Equity in an equal access system? – Quality & timeliness of cancer care in the Veterans Affairs healthcare system

Abstract

The objective of this dissertation was to examine the association between patients' race and receipt of National Comprehensive Cancer Network guideline-adherent and timely colorectal cancer (CRC) and non-small cell lung cancer (NSCLC) care in the Veterans Affairs (VA) healthcare system. Data were from the External Peer Review Program (EPRP) Special Study on CRC and NSCLC, originally purposed for performance monitoring, examined in an observational, retrospective study design. The sample consisted of African American (AA) and Caucasian patients diagnosed with CRC between 2003 and 2006 or NSCLC between 2006 and 2007 at VA hospitals nationwide. Statistical analysis approaches included multivariate logistic regression and survival analysis methods.

Our first analysis used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for Stages II-III; fluorouracil-based adjuvant chemotherapy for Stage III; surveillance colonoscopy for Stages I-III). There were no significant racial differences in receipt of guideline-concordant CRC care. Our second analysis examined associations between race and CRC care timeliness. There were no racial differences in time to chemotherapy initiation (HR 0.82, p=0.61) or surgery to death (HR 0.94, p=0.0.49). Caucasian race was protective for shorter time to first surveillance colonoscopy (HR 0.63, p=0.02). On average, the difference in time to colonoscopy was sixteen days. Our third analysis examined associations between race and NSCLC care timeliness. There were no racial differences in time to initiation of treatment (72 days for AA versus 65 days for Caucasian patients, HR 1.03, p=0.80) or palliative care or hospice referral (129 versus 116 days, HR 1.10, p=0.34). However, the adjusted model found longer survival for African American compared to Caucasian patients (133 versus 117 days, HR 1.31, p=0.00).

In these data there were minimal statistically significant racial differences. We identified no clinically meaningful racial differences in cancer care quality, timeliness, or patient outcomes. This suggests that VA may be a leader in providing equitable cancer care. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.