Colorectal liver metastases management in the Veterans Health Administration: Geographic disparity.

694 Background: Multidisciplinary management including surgical resection of Colorectal Liver Metastases (CLM) offers the greatest chance of long-term survival. We aimed to study surgical intervention types, rates and factors affecting the decision making in the Veterans Health Administration. Methods: The Veterans Affairs Central Cancer Registry (VACCR) and VA Informatics & Computing Infrastructure (VINCI) were queried and linked to retrospectively analyze stage IV CLM from 10/01/2004-12/31/2012. Cohort construction and statistical analyses were performed utilizing SQL Server, SAS software, version 9.4 (SAS Institute Inc., Cary, NC) and Microsoft Excel. Results: We identified 118 VA stations and 1245 subjects meeting the inclusion criteria. Hemicolectomy was identified in 79%, (637) and 21 % (168) liver metastatectomy. Open versus laparoscopic hemicolectomy was 87.96% and 12.04% respectively. Follow-up imaging post metastatic disease diagnosis was carried in 88.9% (1,108) subjects. Immense variation in the percentage of surgeries conducted and the sites of surgery when stratified by geographic location. The percentage of patients receiving surgery at the colon remained high across almost all the stations. In 53 stations, hemicolectomy and hepatectomy were attempted in at least 15% of subjects with stage IV colorectal cancer and isolated liver metastases. Of the high volume stations, only 52% had a 15% or higher percentage of hemicolectomy and hepatectomy. Subjects receiving hepatectomy only were the least frequent and occurred in only three stations. Age at diagnosis, gender, Charlson comorbidity scores and the performance status at diagnosis did not differ significantly among surgery versus no-surgery groups. Conclusions: Geographic disparity emerged as a factor affecting metastatectomy decisions. Ongoing analysis to identify and analyze the differences amongst various stations is underway. Additional characterization of the liver metastases including size, number, and specific hepatic lobe and the surgical expertise is underway.

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Survival and Causes of Death Among Veterans With Lower Extremity Revascularization With Paclitaxel‐Coated Devices: Insights From the Veterans Health Administration

Journal of the American Heart Association ◽

10.1161/jaha.120.018149 ◽

2021 ◽

Vol 10 (4) ◽

Author(s):

Jorge Antonio Gutierrez ◽

Sunil V. Rao ◽

William Schuyler Jones ◽

Eric A. Secemsky ◽

Aaron W. Aday ◽

...

Keyword(s):

Cause Of Death ◽

Veterans Health Administration ◽

Endovascular Intervention ◽

Veterans Administration ◽

Veterans Health ◽

Coding System ◽

Health Administration ◽

Term Survival ◽

All Cause Mortality

BACKGROUND The long‐term safety of paclitaxel‐coated devices (PCDs; drug‐coated balloon or drug‐eluting stent) for peripheral endovascular intervention is uncertain. We used data from the Veterans Health Administration to evaluate the association between PCDs, long‐term mortality, and cause of death. METHODS AND RESULTS Using the Veterans Administration Corporate Data Warehouse in conjunction with International Classification of Diseases, Tenth Revision ( ICD‐10 ) Procedure Coding System, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes, we identified patients with peripheral artery disease treated within the Veterans Administration for femoropopliteal artery revascularization between October 1, 2015, and June 30, 2019. An adjusted Cox regression, using stabilized inverse probability–weighted estimates, was used to evaluate the association between PCDs and long‐term survival. Cause of death data were obtained using the National Death Index. In total, 10 505 patients underwent femoropopliteal peripheral endovascular intervention; 2265 (21.6%) with a PCD and 8240 (78.4%) with a non‐PCD (percutaneous angioplasty balloon and/or bare metal stent). Survival rates at 2 years (77.4% versus 79.7%) and 3 years (70.7% versus 71.8%) were similar between PCD and non‐PCD groups, respectively. The adjusted hazard for all‐cause mortality for patients treated with a PCD versus non‐PCD was 1.06 (95% CI, 0.95–1.18, P =0.3013). Among patients who died between October 1, 2015, and December 31, 2017, the cause of death according to treatment group, PCD versus non‐PCD, was similar. CONCLUSIONS Among patients undergoing femoropopliteal peripheral endovascular intervention within the Veterans Administration Health Administration, there was no increased risk of long‐term, all‐cause mortality associated with PCD use. Cause‐specific mortality rates were similar between treatment groups.

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Utilization patterns of immune checkpoint inhibitors (ICI) for non-small cell lung cancer (NSCLC) within the veterans health administration (VHA).

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e21630 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e21630-e21630

Author(s):

Drew Moghanaki ◽

Renjian Jiang ◽

David Gutman ◽

Abigail Burns ◽

Vidula Sukhatme ◽

...

Keyword(s):

Lung Cancer ◽

Checkpoint Inhibitors ◽

Stage Iv ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Small Cell Lung ◽

Integrated Healthcare ◽

Utilization Patterns ◽

Multivariable Analyses

e21630 Background: ICI are used routinely for treatment of lung cancer. We investigated the utilization of PD-1/PD-L1 inhibitors for NSCLC in the VHA. Methods: The VHA Corporate Data Warehouse was queried for data on ICI utilization in NSCLC [IRB #00113521]. The first date of any ICI dispensed was January 6, 2015 and therefore this investigation evaluated all patients diagnosed with NSCLC between 2015 –2019. Results: A total of 27,586 Veterans were diagnosed with NSCLC during the study period with demographics: 76.3% Caucasian, 16.3% black; 97.0% male; median age 71 years. Stage distribution was 27.9%, 7.9%, 15.8%, and 27.0% for stage I, II, III, or IV, respectively. A total of 3,990 patients were identified to have received any ICI, representing 20.1% of patients diagnosed with stage IV; 159 patients received more than one ICI. The median time from stage IV diagnosis to receipt of ICI was 5 months (IQR: 2-9 months). ICI was dispensed in 83.7% for duration of < 1 year, 13.3% for 1-2 years, and 3% for > = 2 years. The median duration of ICI receipt (with IQR in months): Nivolumab = 2.0 (0.5-5.5), Pembrolizumab = 2.1 (0.3-5.9), Durvalumab = 5.1 (1.8-9.2), and Atezolizumab = 0.3 (0.1-2.1). Multivariable analyses demonstrated female, not married, 0 comorbidity, and higher stage (II-IV) were independently associated with shorter time to receipt of ICI. Conclusions: The use of ICI for NSCLC is increasing within this integrated healthcare system and commonly prescribed within 5 months of stage IV diagnosis. Further investigations of this cohort using available clinical, pharmaceutical, and genomic data within the VHA present an opportunity to enhance our understanding of the efficacy of ICI for NSCLC. [Table: see text]

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Understanding racial disparities in survival among U.S. veterans with localized high-risk prostate cancer, 2004-2019.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.6_suppl.202 ◽

2021 ◽

Vol 39 (6_suppl) ◽

pp. 202-202

Author(s):

Ravi Bharat Parikh ◽

Sumedha Chhatre ◽

Ruchika Talwar ◽

Elina Medvedeva ◽

John Cashy ◽

...

Keyword(s):

Prostate Cancer ◽

High Risk ◽

Racial Disparities ◽

Veterans Health Administration ◽

Equal Access ◽

Localized Prostate Cancer ◽

Veterans Health ◽

Health Administration ◽

Electronic Health Record Data ◽

Term Survival

202 Background: Known racial disparities in prostate cancer outcomes between African-American (AA) and non-Hispanic White (W) men may be ameliorated in the Veterans Health Administration (VA), a large national equal-access health system. We examined factors contributing to racial disparities in mortality among men with high-risk localized prostate cancer diagnosed in the VA. Methods: In this retrospective cohort study, we used linked administrative, survey, and electronic health record data from the Veterans Health Administration (VA) Corporate Data Warehouse to identify AA and W Veterans who were diagnosed with high-risk localized PC, as defined by D’Amico criteria, between January 1, 2004 and December 31, 2013. Patients were followed through December 31, 2019. The primary outcome was all-cause mortality. We used hierarchical Cox regression models, sequentially adjusting for covariates related to social determinants of health (e.g. travel time, marital status), clinical factors at diagnosis (e.g. PSA, Gleason, comorbidity), diagnosing facility, and prostate cancer treatment and adherence to American Cancer Society survivorship care guidelines. Results: Among 21,338 Veterans receiving continuous VA-based care (median age at diagnosis 66 years [interquartile range [IQR] 61-74]), 7,472 (28.7%) were AA, 9,404 (44.1%) died, and median follow-up was 8.4 years (IQR 6.1-11.1). After adjusting for all covariates, AA Veterans (adjusted hazard ratio [aHR] 0.84, 95% confidence interval [CI] 0.83-0.91) had improved overall survival compared to W Veterans. This association persisted in all hierarchical regressions (see Table), was present in all pre-specified subgroups, and was strongest among Veterans living in rural domiciles (aHR 0.70, 95% CI 0.64-0.77). Conclusions: AA Veterans with high-risk localized prostate cancer had improved long-term survival compared to W Veterans, which stands in contrast to prior studies among non-Veterans. Equal access to care may improve racial disparities in prostate cancer, although future studies should clarify mechanisms of improved survival for AA Veterans with prostate cancer in order to provide insights for ameliorating outcome disparities in non-Veterans with prostate cancer. [Table: see text]

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National Trends in End-of-Life Care for Veterans With Advanced Cancer in the Veterans Health Administration: 2009 to 2016

Journal of Oncology Practice ◽

10.1200/jop.18.00559 ◽

2019 ◽

Vol 15 (6) ◽

pp. e568-e575 ◽

Cited By ~ 5

Author(s):

Claire E.P. Smith ◽

Arif H. Kamal ◽

Monica Kluger ◽

Patty Coke ◽

Michael J. Kelley

Keyword(s):

Lung Cancer ◽

End Of Life ◽

Analysis Of Variance ◽

Stage Iv ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Icu Admission ◽

Stage Iv Lung Cancer ◽

Hospice Use

PURPOSE: It is imperative to provide quality end-of-life (EOL) care for patients with cancer. Although rates of hospice use within the Veterans Health Administration have improved, antineoplastic administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, have not clearly declined over recent years. METHODS: We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009 and 2016 using a novel EOL Dashboard Tool created from Veterans Administration Cancer Registry data. This EOL tool reports the incidence of antineoplastic drug use in the last 14 days of life, ICU admission in the last 30 days of life, and hospice admission or consult. Change from 2009 to 2016 was assessed using a repeated measures one-way analysis of variance with post hoc test for linear trend of time for individual cancers and two-way analysis of variance for all cancers combined. RESULTS: Antineoplastic use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 ( P = .03). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was patients with stage IV lung cancer, in whom ICU admissions increased from 12.9% to 16.2% ( P = .01). Patients using hospice services increased from 32.4% to 52.6% ( P < .01). CONCLUSION: Although antineoplastic administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice use.

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An Intervention With Meaning

Crisis ◽

10.1027/0227-5910/a000433 ◽

2017 ◽

Vol 38 (6) ◽

pp. 376-383 ◽

Cited By ~ 2

Author(s):

Brooke A. Levandowski ◽

Constance M. Cass ◽

Stephanie N. Miller ◽

Janet E. Kemp ◽

Kenneth R. Conner

Keyword(s):

High Risk ◽

Qualitative Methodology ◽

Veterans Health Administration ◽

Veterans Health ◽

Safety Planning ◽

Health Administration ◽

Suicide Method ◽

Treatment Providers ◽

Interactive Nature ◽

Behavioral Health Treatment

Abstract. Background: The Veterans Health Administration (VHA) health-care system utilizes a multilevel suicide prevention intervention that features the use of standardized safety plans with veterans considered to be at high risk for suicide. Aims: Little is known about clinician perceptions on the value of safety planning with veterans at high risk for suicide. Method: Audio-recorded interviews with 29 VHA behavioral health treatment providers in a southeastern city were transcribed and analyzed using qualitative methodology. Results: Clinical providers consider safety planning feasible, acceptable, and valuable to veterans at high risk for suicide owing to the collaborative and interactive nature of the intervention. Providers identified the types of veterans who easily engaged in safety planning and those who may experience more difficulty with the process. Conclusion: Additional research with VHA providers in other locations and with veteran consumers is needed.

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