title: Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare.
abstract: OBJECTIVE
  The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences.
  
  
  METHODS
  We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses.
  
  
  RESULTS
  VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences.
  
  
  CONCLUSIONS
  The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.
authors.affiliation: Harvard Medical School, Boston, MA 02115, USA. landrum@hcp.med.harvard.edu
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Landrum
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Lamont
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Bozeman
authors.forename: Steven H
authors.initials: SH
authors.lastname: Krasnow
authors.forename: Lawrence
authors.initials: L
authors.lastname: Shulman
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Brown
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.forename: Michael
authors.initials: M
authors.lastname: Rabin
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: McNeil
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000191:economics / Q000401:mortality; D018288:Carcinoma, Small Cell / Q000191:economics / Q000401:mortality; D015897:Comorbidity; D018588:Fee-for-Service Plans; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000191:economics / Q000401:mortality; D016403:Lymphoma, Large B-Cell, Diffuse / Q000191:economics / Q000401:mortality; D008297:Male; D006278:Medicare; D009101:Multiple Myeloma / Q000191:economics / Q000401:mortality; D009369:Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000401:mortality* / Q000628:therapy; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012004:Rectal Neoplasms / Q000191:economics / Q000401:mortality; D018426:SEER Program; D016019:Survival Analysis; D015996:Survival Rate; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs / Q000191:economics*; D014728:Veterans / Q000706:statistics & numerical data*