In 2007, Phillip Longman suggested that the VA offers the “best care anywhere” in his book of the same name. Today the VA stands at another crossroads and another new beginning as we welcome the new Secretary of Veterans Affairs Robert A. McDonald. With the secretary’s commitment to better customer service and to focusing on veterans’ health care needs, it is more important than ever to find models that work and to replicate those best practices across the VHA. With that goal in mind, this special issue is focused on highlighting and sharing the experiences of successful oncology programs. These programs may not be the only ones that work, but they are important examples of proven models that serve patient needs.
The VA system is unique in that it is tasked with caring for the same patients on a longitudinal basis. No other health system has the honor VA has—to care for veterans from the end of service to the end of life. As a result, the VA can consistently reap the benefits of preventive health care.
In oncology, postcancer surveillance is increasingly important. In the article “Development and Implementation of a Cancer Survivorship Program,” the focus is on the surveillance setting, that critical juncture where a veteran returns to life after cancer. This place where oncology and primary care intersect presents a real opportunity to improve continuity of care. The VA is doing unique work in cancer survivorship.
At the same time, this organization must be fiscally responsible and balance the needs of the veterans with the finite resources of the taxpayers. This dynamic has led to the remarkable health system that is the modern VA. The Pharmacy Benefits Management Services (PBM) department assembles knowledge, provides clinical guidance, and attempts to bridge the gap between cost and value for oncology medications. This good stewardship ensures the VA can meet veterans’ needs at a reasonable cost and maintain the highest standard of medical practice.
It is estimated that more than half of all oncology drugs in the pipeline today are oral medications. Although the inclination is to think of these oral medications as safer, in actuality these medications frequently have toxic adverse effects (AEs). Most come with recommendations for high frequency of monitoring for toxicity, and although those AEs are often different from traditional chemotherapy, they are no less significant. VA pharmacists are well positioned to offer toxicity monitoring and general dispensing oversight of these medications.
The American Society of Health System Pharmacists offers specific guidance for the recommended components of a chemotherapy order, which includes a number of data points not readily adaptable to existing computerized physician order entry technology. Some third-party software is available that does accomplish this; however, due to the complex demands and flexibility required for each unique care center, this software is difficult to incorporate into most practices and is associated with large up-front costs. One VA site has developed a zero-cost process that generates a detailed, standardized order that doubles as a handy checklist. Although it is not perfect, it is a unique solution to the chemotherapy-ordering quandary that plague many sites.
We have focused on some of the best practices in oncology at the VA that capitalize on the resources both technological and human throughout the health system. The VA has been using top-notch technology to practice solid, evidence-based medicine for years.
These articles are only the start of the conversation and quality improvement across the VA. Undoubtedly there are other programs that help patients with malignancies. The more we share our best practices, the more we can help each other and help patients when they need it most. Please visit http://www.fedprac.com/AVAHO for more information and resources and to share your best practices.
Finally, I would like to thank all the authors who contributed to this special issue, the peer reviewers who reviewed the articles, and all the VA officials and health care providers who helped develop the programs described in this issue.