Quality of Prevention and Management of Cancer Therapy-Related Cardiovascular Toxicity

About This Grant

Significance to VA: The VA annually delivers cancer to care to more than 400,000 Veterans at substantial risk of death related to cardiovascular disease (CVD). Mortality risk can be mitigated by high-quality prevention and management of cancer therapy-related cardiovascular toxicity (CTR-CVT). Non-VA studies have demonstrated significant opportunities for improvement in the quality and quality across populations of CVD care, but the quality of cardio-oncologic care in the VA is unknown. In this context, the related performance of VAMCs according to both quality and quality across populations has not been elucidated, and factors influencing hospital performance are unknown. Investigators, Scientific Review and Management priorities addressed include Veteran well-being by evaluating quality of cardio-oncologic care in VA direct and community care; timely access to cardio-oncologic care; differences in care quality according to rural residence or homelessness; and putting VA data work for Veterans by leveraging data elements unique to the VA, including cancer anatomical site, stage, and treatment via the VA Central Cancer Registry and left ventricular function via the VA Corporate Data Warehouse (CDW). Innovation and Impact: The proposed studies will provide proof-of-concept whereby VAMCs are benchmarked according to not only quality but also quality across populations, addressing a need to improve quality across populations on a health care system level. They also answer a call issued in professional society guidelines to conduct large-scale, ‘big data’ studies in the cardio-oncology space. In addition, they account for multidisciplinary perspectives including cardiology, oncology, nursing, and pharmacy via qualitative interviews and blend quality across populations with quality measurement and intervention development, areas with significant opportunities for improvement. Specific Aims: 1. Quality: In a national cohort of Veterans receiving cardiotoxic cancer treatment, assess the quality of prevention and management of CTR-CVT 2. Populations: In a national cohort of Veterans with cancer receiving cardiotoxic cancer treatment, evaluate the quality of prevention and management of CTR-CVT according to rural residence and homelessness 3. Best Practices: Profile VAMC performance according to quality and differences in quality across populations and conduct key informant interviews to identify best practices associated with high-quality care and high-quality care across populations at high-performing centers and barriers to performance at low- performing facilities Methodology: We propose an observational, retrospective, national cohort study of Veterans with cancer receiving cardiotoxic cancer treatment in conjunction with an explanatory sequential mixed methods study. Quantitative data sources will consist of the VA CDW, the VA Central Cancer Registry, the Centers for Medicare & Medicaid Services, and VA community care data; qualitative data sources will consist of semi- structured interviews of VA staff. Analyses will include mixed effects regression modeling and augmented inverse probability weighting estimation (Aims 1-2), hospital profiling via regularized regression modeling (Aim 3a), and rapid, team based approach to qualitative content analysis (Aim 3b). Path to Translation/Implementation: A stakeholder advisory panel, led by the research team and joined by representatives from the VA National Oncology Program Office, the National Cardiology Program Office, the Office of Quality and Patient Safety, the Office of Rural Health, the Office of Health Equity, and the Cardio- Oncology Veteran Consultation Group, will be convened to develop comprehensive recommendations to optimize the quality and quality across populations of prevention and management of CTR-CVT delivered to Veterans receiving cardiotoxic cancer treatment.