By Annette M. Boyle
DENVER — Are increased wait times at the VA for colorectal cancer procedures because patients are receiving more appropriate care, or are they simply dangerous delays that could be deadly for some patients?
That question has been raised both by recent research and a VA Office of the Inspector General’s report last month.
From 1998 to 2008, the median time from diagnosis to treatment at high-volume Veterans Administration hospitals grew by two weeks for colon cancer and nearly a month for rectal cancer, according to a study recently published in the Journal of Oncology Practice (JOP).1
While the researchers in that study suggest that some delays might result from improved care, a recent report from the VA’s OIG found that the monthslong delays in diagnosis and treatment experienced by gastrointestinal patients at the William Jennings Bryant Dorn VAMC in Columbia, SC, contributed to at least one death from colorectal cancer and required 19 institutional disclosures.
“The assumption is that delays in care are always harmful, but there might be very good reasons why delays are more common than before. Patients may be receiving more appropriate care,” Martin D. McCarter, MD, a co-author of the JOP study and a surgical oncologist at the University of Colorado Hospital, told U.S. Medicine.
The study analyzed 17,487 patient records from the VA Central Cancer Registry from 1998 to 2008 and compared the time from diagnosis to definitive, cancer-directed therapy such as colectomy or rectal resection. During the study period, the median time to treatment for colon cancer rose 68% to 32 days and increased 74% for rectal cancer to 47 days. Colorectal cancer is the second most common cause of death by cancer in the country and affects more than 4,000 VA-treated veterans each year.
Focus on Quality Care
“Some of it is purely staffing — we don’t have enough surgeons or nurses or anesthetists or O.R. time to meet the need,” McCarter said. “But some of this increase in wait times for cancer procedures at the VA may be due to an increased focus on quality and outcomes.”
Physicians may treat certain comorbid conditions prior to initiating direct treatment for cancer, such as “tuning up” diabetes or conducting a stress test for those with cardiology issues to ensure they can withstand surgery, suggested McCarter. Alternatively, patients may take time to seek second opinions.
There’s also been “some consolidation within the VA where certain procedures are channeled to higher-volume centers for rectal cancer when chemotherapy, radiation and surgery are required. There may be delays to get into those centers, but there is a strong association between receiving more complicated care in higher volume centers and higher rates of survival,” he noted.
The study was unable to correlate five-year survival rates to wait times. “There’s a delay in getting the survival data, and a lot of things that weren’t measured changed during the study period,” McCarter added.
“Biology dictates survival, not the timing of care,” he noted. “Everyone believes that once a tumor is discovered, you need to move quickly. That’s not necessarily true. The tumor has likely been there for years. If it takes two to four weeks to get the right plan, it’s unlikely to jeopardize the patient’s long-term survival.”
While some of the reasons for increased wait times for treatment of colorectal cancers in the VA nationwide may be attributed to improved planning and care, delays caused by staffing shortages in the gastroenterology (GI) service and poor administrative procedures jeopardized veterans’ health and lives at the VAMC in Columbia, SC, according to a report last month by the VA’s Office of Inspector General.
The Office of Healthcare Inspections investigated reports of deficient practices, delays in care and inappropriate response by leadership of the William Jennings Bryan Dorn VAMC. The report built on the results of an Administrative Investigation Board into clinical mismanagement which found that “facility leaders had not taken prompt actions to address the issues” that included “chaos” within the GI service and a backlog of more than 3,880 GI consultations.
The facility acknowledged responsibility in one patient death as a result of delays in care. That patient presented to the Dorn emergency department in May 2012 and was diagnosed with cancer. A review of the case found that a delay in GI care caused patient harm, and an institutional disclosure was made to the patient in June. He died in August 2012.
Following awareness of that case, the facility reviewed the 2011 and 2012 cancer registries and positive pathology for GI malignancies and found 280 patients diagnosed with GI malignancies, 52 of which were associated with a delay in diagnosis and treatment. As a result, the facility completed 19 institutional disclosures, with three second-level reviews pending as of mid-September. Nine patients or their families have filed lawsuits.
Meanwhile, research being conducted by a team at Harvard Medical School, the Dana-Farber Cancer Institute and Abt Associates may soon shed some light on the question of the VA’s timing of cancer treatment as well as a number of other issues.
The group is conducting a four-year program evaluation to assess cancer care within the VA, focusing specifically on breast, colorectal, lung and prostate cancers and two hematological malignancies and will be comparing survival rates among VISNs and between the VA and the private sector.
The researchers also will assess and compare the extent to which cancer patients received recommended “processes of care.” In addition, the team will look at use of medications, access to clinical trials and use of specialized treatments in the VA and private sector. The study draws on data from the general administrative data of the VA and Medicare, the VA tumor registry, the SEER-Medicare data and other sources.2
- Merkow RP, Bilimoria KY, Sherman KL, McCarter MD, et al. Efficiency of Colorectal Cancer Care Among Veterans: Analysis of Treatment Wait Times at Veterans Affairs Medical Centers. Journal of Oncology Practice. July 2013;(9):4e154-e163.
- Study of Cancer Care in the Veterans Administration
Faculty: Barbara J. McNeil, MD, PhD; Mary Beth Landrum, PhD; Nancy L. Keating, MD, MPH; and Elizabeth B. Lamont, MD, MS. Funder(s): Abt Associates/Veterans Administration.