Some Long Wait Times Attributable to Treatment Modalities
by Annette M. Boyle
CHICAGO – The news media frenzy of the last six months might suggest otherwise, but concerns about delays in treatment for veterans are nothing new at the VA, especially related to cancer treatment.
For example, at least two studies have documented increasing delays in initiation of treatment for cancer since 1995, although the impact of the treatment delays on outcomes has not been clear.
Those earlier reports attributed much of the increase in wait times to demographic and diagnostic developments and changes in treatment, said Karl Bilimoria, MD, director of the surgical outcomes and quality improvement center and co-director of the Northwestern Institute for comparative effectiveness research in oncology at the Feinberg School of Medicine at Northwestern University in Chicago.
“The lengthening of wait times is multifactorial and not entirely understood but likely involves the fact there are more veterans, more cancers diagnosed (particularly early cancers due to better screening and imaging) and more involved staging of cancer,” he told U.S. Medicine. In addition, the multimodal approach to treatment of many cancers requires more appointments and more coordination of care, which can extend the time from diagnosis to first treatment.
Wait Increase for All Cancers
In a study published in the Annals of Surgery in 2011, Bilimoria and colleagues analyzed the National Cancer Data Base records of 1,228,071 patients treated at 1,443 hospitals for non-metastatic breast, colon, esophageal, gastric, liver, lung, pancreatic and rectal cancer from 1995 to 2005. They found that patients treated at National Cancer Institute Comprehensive Cancer Centers (CCCs) and VA hospitals experienced longer times from diagnosis to treatment than patients treated in community hospitals across all eight types of cancer and that average wait times for cancer surgery had risen by more than 20% overall during the 10 years studied.1
For both CCCs and VAMCs, the researchers noted that increased wait times may be partially attributed to higher patient volumes resulting from a push toward concentration of cancer care in high-volume regional centers where outcomes have historically been better.
In a more recent study published in the Journal of Oncology Practice, Bilimoria and his colleagues looked at 17,487 patient records to determine wait times for colorectal surgery at 124 VA hospitals. They found that the median time to treatment rose 68% from 1998 to 2008 for colon cancer and 74% for rectal cancer.2
The wait times at VA hospitals were much longer than at other medical facilities. Patients with colon, liver, rectal and gastric cancers waited two to two and a half times longer for treatment in VA hospitals than patients in community hospitals. For the other four types of cancer, patients treated at VA hospitals waited at least 40% longer for treatment than those treated in community hospitals. They also waited 20% to 50% longer than patients treated at comprehensive cancer centers (CCCs).
For most cancers, veterans waited about 30 days from diagnosis to treatment, but for rectal, lung and liver cancers the median time to treatment rose to 41 days for rectal cancer to 66 days for liver cancer if they were treated in the same hospital in which they were diagnosed. The wait times were 51 days for rectal cancer and 71 days for lung cancers if patients transferred to another facility for treatment.
Regionalization of Care
In addition to extending time to treatment, regionalization has other unintended consequences, noted Bilimoria. For some veterans, “regionalization of care may not be feasible as the distance to the high-volume center is too far and patients do not want to travel or they may want to stay with their own local doctors.” For veterans who need multiple appointments to complete the multimodal treatment approach common to many cancers, seeking care in a remote center may simply be too difficult.
Regionalization also reduces the quality of care available at local VA hospitals. As low-volume facilities, some VAMCs are more similar to community hospitals than to CCCs. If the treatment for complex cancers is concentrated at regional centers, the local hospital may not be able to help a patient with post-operative complications when they return home.
“Thus, it is important to keep seeking opportunities and innovating approaches to improving the quality of care at all hospitals,” Bilimoria said.
But regionalization doesn’t account for all the delays. The researchers noted in the 2013 Journal of Oncology Practice study that “extended wait times may be related to limited hospital resources in the face of a growing patient population within the VA system, the fragmentation and lack of coordination of specialized care, the increasing complexity and demands of care, and the lack of systems to improve efficiency.”
Consequently, reducing the wait times requires a systemic commitment and new approaches. In the JOP article, the researchers suggested that a coordinated, multidisciplinary approach to cancer care could help.
Bilimoria suggested that addressing the resource issue should be a priority. “The VA system needs more resources to get patients through the system faster: navigators to help patients through the system, more physicians, physician extenders, nurses, CT scanners, operating rooms.”
If more resources cannot be made available within the VA, leadership needs “to admit the VA cannot handle their charge of providing safe, effective and timely care for all veterans, and all veterans should be given a version of the best type of Medicare so they can go to any hospital or doctor, have all the expenses covered and receive timely care,” Bilimoria added.
A corrected version of the National Consult Delay Review, delivered to Congress in April, found that the deaths of 24 veterans from 2010-2012 could have been attributed to delays in treatment for gastrointestinal cancers, but the connection between extended delays and mortality is not always clear.
At the Phoenix VAMC, however, the VA Office of Inspector General found in a recent report that extended delays in receiving consults or follow-up treatment for cancer were attributed to poor management practices — and had potentially devastating effects on patients. In one case, a chest X-ray during a hospitalization of a veteran with a history of smoking and persistent cough found a large density in the right lung and he was advised to get a CT scan of his chest within two months. Six weeks later, he presented to the ED with shortness of breath and was diagnosed with non-small cell lung cancer. He died within several days. The OIG noted that the follow-up recommendation at the time of discharge was “unacceptable” and the CT scan should have been performed during the patient’s hospitalization or, barring that, he should have been discharged with a scheduled radiology appointment.
At another VA facility, a veteran had been treated for prostate cancer and had achieved undetectable PSA levels, according to the IG’s report. A follow-up appointment was made for retesting in six months, but the urology staff canceled the appointment and did not reschedule. Three months later, another PSA test showed a level of 0.9 ng/ml. As part of a routine appointment, a third PSA test done seven months later showed a value of 98 ng/ml and another urology consult was placed. Within a month, the patient presented to the ED with acute back pain and X-rays found lytic lesions in his lumbar spine, presumably from metastatic prostate cancer. Urology initiated treatment immediately, but he died within a few months. The IG concluded that “at one of this patient’s canceled urology service appointments, providers might have identified or confirmed the patient’s rising PSA, which could have prompted an earlier initiation of aggressive treatment.”
Both of the clinical studies of wait times for cancer treatment found that early stage disease was a primary risk factor for longer delays between diagnosis and treatment. But Bilimoria pointed out that survival is far from the only indicator of quality care.
“Demonstrating a survival difference is challenging,” Bilimoria noted. “A couple of months probably does not matter for most patients, but for those two months, the patient’s life is on hold. They are under tremendous mental stress, so timeliness of cancer care is about far more than just improving their chances of surviving.”
1Bilimoria KY, Ko Cy, Tomlinson JS, Stewart AK, Talamonti MS, Hunes DL, Winchester DP, Bentrem DJ. Wait Times for Cancer Surgery in the United States: Trends and Predictors of Delays. Ann Surg 2011;253:770-785.
2Merkow RP, Bilimoria KY, Sherman KL, McCarter MD, Gordon HS, Bentrem DJ. Efficiency of Colorectal Cancer Care Among Veterans:AnalysisofTreatment Wait Timesat Veterans Affairs Medical Centers. J Oncol Pract (2013) 9 (4): e154-163.
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