The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer

Leah L Zullig,^1,2 William R Carpenter,² Dawn T Provenzale,^1,3 Morris Weinberger,^1,2 Bryce B Reeve,² Christina D Williams,¹ George L Jackson<sup>1,4

1</sup>Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA; ²Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; ³Division of Gastroenterology, Duke University, Durham, NC, USA; ⁴Division of General Internal Medicine, Duke University, Durham, NC, USA

Background: Non-small cell lung cancer is the leading cause of cancer-related mortality in the United States. Patients with late-stage disease (stage 3/4) have five-year survival rates of 2%–15%. Care quality may be measured as time to receiving recommended care and, ultimately, survival. This study examined the association between race and receipt of timely non-small cell lung cancer care and survival among Veterans Affairs health care system patients.
Methods: Data were from the External Peer Review Program, a nationwide Veterans Affairs quality-monitoring program. We included Caucasian or African American patients with pathologically confirmed late-stage non-small cell lung cancer in 2006 and 2007. We examined three quality measures: time from diagnosis to (1) treatment initiation, (2) palliative care or hospice referral, and (3) death. Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models.
Results: After controlling for patient and disease characteristics using Cox regression, there were no racial differences in time to initiation of treatment (72 days for African American versus 65 days for Caucasian patients, hazard ratio 1.04, P = 0.80) or palliative care or hospice referral (129 days versus 116 days, hazard ratio 1.10, P = 0.34). However, the adjusted model found longer survival for African American patients than for Caucasian patients (133 days versus 117 days, hazard ratio 0.31, P < 0.01).
Conclusion: For process measures of care quality (eg, time to initiation of treatment and referral to supportive care) the Veterans Affairs health care system provides racially equitable care. The small racial difference in survival time of approximately 2 weeks is not clinically meaningful. Future work should validate this possible trend prospectively, with longer periods of follow-up, in other veteran groups.

Keywords: non-small cell lung carcinoma, Veterans Affairs, quality of health care