VA Colon Cancer Quality and C

Study: Estimating Healthcare 

for Colon Cancer

Denise M. Hynes, RN, MPH, PhD Denise M. Hynes, RN, MPH, PhD 

Center for Management Center for Management of Complex of Complex Chronic Care &

VA Information Resource Information Resource Center, Edward Hines Jr. VA Hospital Hin

College ofCollege of Medicine and Medicine and School ofSchool of Public Health, Public Health, 

University UniversityUniversity University of IllinoisIllinois Illinois, Chicago Chicago, IL
Focus for Today

• VA C l o on Cancer Q lit ua y of Care and C 

Study

• Approaches and Data Sources Used fo

Estimating Costs

• Alternative Methods for Dealing with 

and Impacts on Results
Overview

VA COLON CANCER QUALITY QUALITY A

COSTS STUDY
Objective

• Examine and compare healthcare use 

costs for colon cancer patients treated 

Veterans Health Administration (VA) a

Medicare

• Completed study funded by VA HSR&D 

begun in 2004
– 

Acknowledgements

• Advisors: • Coauthors/Investigators:

– Al Benson, MD, 

Elizabeth Tarlov, PhD, RN

– Nirmala Bhoopa

Bhoopa

– Todd A. Lee, PharmD, PhD – Vivien W. Chen, 

– Thomas Weichle, MS – Marc T. Goodma

– Dawn Provenzal

– Ramon Durazo‐Arvizu, PhD

– Beth Virnig, PhD

– Ruth Perrin, MA – Min Woong‐Soh– Qiuying Zhang, MS – David Bentrem, 

– Charles Bennet

– Rosario Ferreira MD, MAPP

Funding from the Department of Veterans Affairs (VA) Health SeResearch and Development Service, No. IIR‐03‐196
~

How Much Does Colon Cancer 

Cost ?

• Direct Medical Cost• Est. average cost of between $35,000 and $80,000 for e

episode

• T t o al cost for treatment of anticipated new cases ~ $8.3 

• Medicare Treatment Cost

• With first‐year Medicare treatment spending after dete

estimated at $35,800 per case,

• Medicare Medicare spending spending for new colorectal colorectal cancer cases ~ $

• Treatment Cost: Early Detection vs. Late Stage

• Early ~ $30,000/patient

• Late ~ $120,000/patient

2007 
Cost of Care Varies Wide

• The total cost of chemotherapy to tre

colorectal cancer may differ by as muc

$36,999 per patient, depending on th

regimen

– Lyman ,et al., AmJ Managed Managed Care, 2008 (See Variation Variation in the cost of medications medications 

colorectal cancer. Ferro SA, Myer BS, Wolff DA, et al. Am J Manag Care. 2008 No
VA and Cancer Care

• VA treats about 175,000 cancer patien

year

• VA cancer care is the focus of a

congressionally mandated Governmen

Performance and Results Act study

• Evaluation Evaluation and measurement measurement of cance

and outcomes in the VA population is

complicated complicated by veterans veterans’ use of both 

non‐VA
VA Cancer Care Facility Facility Characte

Characte

Source: Program Evaluation of Oncology Programs in the VHA – 

Facilities, GPRA Evaluation, 2006
What We Know About

Dual VA and Medicare Use

• Over 80% of elderly veterans eligible to use VA, us

alone or with VA services (Hynes, et al., 2007)

• Empirical evidence of quality of care problems for 

medi l ca illnesses in a muli l t p e provider situation (

Cowper, 1999 and Petersen, et al., 2001)

• Patients using more than one healthcare system m

coordination coordination of care across systems systems to be lacking lacking, 

delays in care and excessive healthcare use and co
Colon Cancer Management Stra

1999‐2002

• Stage 0 • Stage IV

 Local excision or simple  Surgical resection/ a

p yp ol ectomy with clear margins b f ypass of primary l 

e

 Radiation therapy t

• Stage I & II

 Wide surgical surgical resection resection &  Surgical Surgical resection resection o

anastomosis metastases (liver, lu

 Adjuvant chemotherapy in  Adjuvant chemothe

controlled clinical trials only

 Clinical trials evalua

& biologic therapy • Stage III

 Wide surgical surgical resection resection &

anastomosis

 Adjuvant chemotherapy


Methods

 Retrospective cohort

 Dually eligible for VA and Medicare ben

 At least 66 yrs old in 1999–2001

 Matched & linked to incident cancer reco

Central Cancer Registry or one of 8 NCI Sregistries

– Participating SEER registries: Atlanta, C

Detroit Detroit, Hawaii, Iowa, Louisiana Louisiana, New J

Western Washington
Methods

• D l ua Use Measure

– Specific to Colon Cancer Care

• Colon cancer, colectomy, or chemotherapy even

by diagnosis, DRG, procedure, HCPCS, BETOS, re

center, clinic stop, or pharmacy class codes

• Calculated based on percentage of colon cancer 

inpatient inpatient and outpatient outpatient healthcare healthcare use in the V

• Three CC User Groups: Dual, Predominantly Me

Pd i re om nantly VA
e

Number of VA

Colon Cancer

Related Inpatient

Stays

& Outpatient

Events

Number of

VA

+ Medicare

Colon Cancer

Related Inpatient

Stays

& Outpatient

Events

0‐14% Predom

Medica

Percent of

Care

Provided in

VA

15 Dual 

‐85%

Predomi

Us

86–100%
Methods

APPROACHES AND DATA SOURUSED FOR ESTIMATING ESTIMATING COSTS
-

VIReC Finder file VIReC Finder file 

Veterans known to VA

at least 66 years old

dually eligible to use VHA and Medicare 

between 1999 between 1999 -2001

3,482,654 

Exclusions: 1 485, 

Incomplete or absent utilization information 

At some point during the study period*: 

Not enrolled or not elig ible for VA care (259) 

Medicare HMO enrollment (1,056) Non-Medicare primary payer (private insurance) (86) Medicare Part B coverage only (19) 

No healthcare utilization records during study period No healthcare utilization records during study period, 

reason unknown (60) No utilization records during 6-month period surrounding diagnosis date, reason unknown (438) 

Autopsy-only diagnosis (1 )5 No colon cancer-related health care within 12 month after diagnosis (101) Zero colon cancer Zero colon cancer-related costs related costs (92) 

8 SEER pro8 SEER pro

California Io

Louisiana N

Wester

MetMet

and VA C

R

Ma

Vet

stage I stage I –

diagno

7/1/9

who were 

at the timat the tim

Analy
–

Summary Summary of Data Sources Sources U

• Define Cohort

– VIReC Finder File

– NCI SEER (8)

– VA Central Central Cancer Registry Registry (VA CCR)

• Determine Exclusions based on Healthcare 

– VA Workload data‐‐MEDSAS

– Medicare Claims
Methods: Methods: Measuring Measuring Co

• 12 M th on s from diagnosis

• Valuation:

– VA cost val d ue using H lth ea Economic Reso

Center (HERC) average cost approach

– Medicare Medicare valued using Medicare Medicare payments payments

• Includes

– VA and Medicare Medicare acute and intermediate intermediate in

in

and outpatient utilization, including pharma

• Excludes

– VA long term care

– Medicare home health care, hospice, & DM
A li na ys s

• Healthcare use & costs within 12 months af

diagnosis

Descriptive analyses (StataTM)

 Compared overall ( p in atient and outpatient) costs Examined association of user group (Dual, Predominantly 

Predominantly VA) with costs

 Adjusted for predisposing, enabling, and contextual facto

Multivariable Multivariable regression regression analysis analysis (GLM) (StaAll costs adjusted to 2004 dollars
Cohort Characteristics Characteristics (N=3

Age at diagnosis (yrs) 66–75 

76–85 86 and older 

Gender Male Race African American Marital Marital status Not married married 

Married Unknown 
Cohort Characteristics Characteristics (N=3

Stage at diagnosis diagnosis I 

II III IV 

Comorbidity scoreb 0 

1 2–3 4 or higher 

Chemotherapyc Yes 

Colectomyd Yes 

b Measured from months ‐6 to 0 in study period; c Measured from mont

period.; d Measured from months ‐1 to 6 in study period.
Colon Cancer Care 12 Month C

By User Group (N=3,842)

P

Predominantly Medicare Dual Use

P

N Mean (SD) N Mean (SD) N 

Total CCCosts 1,417 39,136 (31,567) 510 44,264 (50,567) 1,915 

Inpatient 1,370 32,907 (29,836) 492 42,174 (50,866) 1,808 

VA 35 37,166 (42,554) 340 41,785 (51,806) 1,797 

Medicare 1,357 32,264 (29,159) 337 19,181 (18,622) 83 

Outpatient 1,308 7,930 (10,587) 498 3,665 (6,347) 1,706 

VA 166 357 (462) 460 1,213 (1,976) 1,697 

Medicare 1,306 7,897 (10,557) 453 2,750 (5,967) 186 

* All s
Colon Cancer Care 12 Month 

By User Group (N=3,842)

Predominantly 

Medicare Dual use 

(N = 1,417) (N = 510) 

Mean (SD)

Inpatient admissions per

patient 1.5 (1.0) 1.9 (1.2) Days per inpatientadmission 13.7 (15.8) 15.5 (19.0) T t o al inpatient days per

patient 21.3 (23.4) 29.4 (33.7) 

Outpatient Outpatient visits per patient patient 35.7 (29.9) 19.2 (22.0) Total outpatient visit days 24.8 (20.1) 14.4 (14.4) 

* All signif
–

a ed

Estimated Expense Rate Rat

(N=3,842)

Adjusted ERR

(95% Confidence Intervals)

Age at Diagnosis

66–7576–8586 and older

Race

Non‐African American

African American

Married

NoYesUnknown

Stage at diagnosis

IIIIIIIV

Ref

1.17 (1.08–1.27)

1.24 (1.04–1.47)

Ref

1.14 (1.03–1.28)

Ref

0.88 (0.81–0.95)

0.58 (0.40‐0.86)

Ref

1.37 (1.23–1.53)1.84 (1.63–2.07)

2.27 (2.01–2.56)
Estimated Expense Rate Rat

(N=3,842)

Adjusted ERR

(95% Confidence Confidence Interv

Interv

Comorbidity score

0 Ref

1 1 17 . (1.08–1.28)2 or 3 1.48 (1.33‐1.66)

4 or higher 2.07 (1.74–2.42)

Chemotherapy

No RefYes 0.92 (0.85–1.00)

Surg y er

No colectomy RefColectomy 1.51 (1.31–1.73)

User Group

Predominantly Medicare 0.85 (0.76–0.95)

Dual user Ref

Predominantly VA 0.88 (0.78–0.99)

Expense rate ratios from GLM model (gamma family with log link

adjusters include hospitals w/oncology services and outpat
Results Summary

Adjusted costs were lower among sing

system CC users compared compared to dual CC 

 Compared Compared to dual users, adjusted adjusted costs were:

15% lower among predominantly Medicare CC use

(ERR: 0.85, CI95%: 0.76–0.95)

 12% lower among predominantly VA CC users

(ERR: 0.88, CI95%: 0.78 – 0.99)
Impact on Results

ALTERNATIVE METHODS FOR DEAWITH OUTLIERS OUTLIERS AND INFLUENTIA

INFLUENTIA

CASES
GLM Models & Limitatio

Limitatio

• Can accommodate accommodate skewness skewness in large

datasets by weighting variances witho

assumptions assumptions regarding regarding distribution distribution

• Mis‐specifying variance function in GL

can result in losses of preci is on

• Can lose efficiency if data have large lo

scale error variance or error distributio

log scale is symmetrical but has a heav
Colon Cancer Care 12 Month C

By User Group (N=3,842)

P

Predominantly Medicare Dual Use

P

Mean

(SD)

Mean

(SD)

N

(SD)

Range N

(SD)

Range N

Total ColonCancerCost 1,417

39,136

(31,567)

(42 ‐ 405,892) 510

44,264

( , 50 567)

(138 ‐ 679,471) 1,915

Inpatient 1,370 32,907 (29,836) 492 42,174 (50,866) 1,808 Outpatient 1,308 7,930 (10,587) 498 3,665 (6,347) 1,706 

* All s
–

Approaches to Identify Outlie

Influential Observations

• Adjusting outliers

– Box‐plot analysis

• Interquartile method

– Winsorization

• Involves replacing (or limiting) extreme values

• Influential observations

– Cook’s distance

• Measures the aggregate change with omission

DFBETAs

• Focuses on impact on each regressor
Characteristics of Each Appr
Key Cost Drivers
Limitations

• S l ti e ec on bias: three level exposure vari bl a e (use

not easily amenable to propensity score matchin

• Cases reported from NCI SEER may not represen

reported cases outside VA

• Coverage in VA and Medicare differs; attempted 

comparable care, i.e. inpatient and outpatient ca
Conclusions

 Costs were lower for single system users compar

users

 These differences were similar using different ap

for accounting for outliers and influential cases

 Costs were also higher among patients who wer

American, had more comorbidities, were older, o

more advanced‐stage disease

 Differences in the course of treatment, quality o

costs attributable to colon cancer warrants furth
Time for Questions Questions

THANK YOU !
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