Quality indicators for supportive and end-of-life care have been successfully applied to electronic health record (EHR) data in research studies assessing care quality in patients with different cancer types and showing supportive care for cancer to be generally in need of quality improvement. 10-15 In this paper, we examine supportive care findings from the first largescale application of quality indicators in a system-wide evaluation of lung cancer care in the Veterans Health Administration (VHA). The evaluation was part of a series of operationally motivated projects to identify targets for cancer care improvement in VHA. Lung cancer, the most common malignancy in the United States, accounts for one-fifth of all tumors diagnosed each year within this large, integrated health care system and is responsible for a significant proportion of the system’s supportive care needs. Recently demonstrated benefits of early palliative care on the quality of life and end-of-life care in patients with advanced lung cancer point to the particular importance of assessing supportive care in this population. 16 We report VHA evaluation findings and subsequent research analyses seeking to identify patient and facility characteristics associated with better quality supportive lung cancer care.
Methods
Quality Indicators
Quality indicators for supportive cancer care were identified from a systematic review of existing measures and expert guidelines. A panel of 9 national palliative and supportive cancer care experts rated the validity and feasibility of the indicators for use in the VHA using a modified Delphi panel method adapted from the RAND-UCLA appropriateness method 17 and prioritized candidate indicators in a ranking exercise. Those with low validity or feasibility scores, or low priority rankings, were excluded, resulting in a final set of 12 quality indicators (8 supportive care, 4 end-of-life care) for use in the national evaluation.
Evaluation Population
All incident non-small-cell (NSCLC) and small-cell (SCLC) lung cancer cases diagnosed within the VHA during 2007 (N = 7,816) were identified through the Veterans Affairs Central Cancer Registry (VACCR). Cases were eligible for the study if the patient had advanced cancer (extensive small-cell or metastatic non-small-cell lung cancer) and had lived long enough to be eligible for the supportive care that was being evaluated. Patients were excluded if the health record did not confirm the lung cancer diagnosis (eg, no pathologic diagnosis or diagnosis outside the VHA, n = 1,297); they had a preexisting or concurrent diagnosis of metastatic neoplasm other than lung cancer (n = 540); had died or enrolled in hospice ≤ 30 days after diagnosis (n = 947); had documented
“comfort measures only” ≤ 30 days after diagnosis (n = 91); had documented life expectancy of ≤ 6 months at time of diagnosis (n = 39); or enrolled in a clinical trial (as care received as part of a trial may not be completely captured in the VHA record (n = 57). Of the patients meeting inclusion criteria, 2,969 were eligible for at least one of the supportive care quality indicators.
Data Collection
EHRs were reviewed remotely by abstractors from the West Virginia Medical Institute, the VHA’s contractor for its external peer-review program. Data were collected retrospectively from the year before to the 2007 diagnosis, with follow-up through 2009. Stage was determined through the VACCR or by abstraction if no VACCR stage was available. The VACCR also provided sociodemographic information including race, which is abstracted from patient charts by cancer registrars. Urban or rural residence was determined by using the rural-urban commuting area codes. Case-level quality indicator results were provided to each facility for review to identify any missed documentation, and abstractors updated data as appropriate. Facility characteristics for the Veterans Administration Medical Centers (VAMCs) at which patients received care were obtained from the 2009 Veterans Health Administration (VHA) Oncology Services
Survey.18 The study was approved by the Veterans Administration Greater Los Angeles Healthcare System Institutional Review Board Subcommittee on Human Studies.
