title: Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes.
abstract: BACKGROUND
  Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system.
  
  
  METHODS
  Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery).
  
  
  RESULTS
  Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001).
  
  
  CONCLUSIONS
  The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.
authors.affiliation: Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
authors.forename: Sonia T
authors.initials: ST
authors.lastname: Orcutt
authors.affiliation: Veterans Affairs Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.|Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Nader N
authors.initials: NN
authors.lastname: Massarweh
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Linda T
authors.initials: LT
authors.lastname: Li
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Avo
authors.initials: A
authors.lastname: Artinyan
authors.affiliation: Veterans Affairs Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA.|Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Richardson
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Albo
authors.affiliation: Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA. Daniel.Anaya@moffitt.org.|Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Daniel.Anaya@moffitt.org.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Anaya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000473:pathology*; D003131:Combined Modality Therapy; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D019317:Evidence-Based Medicine; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs