BACKGROUND/RATIONALE:
Many VA patients use more than one healthcare system. Dual VA-Medicare use among cancer patients may lead to service redundancy, delays in care, and lack of care coordination, which may have deleterious effects on outcomes and costs of care.

OBJECTIVE(S):
This observational study examines the quality and cost of colon cancer care among Veterans treated in the two largest healthcare systems in the United States: VA and Medicare. Specific aims were to:
1. Assess and compare structure and process of colon cancer surgical and adjuvant treatment patterns;
2. Characterize and compare healthcare quality, use and costs for colon cancer care;
3. Examine factors that explain healthcare system choice, delays in colon cancer initial surgical and adjuvant treatment, healthcare use, and costs; and
4. Evaluate and compare survival rates for colon cancer patients treated predominantly in the VA compared to those treated outside the VA, controlling for stage and treatment regimen.

METHODS:
This study employs a retrospective cohort of incident Stage I-IV colon cancer patients diagnosed 1999-2001, at least 66 years old and eligible to use both VA and Medicare services. The cohort includes 3,949 Veterans diagnosed either in the VA (1,987), or outside the VA and reported to one of 8 NCI regional tumor registries (1,962). The study links multiple VA and non-VA data sources, including VA workload and pharmacy data, Medicare claims, and tumor registry records, for measurement of healthcare quality and costs.

FINDINGS/RESULTS:
Our cohort is 97% male and 16% African American. At diagnosis, 27%, 31%, 23%, and 19% are stage I - IV disease, respectively. Twenty-eight percent died within 12 months of diagnosis. Forty-eight percent of the cohort receives their cancer care predominantly from the VA, 36% predominantly from Medicare and 13% use both systems for substantial portions of their cancer care. Odds of receiving cancer-directed surgery and chemotherapy are similar in both systems. However, compared to patients aged 66-72 years old, the adjusted likelihood of receiving adjuvant chemotherapy among those 73-78 years and 79 years and older is reduced by 34 percent (HR: 0.66, CI95%: 0.54 - 0.80) and 60 percent (HR: 0.40, CI95%: 0.31 - 0.50), respectively. African American patients are equally as likely as non-African Americans to receive adjuvant chemotherapy (HR: 0.88, CI95%: 0.67 - 1.16). Stage II patients outside the VA are over twice as likely as their VA counterparts to receive chemotherapy (IRR: 2.64, CI95%: 1.06 - 6.61), despite no convincing evidence of a survival benefit of chemotherapy for that group. Cox proportional hazards ratios for Stage II and III reveal that Stage I dual users are twice as likely to experience a cancer relapse/progression (HR: 2.01, CI95%: 1.40 - 2.87), even after adjustment for confounders. Of the 3842 cases for the cost analysis cohort, initial analyses suggest that dual users of Medicare and VA healthcare are more likely to incur greater healthcare costs.

IMPACT:
As policymakers consider ways to improve colon cancer care, and with renewed policy interest in the quality of cancer care across the VA and Medicare systems in particular, results to date from this study show that efforts to identify patients who are dual users may yield opportunities to coordinate care across providers/systems. Care coordination may lead to improved quality and reduced costs for cancer care. In addition, care coordination efforts across VA and Medicare providers may reduce use of treatments of uncertain benefits. However, any care coordination across VA and non-VA providers will also need to be balanced with patients' ability to choose their own providers and care options.

We are sharing results with our clinical advisory committee, including VA Hematology/Oncology Service. We are also sharing our improved methodologies for comorbidity assessment and ascertainment of colon cancer care specific costs.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Weichle T, Hynes DM, Durazo-Arvizu R, Tarlov E, Zhang Q. Impact of alternative approaches to assess outlying and influential observations on health care costs. SpringerPlus. 2013 Nov 18; 2(1):614. [view]
2. Tarlov E, Lee TA, Weichle TW, Durazo-Arvizu R, Zhang Q, Perrin R, Bentrem D, Hynes DM. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2012 Dec 1; 21(12):2231-41. [view]
3. Hynes DM, Tarlov E, Durazo-Arvizu R, Perrin R, Zhang Q, Weichle T, Ferreira MR, Lee T, Benson AB, Bhoopalam N, Bennett CL. Surgery and adjuvant chemotherapy use among veterans with colon cancer: insights from a California study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2010 May 20; 28(15):2571-6. [view]

Journal Other

1. Hynes DM, Tarlov E, Lee TA, Perrin RA, Zhang Q, Ferreira M, Durazo-Arvizu R, Benson AB, Bentrem D, Bennett CL. Examining disparities in colon cancer treatment patterns. [Abstract]. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2008 May 20; 26(15S):6534. [view]
2. Hynes DM, Tarlov E, Perrin RA, Zhang Q, Bennett CL, Ferreira M, Lee TA, Benson A. Patterns of care among veterans with colon cancer: Insights from California SEER, Medicare and VA-linked data. [Abstract]. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2007 Jun 27; 25(18S):6586. [view]

Conference Presentations

1. Tarlov E, Lee TA, Durazo-Arvizu R, Zhang Q, Bennett CL, Hynes DM. Adjuvant Chemotherapy in Colon Cancer: Differences by System of Care and Stage. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
2. Weichle TW, Zhang Q, Durazo-Arvizu R, Bentrem D, Hynes DM. Comparing Colon Cancer Outcomes Across Systems of Care: Patients with Stage IV Cancer in VA and SEER-Medicare Data. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA. [view]
3. Tarlov E, Perrin RA, Zhang Q, Koelling K, Ferreira MR, Hynes DM, Bennett CL. Consequences Of Ignoring VA Data in Studies Of Medicare-Enrolled Elderly with Cancer. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 1; Orlando, FL. [view]
4. Hynes DM, Tarlov E, Lee TA, Perrin R, Zhang Q, Ferreira MR, Durzao-Arvizo RA, Benson AB, Bentram DJ, Bennett CL. Examining disparities in colon cancer treatment patterns. Presented at: American Society of Clinical Oncology Annual Meeting; 2008 May 1; Chicago, IL. [view]
5. Tarlov E, Durzao R, Weichle T, Zhang Q, Perrin R, Lee TA, Bennett CL, Hynes DM, Armstrong DG. Examining disparities in colon cancer treatment: length of time to chemotherapy initiation. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
6. Hynes DM, Perrin RA, Zhang Q, Koelling K, Tarlov E, Ferreira MR, Lee TA, Bennett CL. Healthcare Utilization Patterns of California Veterans with Colon Cancer – VA Patients Rely on Medicare. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]
7. Lee TA, Weichle TW, Tarlov E, Zhang Q, Perrin RA, Durazo-Arvizu R, Hynes DM. Impact of Alternative Approaches to Identifying Outliers on Costs of Colon Cancer Episodes of Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]
8. Hynes DM, Tarlov E, Perrin R, Zhang Q, Bennett CL, Ferreira MR, Lee TA, Benson A. Patterns of care among veterans with colon cancer: Insights from California SEER, Medicare and VA-linked data. Poster session presented at: American Society of Clinical Oncology Annual Meeting; 2007 Jun 1; Chicago, IL. [view]
9. Hynes DM, Tarlov E, Lee TA, Weichle TW, Durazo-Arvizu R, Perrin RA, Zhang Q, Ferreira M, Bennett CL. Policy and Cost Implications of VA and Medicare Dual Use for Colon Cancer Care. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
10. Tarlov E, Lee TA, Weichle TW, Zhang Q, Perrin RA, Bentrem D, Hynes DM. Reduced Overall and Event-Free Survival Among Colon Cancer Patients Using Dual System Care. Paper presented at: VA HSR&D National Meeting; 2012 Jul 17; National Harbor, MD. [view]
11. Hynes DM, Perrin RA, Zhang Q, Koelling K, Sohn MW. Timing of Surgical and Adjuvant Therapy for Colorectal Cancer. Paper presented at: AcademyHealth Annual Research Meeting; 2005 May 1; Boston, MA. [view]
12. Tarlov E, Lee TA, Weichle TW, Durazo-Arvizu R, Zhang Q, Perrin RA, Bentrem D, Hynes DM. VA and Medicare dual healthcare system use: impacts on 3-year event free survival for colon cancer. Poster session presented at: American Society of Clinical Oncology Annual Meeting; 2011 Jun 6; Chicago, IL. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems Science
DRE: Epidemiology, Treatment - Observational
Keywords: Cancer, Cost effectiveness, VA/non-VA comparisons
MeSH Terms: none