National evaluation of the VA’s quality of supportive care.

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218 Background: Although known to provide more efficient end-of-life cancer care, the quality of VA’s end of life cancer care is unknown. We used Cancer Quality ASSIST to evaluate supportive care comprehensively in a national sample. Methods: We measured ASSIST QIs addressing symptoms, communication, treatment toxicities, and complications among 719 Veterans with a 2008 registry diagnosis of stage IV colorectal (37%), pancreatic (30%), or lung cancer (33%). We abstracted records from diagnosis for 3 years or until death among eligible Veterans (lived >= 30 days following diagnosis with >= 1 VA hospitalization or >=2 VA outpatient visits). We determined patient-level overall and individual QI scores (%delivered/appropriate care) and confirmed reliability on a 5% sample, retaining 39 of 42 QIs. Results: Most Veterans were older (mean 66 years) male (97%), and white (68%) with 20% African American, and 3% Hispanic. 85% had >=1 hospitalization and 93% died. Overall, subjects received 48% of recommended care. The average Veteran triggered 13 QIs, and scores ranged from 0-98% (pain 0-96%; dyspnea 11-98%, depression 36-79%, fatigue 4-80%, nausea/vomiting 41-87%, treatment toxicities 13-70%, care planning 18-86%). Notable gaps in care were identified. Inpatient pain screening was common (96%) but lacking for outpatients (58%). With opioids, bowel prophylaxis occurred for only 52% of outpatients and 70% of inpatients. Few patients had timely dyspnea evaluation (16%) or treatment (11%). Outpatient assessment of fatigue occurred for 32%. 24% of patients who received chemotherapy high risk for diarrhea were offered appropriate anti-diarrheals. Only 19% of Veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63% of patients had timely discussion of goals following ICU admission. Most decedents (86%) were referred to palliative care or hospice before death. Single vs. multiple fraction radiotherapy should have been considered in 28 Veterans with bone metastasis, but none were offered it. Conclusions: These patient and family-centered supportive care gaps reflect important HRQOL impacts and targets for quality improvement in a system known for excellence in chronic disease care.