Samuel and Keating Respond

We agree with Stirling on the need for quality measurement and reporting practices that effectively engage health systems in the improvement of care delivery and outcomes. The efforts of the cancer registries in Australia and Denmark to improve lung cancer care^1,2 are indeed noteworthy. The quality measures included in our study were developed to reflect recommendations from evidence-based national guidelines for cancer care that could be ascertained relatively efficiently using existing data sources (cancer registry and administrative data). Although our study focused on cancer care within the Veterans Affairs (VA) health care system, such measures can similarly be used to assess care for other populations, including Medicare beneficiaries in the United States.^3,4

We focused on care in the VA because the goal of our study was to better understand the extent and nature of health care disparities in a large “equal-access” integrated health system, such as the VA health care system. With recent legislation expanding health care access in the United States, studies that shed light on care delivery in the VA can help inform future planning and policies that impact cancer care quality and disparities in other segments of our health care system. A primary aim of our study was to examine the role of site of care in explaining disparities in VA cancer care (i.e., do minority patients receive cancer care at low-quality hospitals?). Distinguishing between the patient-, provider-, and system-level factors that account for health care disparities is critical to quality improvement and disparities reduction efforts.⁵ Our observation of substantial within-hospital cancer-related disparities suggests the need for efforts addressing the within-hospital drivers of health care disparities in the VA (e.g., patient-provider communication, care coordination) rather than efforts to influence the settings from which minority patients obtain care. Although our data were relatively old, other studies reveal that racial disparities in cancer treatment and outcomes in the United States have persisted over time both within and outside of the VA,^6,7 suggesting that our findings can nevertheless inform our understanding of factors contributing to cancer care disparities and opportunities for improvement.

We agree completely with Stirling that going forward, regional and national efforts to continuously measure and improve care will be important to achieving the goal of delivering high-quality and equitable cancer care in the United States. The integration of cancer registry data with real-time data from electronic health records and other data systems will be critical to the success of such efforts and should be prioritized.