*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.
J Thorac Oncol. 2014 Apr;9(4):447-55. doi: 10.1097/JTO.0000000000000108.
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.
在一个全国性的综合医疗保健系统中，我们试图确定与肺癌护理质量相关的机构层面特征。
通过从 2007 年在 131 个退伍军人健康管理机构诊断的 4804 例肺癌患者的电子病历中提取信息，评估了四个领域（诊断和分期、治疗、支持性护理、临终关怀）的 23 个质量指标的依从性。通过符合标准的患者比例报告表现。根据阶段分层患者，广义估计方程确定了与每个领域的绩效相关的机构层面特征。
年龄较大（平均年龄 67.7 岁，标准差 9.4 岁）、主要为男性（98%）的退伍军人总体表现良好。然而，没有一个机构在所有指标上都表现出色，而且各机构之间的依从性范围很大；9%的机构在一个或多个护理领域处于最高四分位数，超过 30%的机构在两个领域，65%的机构在三个领域。没有一个机构在所有领域都表现出色。不到 1%的机构在所有领域都表现不佳。很少有机构层面的特征与护理质量相关。临终关怀方面，在同一机构内进行诊断和治疗、提供癌症精神病学/心理学咨询服务以及提供住院和门诊姑息治疗咨询服务与更好的依从性相关。
退伍军人健康管理局肺癌护理质量总体较高，但各机构之间存在很大差异。除姑息治疗咨询服务对临终关怀质量的有益影响外，观察到的机构层面特征并不能始终预测指标的依从性，这表明质量可能由难以衡量的复杂当地因素决定。
