title: Patient preference and contraindications in measuring quality of care: what do administrative data miss?
abstract: OBJECTIVE
  Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy.
  
  
  METHODS
  Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment.
  
  
  RESULTS
  Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments.
  
  
  CONCLUSIONS
  Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.
authors.affiliation: Administration Greater Los Angeles Healthcare System, West Los Angeles, CA, USA. joan.j.ryoo@kp.org
authors.forename: Joan J
authors.initials: JJ
authors.lastname: Ryoo
authors.forename: Diana L
authors.initials: DL
authors.lastname: Ordin
authors.forename: Anna Liza M
authors.initials: AL
authors.lastname: Antonio
authors.forename: Sabine M
authors.initials: SM
authors.lastname: Oishi
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Malin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003625:Data Collection; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000523:psychology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D058996:Quality Improvement; D019984:Quality Indicators, Health Care