cell Lymphoma (DLBCL) cases are in people age ≥75. Although a potentially curable malignancy, older adults have a comparatively lower survival rate. This may be due to multiple factors including suboptimal management. In one study, up to 23% of patients age ≥80 did not receive any therapy for DLBCL. This age-related survival disparity is potentially magnified in patients who reside in rural areas. As there is no standard of care for this population, we speculate that there is wide variation in treatment practices which may influence outcomes. The purpose of this study is to describe treatment patterns and outcomes in in veterans age ≥80 with DLBCL by area of residence.
Methods
We conducted a retrospective study of veterans age ≥80 newly diagnosed with Stage II-IV DLBCL between 2006-2023 using the Veterans Affairs (VA) Cancer Registry System (VACRS). Patient, disease, and treatment variables were extracted from the VA Corporate Data Warehouse (CDW) and via chart review. Variables were compared amongst Veterans residing at urban vs. rural addresses.
Results
We evaluated a total of 181 Veterans. Most veterans resided in an urban area (60.2%). At least 18.8% of veterans failed to start lymphoma-directed therapy, but only 6.6% of veterans were not explicitly offered treatment per documentation. In total, 68.5% of veterans were offered a curative treatment regimen by their provider; curative treatment was more likely to be offered to urban patients (68.8% vs 61.5%, p=0.86). Pre-phase steroids and geriatric assessments prior to treatment were severely underutilized (2.8% and 0.6%). More urban veterans started treatment (75.2% vs 65.4%, p=0.38) and 40.9% started an anthracyclinecontaining regimen. Only 27.6% of veterans completed 6 total cycles of treatment. Only 37.6% of veterans achieved a complete response at end of treatment, although response was not reported in 46.4% of patients.
Conclusions
Most elderly veterans with DLBCL are being offered and started on a curative treatment regimen; however, most do not complete a full course of treatment. Although not statistically significant, more urban veterans were offered a curative regimen and received treatment. Wider adoption of pre-phase steroids and geriatric assessments could improve response outcomes.
Background
Over one-third of newly diagnosed Diffuse Large B-Cell Lymphoma (DLBCL) cases are in people age ≥75. Although a potentially curable malignancy, older adults have a comparatively lower survival rate. This may be due to multiple factors including suboptimal management. In one study, up to 23% of patients age ≥80 did not receive any therapy for DLBCL. This age-related survival disparity is potentially magnified in patients who reside in rural areas. As there is no standard of care for this population, we speculate that there is wide variation in treatment practices which may influence outcomes. The purpose of this study is to describe treatment patterns and outcomes in in veterans age ≥80 with DLBCL by area of residence.
Methods
We conducted a retrospective study of veterans age ≥80 newly diagnosed with Stage II-IV DLBCL between 2006-2023 using the Veterans Affairs (VA) Cancer Registry System (VACRS). Patient, disease, and treatment variables were extracted from the VA Corporate Data Warehouse (CDW) and via chart review. Variables were compared amongst Veterans residing at urban vs. rural addresses.
Results
We evaluated a total of 181 Veterans. Most veterans resided in an urban area (60.2%). At least 18.8% of veterans failed to start lymphoma-directed therapy, but only 6.6% of veterans were not explicitly offered treatment per documentation. In total, 68.5% of veterans were offered a curative treatment regimen by their provider; curative treatment was more likely to be offered to urban patients (68.8% vs 61.5%, p=0.86). Pre-phase steroids and geriatric assessments prior to treatment were severely underutilized (2.8% and 0.6%). More urban veterans started treatment (75.2% vs 65.4%, p=0.38) and 40.9% started an anthracyclinecontaining regimen. Only 27.6% of veterans completed 6 total cycles of treatment. Only 37.6% of veterans achieved a complete response at end of treatment, although response was not reported in 46.4% of patients.
Conclusions
Most elderly veterans with DLBCL are being offered and started on a curative treatment regimen; however, most do not complete a full course of treatment. Although not statistically significant, more urban veterans were offered a curative regimen and received treatment. Wider adoption of pre-phase steroids and geriatric assessments could improve response outcomes.
Data Elements Captured in Breast and Gynecologic Oncology System of Excellence Health Informatics Tool
Background
The VA National Oncology Program (NOP) Breast and Gynecologic Oncology System of Excellence (BGSOE) aims to ensure that Veterans with breast and gynecologic cancers receive state-of-the-art, guidelineadherent, Veteran-centric, timely, and well-coordinated care. Achieving these aims relies on a national multidisciplinary Cancer Care Navigation Team that provides tele-oncology navigation services. The teams connect with Veterans to identify and support clinical, psychological, system, coordination-related needs. To assist the navigation team to find these relatively rare diagnoses within VA, we developed a health informatics tool (HIT) that automatically identifies patients with breast or gynecologic cancers, displays demographic and clinical information, and facilitates systematic needs assessment and care coordination and tracking.
Methods
We used multiple frameworks to ensure alignment between HIT mission and coordinator workflow. A separate view was provided for each phase of the workflow: assessment of Veteran eligibility, intake assessment, and care coordination and tracking. Algorithmic identification of candidate Veterans was validated to ensure coordinators were not inundated with information on Veterans outside the scope of the program. User interface was implemented in accordance with Lean principles applied to HIT design, with close attention to information inventory, efficient user motion, information transportation, and avoidance of overprocessing.
Results
From January 1, 2021, to March 6, 2024, the HIT captured 5,561 breast cancer and 1,663 gynecologic cancer patients. 908 patients were reviewed by the coordinator, of whom 817 patients had a correct diagnosis assigned by the screening algorithm. From these, 332 patients were added to the intake process. The intake process is pending for 207 patients and complete for 102 patients; 23 patients declined intake. For patients who have completed intake, we have captured information that includes Veteran demographics, social history, insurance details, medical history, family history, hazards, barriers, and information specific to BGSOE care coordination.
Conclusions
We applied a novel framework to design and implement mission-driven, workflow-aligned HIT that achieves high user efficiency using Lean principles. This facilitated an exciting new model in tele-oncology care navigation delivery. Although the program is still in early phases, it has improved care coordination for Veterans with breast and gynecologic cancers across the United States.
Background
The VA National Oncology Program (NOP) Breast and Gynecologic Oncology System of Excellence (BGSOE) aims to ensure that Veterans with breast and gynecologic cancers receive state-of-the-art, guidelineadherent, Veteran-centric, timely, and well-coordinated care. Achieving these aims relies on a national multidisciplinary Cancer Care Navigation Team that provides tele-oncology navigation services. The teams connect with Veterans to identify and support clinical, psychological, system, coordination-related needs. To assist the navigation team to find these relatively rare diagnoses within VA, we developed a health informatics tool (HIT) that automatically identifies patients with breast or gynecologic cancers, displays demographic and clinical information, and facilitates systematic needs assessment and care coordination and tracking.
Methods
We used multiple frameworks to ensure alignment between HIT mission and coordinator workflow. A separate view was provided for each phase of the workflow: assessment of Veteran eligibility, intake assessment, and care coordination and tracking. Algorithmic identification of candidate Veterans was validated to ensure coordinators were not inundated with information on Veterans outside the scope of the program. User interface was implemented in accordance with Lean principles applied to HIT design, with close attention to information inventory, efficient user motion, information transportation, and avoidance of overprocessing.
Results
From January 1, 2021, to March 6, 2024, the HIT captured 5,561 breast cancer and 1,663 gynecologic cancer patients. 908 patients were reviewed by the coordinator, of whom 817 patients had a correct diagnosis assigned by the screening algorithm. From these, 332 patients were added to the intake process. The intake process is pending for 207 patients and complete for 102 patients; 23 patients declined intake. For patients who have completed intake, we have captured information that includes Veteran demographics, social history, insurance details, medical history, family history, hazards, barriers, and information specific to BGSOE care coordination.
Conclusions
We applied a novel framework to design and implement mission-driven, workflow-aligned HIT that achieves high user efficiency using Lean principles. This facilitated an exciting new model in tele-oncology care navigation delivery. Although the program is still in early phases, it has improved care coordination for Veterans with breast and gynecologic cancers across the United States.
Background
The VA National Oncology Program (NOP) Breast and Gynecologic Oncology System of Excellence (BGSOE) aims to ensure that Veterans with breast and gynecologic cancers receive state-of-the-art, guidelineadherent, Veteran-centric, timely, and well-coordinated care. Achieving these aims relies on a national multidisciplinary Cancer Care Navigation Team that provides tele-oncology navigation services. The teams connect with Veterans to identify and support clinical, psychological, system, coordination-related needs. To assist the navigation team to find these relatively rare diagnoses within VA, we developed a health informatics tool (HIT) that automatically identifies patients with breast or gynecologic cancers, displays demographic and clinical information, and facilitates systematic needs assessment and care coordination and tracking.
Methods
We used multiple frameworks to ensure alignment between HIT mission and coordinator workflow. A separate view was provided for each phase of the workflow: assessment of Veteran eligibility, intake assessment, and care coordination and tracking. Algorithmic identification of candidate Veterans was validated to ensure coordinators were not inundated with information on Veterans outside the scope of the program. User interface was implemented in accordance with Lean principles applied to HIT design, with close attention to information inventory, efficient user motion, information transportation, and avoidance of overprocessing.
Results
From January 1, 2021, to March 6, 2024, the HIT captured 5,561 breast cancer and 1,663 gynecologic cancer patients. 908 patients were reviewed by the coordinator, of whom 817 patients had a correct diagnosis assigned by the screening algorithm. From these, 332 patients were added to the intake process. The intake process is pending for 207 patients and complete for 102 patients; 23 patients declined intake. For patients who have completed intake, we have captured information that includes Veteran demographics, social history, insurance details, medical history, family history, hazards, barriers, and information specific to BGSOE care coordination.
Conclusions
We applied a novel framework to design and implement mission-driven, workflow-aligned HIT that achieves high user efficiency using Lean principles. This facilitated an exciting new model in tele-oncology care navigation delivery. Although the program is still in early phases, it has improved care coordination for Veterans with breast and gynecologic cancers across the United States.
Close to Me: Cost Savings Analysis and Improving Veteran Access
BACKGROUND
While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.
DISCUSSION
In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.
CONCLUSIONS
By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.
BACKGROUND
While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.
DISCUSSION
In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.
CONCLUSIONS
By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.
BACKGROUND
While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.
DISCUSSION
In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.
CONCLUSIONS
By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.