1. Understanding Quality of Cancer Care in the VA Health System Nancy L. Keating, MD, MPH Department of Health Care Policy, Harvard Medical School October 14, 2011 Funding: VA Office of Policy and Planning Contract 101-35-04

8. VA Facilities Annu Rev Public Health 2009; 30:313-339

9. SEER Areas UT NM Hawaii IA Seattle/ Puget Sound Connecticut Since 1992 or earlier Metro Detroit Los Angeles San Jose/ Monterey San Francisco / Oakland Atlanta 2000 SEER Expansion CA LA KY New Jersey

19. Results—Quality of Care

20. Stage at Diagnosis - Colon Cancer Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P<.001 % .0

21. Surgery for Colorectal Cancer P=.01 Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P=.11

22. Adjuvant Therapy for Colorectal Cancer Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P=.35 P=.39 %

23. Non Small Cell (NSC) Lung Cancer Primary Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P=.11 P=.87 %

24. Non Small Cell & Small Cell Lung Cancer Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P=.82 P=.36 %

25. Prostate Cancer Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P=.75 P<.001 %

26. Lymphoma Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P<.001 P=.52 %

27. Multiple Myeloma Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. P<.001 %

28. Role of Unobserved Confounders— Incomplete Adjustment for Comorbidity Respiratory Disease

30. Role of Unobserved Factors: Sensitivity Analyses—Adjusted Difference in Quality *Comparing VA with FFS-Medicare Observed Covariates Performance Status Severe Comorbidity Adjuvant Chemo & Radiation for Rectal Cancer 3.2 [-4.0, 10.3] 5.6 [-1.5, 12.8] 7.6 [0.4, 14.7] Curative Surgery NSC Lung Cancer -3.6 [-8.1, 0.8] -1.3 [-5.8, 3.1] 2.6 [-1.8, 7.1] Chemo & RT for Limited Stage SC Lung Cancer 2.6 [-3.0, 8.2] 4.7 [-0.9, 10.3] 8.4 [2.8, 14.0]

31. Results—Survival

32. Survival for Colon Cancer Adjusted median survival VA=49 months; SEER=43 months p<0.001

33. Survival for Rectal Cancer Adjusted median survival VA=36 months; SEER=37 months p=0.55

34. Survival for NSC Lung Cancer Adjusted median survival VA=8 months; SEER=6 months p<0.001

35. Survival for Small Cell Lung Cancer Adjusted median survival VA=5 months; SEER=5 months p=0.64

36. Survival for Lymphoma Adjusted median survival VA=14 months; SEER=16 months p=0.75

37. Survival for Myeloma Adjusted median survival VA=19 months; SEER=17 months p=0.15

38. Role of Unobserved Factors: Sensitivity Analyses—Adjusted Hazard of Death *Comparing VA with FFS-Medicare Observed Covariates Performance Status Severe Comorbidity Colon Cancer 0.87 [0.81, 0.93] 0.82 [0.76, 0.87] 0.76 [0.71, 0.82] Rectal Cancer 1.03 [0.93, 1.14] 0.97 [0.88, 1.07] 0.90 [0.82, 1.00] NSC Lung Cancer 0.91 [0.88, 0.94] 0.85 [0.82, 0.88] 0.77 [0.74, 0.80] SC Lung Cancer 0.99 [0.93, 1.05] 0.92 [0.87, 0.98] 0.84 [0.79, 0.89] Lymphoma 1.02 [0.89, 1.18] 0.96 [0.84, 1.10] 0.90 [0.78, 1.03]

39. Results— Preference Sensitive Care

40. Primary Prostate Cancer Treatment Adjusted for age, race/ethnicity, marital status, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, % with college degree in zip code, % professionals in zip code, % over 64 living in poverty in zip code, % African American in zip code, and median household income in zip code. Overall P<.001 %

41. Aggressive End of Life Care Adjusted for age, race/ethnicity, marital status, cancer site, quarter-year of diagnosis, Charlson comorbidity score, history of prior cancer, census region, percent with college degree in zip code, percent professionals in zip code, percent over 64 living in poverty in zip code, percent African American in zip code, and median household income in zip code. P<.001 P=.09 P<.001 %

42. Within-VA Analyses Variation in Primary Prostate Cancer Treatment

43. Rates of Radiation Therapy by VAMC *Adjusted for patient, tumor, & hospital characteristics & VISN.

44. Rates of Radical Prostatectomy by VAMC *Adjusted for patient, tumor, & hospital characteristics & VISN.

45. Results—Reasons for Underuse of Effective Therapies

46. Rates of Treatments %

47. Reasons for Underuse of Therapies