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J Thorac Oncol. 2014 Apr;9(4):447-55. doi: 10.1097/JTO.0000000000000108.

Facility characteristics and quality of lung cancer care in an integrated health care system.

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*Veterans Administration Greater Los Angeles Healthcare System, West Los Angeles; Los Angeles, California; †Jonsson Comprehensive Cancer Center, University of California, Los Angeles; Los Angeles, California; ‡Department of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center; Los Angeles, California; §WellPoint, Inc., Indianapolis, Indiana; ‖Office of Informatics and Analytics, Veterans Health Administration; Washington, District of Columbia; ¶Ordin Associates; Silver Spring, Maryland; #Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco; San Francisco, California; **Veterans Administration Palo Alto Healthcare System; Palo Alto, California; ††Division of General Medical Disciplines, Stanford School of Medicine; Palo Alto, California; ‡‡Department of Biostatistics, University of California, Los Angeles; Los Angeles, California; and §§Department of Research and Evaluation, Kaiser Permanente Southern California; Pasadena, California.



In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care.


Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain.


Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence.


Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

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