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Timeliness of Specialty Palliative Care for Veterans With Cancer: An Analysis of Administrative Data
Background
Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.
Methods
We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.
Results
Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.
Conclusions
We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.
Background
Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.
Methods
We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.
Results
Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.
Conclusions
We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.
Background
Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.
Methods
We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.
Results
Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.
Conclusions
We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.
“It Takes a Village”: Benefits and Challenges of Navigating Cancer Care with the Pacific Community and the Veterans Health Administration
Background
The Palliative Care in Hawaii/Pacific Island Communities for Veterans (PaCiHPIC Veterans) study is a VA-funded research study that explores social determinants of health, cultural values, and cancer disparities impacting Native Hawaiian/Pacific Islander/US-affiliated Pacific Island resident (NHPI/USAPI) Veterans.Cancer prevalence and mortality are increasing among NHPI/ USAPI Veterans which can be partly attributed to nuclear fallout from U.S. military activities in the region. This population faces geographic, financial, and logistical barriers to cancer care. There is an imminent need to understand and address access to cancer care and palliative care to reduce disparities within this population.
Methods
We interviewed 15 clinicians including physicians, nurses, nurse practitioners, social workers, and clinical psychologists specializing in primary care, palliative care, and oncology, self-identifying as White, Asian American, NHPI, and Multiracial. Interviews were transcribed verbatim and de-identified. Using inductive and deductive strategies, we iteratively collapsed content into codes formulating a codebook. Thematic analyses were performed using dual-coder review in Atlas.ti v23. Themes were mapped to the socioecological model.
Results
Clinicians described how NHPI/USAPI Veterans receive healthcare and instrumental support at individual, community, and systems levels, including from family caregivers, “high-talking chiefs,” traditional healers (“suruhanu”), community health clinics, and the VHA. Clinicians identified challenges and opportunities for care coordination: (1) financial and logistical barriers to involve family and decision-makers; (2) clinician understanding of cultural values and influence on medical decision-making; (3) care fragmentation resulting from transitions between community care and VHA; and (4) collaboration with key individuals in Pacific social hierarchies.
Conclusions
Cancer navigation and care coordination gaps create challenges for clinicians and NHPI/USAPI Veterans managing cancer in the Pacific Islands. Better understanding of these systems of care and associated gaps can inform the development of an intervention to improve cancer care delivery to this population. NHPI/ USAPI Veterans may experience care fragmentation due to care transitions between community care and the VHA. At the same time, these sources also create multiple layers of support for Veterans. Interventions to address these challenges can leverage the strengths of Pacific communities, while striving to better integrate care between community healthcare providers and VHA.
Background
The Palliative Care in Hawaii/Pacific Island Communities for Veterans (PaCiHPIC Veterans) study is a VA-funded research study that explores social determinants of health, cultural values, and cancer disparities impacting Native Hawaiian/Pacific Islander/US-affiliated Pacific Island resident (NHPI/USAPI) Veterans.Cancer prevalence and mortality are increasing among NHPI/ USAPI Veterans which can be partly attributed to nuclear fallout from U.S. military activities in the region. This population faces geographic, financial, and logistical barriers to cancer care. There is an imminent need to understand and address access to cancer care and palliative care to reduce disparities within this population.
Methods
We interviewed 15 clinicians including physicians, nurses, nurse practitioners, social workers, and clinical psychologists specializing in primary care, palliative care, and oncology, self-identifying as White, Asian American, NHPI, and Multiracial. Interviews were transcribed verbatim and de-identified. Using inductive and deductive strategies, we iteratively collapsed content into codes formulating a codebook. Thematic analyses were performed using dual-coder review in Atlas.ti v23. Themes were mapped to the socioecological model.
Results
Clinicians described how NHPI/USAPI Veterans receive healthcare and instrumental support at individual, community, and systems levels, including from family caregivers, “high-talking chiefs,” traditional healers (“suruhanu”), community health clinics, and the VHA. Clinicians identified challenges and opportunities for care coordination: (1) financial and logistical barriers to involve family and decision-makers; (2) clinician understanding of cultural values and influence on medical decision-making; (3) care fragmentation resulting from transitions between community care and VHA; and (4) collaboration with key individuals in Pacific social hierarchies.
Conclusions
Cancer navigation and care coordination gaps create challenges for clinicians and NHPI/USAPI Veterans managing cancer in the Pacific Islands. Better understanding of these systems of care and associated gaps can inform the development of an intervention to improve cancer care delivery to this population. NHPI/ USAPI Veterans may experience care fragmentation due to care transitions between community care and the VHA. At the same time, these sources also create multiple layers of support for Veterans. Interventions to address these challenges can leverage the strengths of Pacific communities, while striving to better integrate care between community healthcare providers and VHA.
Background
The Palliative Care in Hawaii/Pacific Island Communities for Veterans (PaCiHPIC Veterans) study is a VA-funded research study that explores social determinants of health, cultural values, and cancer disparities impacting Native Hawaiian/Pacific Islander/US-affiliated Pacific Island resident (NHPI/USAPI) Veterans.Cancer prevalence and mortality are increasing among NHPI/ USAPI Veterans which can be partly attributed to nuclear fallout from U.S. military activities in the region. This population faces geographic, financial, and logistical barriers to cancer care. There is an imminent need to understand and address access to cancer care and palliative care to reduce disparities within this population.
Methods
We interviewed 15 clinicians including physicians, nurses, nurse practitioners, social workers, and clinical psychologists specializing in primary care, palliative care, and oncology, self-identifying as White, Asian American, NHPI, and Multiracial. Interviews were transcribed verbatim and de-identified. Using inductive and deductive strategies, we iteratively collapsed content into codes formulating a codebook. Thematic analyses were performed using dual-coder review in Atlas.ti v23. Themes were mapped to the socioecological model.
Results
Clinicians described how NHPI/USAPI Veterans receive healthcare and instrumental support at individual, community, and systems levels, including from family caregivers, “high-talking chiefs,” traditional healers (“suruhanu”), community health clinics, and the VHA. Clinicians identified challenges and opportunities for care coordination: (1) financial and logistical barriers to involve family and decision-makers; (2) clinician understanding of cultural values and influence on medical decision-making; (3) care fragmentation resulting from transitions between community care and VHA; and (4) collaboration with key individuals in Pacific social hierarchies.
Conclusions
Cancer navigation and care coordination gaps create challenges for clinicians and NHPI/USAPI Veterans managing cancer in the Pacific Islands. Better understanding of these systems of care and associated gaps can inform the development of an intervention to improve cancer care delivery to this population. NHPI/ USAPI Veterans may experience care fragmentation due to care transitions between community care and the VHA. At the same time, these sources also create multiple layers of support for Veterans. Interventions to address these challenges can leverage the strengths of Pacific communities, while striving to better integrate care between community healthcare providers and VHA.
