Guideline-discordant care more common among Medicare beneficiaries than VA patients

U.S. veterans who opt for fee-for-service health systems like Medicare are less likely to receive guideline-concordant care than their counterparts in the Veterans Health Administration (VA), researchers reported in a JAMA Network Open original investigation this month.

Corresponding author Danil V. Makarov, MD, MHS, of the VA New York Harbor Healthcare System and New York University School of Medicine, and colleagues said in the journal that reducing guideline-discordant prostate cancer staging imaging is “an important national priority”—one that could extend beyond the reach of the VA. And with the 2014 extension of the Veterans Access, Choice and Accountability Act, which allocates government funds to veterans seeking care outside the VA system, physicians are unsure of the quality and cost-effectiveness of care patients are currently seeing.

“Outside the VA health system, there may be higher rates of guideline-discordant prostate cancer imaging, suggesting a trade-off of resources for quality of care in a fee-for-service setting,” Makarov et al. wrote. “If the rates of guideline-discordant prostate cancer imaging [were] actually lower outside the VA health system, it is possible that there is a problem in terms of quality of care in an integrated health system.”

In an effort to assess the link between prostate cancer imaging rates and a VA versus Medicare healthcare model, the researchers collected data from 98,867 men diagnosed with prostate cancer between 2004 and 2008. The men were identified from the VA Central Cancer Registry, the Surveillance, Epidemiology and End Results Program database, and Medicare claims, and were grouped into three cohorts: Medicare only, VA only and combined VA and Medicare.

Of the nearly 100,000 men studied, 57.3 percent were in the Medicare-only group, the authors said. Nearly 15 percent were in the combined group, while 28 percent fell into VA-only care. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging, followed by the combined group and VA-only group. In a cohort of men with high-risk prostate cancer, imaging rates didn’t vary.

The researchers said veterans who sought care through both the VA and Medicare were perhaps most likely to experience guideline-discordant imaging and overuse because of the potential for poor care in two systems, but results didn’t echo that concern.

“The results suggest that patients using the Choice Act are likely to experience more utilization of care without a guarantee of improved quality of care,” Makarov et al. wrote. “Future research to improve guideline-concordant care for prostate cancer imaging should consider and explore varying contexts and the role of unique settings of different health systems.”