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. Author manuscript; available in PMC: 2024 Mar 1.
Published in final edited form as: Ann Surg. 2021 May 11;277(3):e664–e669. doi: 10.1097/SLA.0000000000004928

Comparison between Veteran and Non-Veteran Populations with Clinical Stage I Non-Small Cell Lung Cancer Undergoing Surgery

Brendan T Heiden 1, Daniel B Eaton Jr 2, Su-Hsin Chang 2,3, Yan Yan 2,3, Martin W Schoen 2,4, Mayank R Patel 2, Daniel Kreisel 1,2, Ruben G Nava 1,2, Bryan F Meyers 1, Benjamin D Kozower 1, Varun Puri 1,2
PMCID: PMC8581073  NIHMSID: NIHMS1697518  PMID: 34550662

Abstract

Objective:

The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC).

Background:

Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the Veterans Health Administration (VHA). We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population.

Methods:

We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB).

Results:

The unmatched cohorts included 9,981 VHA and 176,304 NCDB patients. The VHA had more male, non-white patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, p=0.011) and median overall survival (69.0 vs 88.7 months, p<0.001). In the propensity matched cohort of 6,792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, p<0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, p=0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, p<0.001) but similar readmission rates (7.7% vs 7.0%, p=0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, p<0.001) and median overall survival (71.4 vs 65.2 months, p<0.001).

Conclusions:

Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.

Mini-Abstract

The quality of surgical care that Veterans with lung cancer receive through the Veterans Health Administration (VHA) has been questioned in published literature and lay media. In this study, we found that Veterans, despite having significantly more comorbidities, receive quality of care that is comparable to or better than the general population with better short- and long-term outcomes.

Introduction

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death in the United States among both Veterans and the general population1,2. The gold standard for treating early-stage NSCLC is surgery3,4. Significant variation exists in the delivery of lung cancer care through the Veterans Health Administration (VHA)5. For example, despite being diagnosed with disease at earlier stages, Veterans tend to wait longer for care6. Veterans are also less likely to receive stage-appropriate lung cancer treatments7, including surgery8. It is known that deviating from appropriate surgical management of lung cancer is directly associated with worse survival, even in early-stage disease4. Despite these concerns, the quality of care and associated outcomes among Veterans with early-stage NSCLC undergoing surgery in the VHA remain unclear.

The VHA has previously faced scrutiny for delivering care which is perceived to be inferior or low-quality9–11; these negative perceptions have resulted in new policy shifts that some experts fear could weaken the VHA system12. However, recent studies have shown that contrary to public sentiment the VHA outperforms civilian hospitals in several metrics of care for common clinical conditions13. High-quality surgery for lung cancer should be associated with lower risk of perioperative complications as well as optimal long-term survival. One caveat when evaluating this in the VHA, however, is that the Veteran population has a significantly greater burden of comorbid conditions, making direct comparisons to the civilian population difficult14. Therefore, while the VHA may provide optimal care, the short- and long-term outcomes could be heavily influenced by the higher medical acuity of the patient population. Various quality metrics have been proposed for lung cancer surgery, including timely surgery15, minimally invasive operations16, and adequate lymph node sampling17,18. Importantly, adhering to these quality measures in stage I NSCLC is associated with improved survival4. Adherence to these quality measures in the VHA and how this compares to the general population is largely unknown.

We performed a retrospective cohort analysis of patients undergoing surgery for clinical stage I NSCLC in the VHA. Using propensity matching, our primary objective was to compare short- and long-term outcomes between Veterans and a matched cohort of patients from the National Cancer Database (NCDB). Our secondary objective was to compare several quality metrics for clinical stage I lung cancer resection between the two cohorts. We hypothesized that Veterans undergoing surgery in the VHA receive high-quality care and have similar outcomes compared to the general population.

Methods

Study Population

A retrospective cohort study was performed using the VA Informatics and Computing Infrastructure (VINCI) system, which collates clinical and administrative data from multiple platforms in the Corporate Data Warehouse (CDW)19. NSCLC cases were identified using International Classification of Diseases for Oncology (Third Edition) codes. Patients having surgery were further identified using ICD 9/10 or CPT procedure codes. Inclusion criteria were all patients with clinical stage I NSCLC (as defined in American Joint Commission on Cancer staging manual, 7th edition) undergoing resection from 2006 to 2016. Staging data were harvested from VINCI; if clinical staging data were missing in VINCI, then tumor characteristics were extracted from VHA physician notes. Exclusion criteria were age less than 18 years old, patients receiving neoadjuvant chemotherapy, or patients having surgery for recurrent disease. The study protocol was reviewed and approved by the local VHA Research and Development Committee.

The National Cancer Database (NCDB) was used for the comparison cohort. The NCDB is a joint collaboration between the American Cancer Society and the American College of Surgeons Commission on Cancer (CoC) that captures more than 70% of newly diagnosed cancers in the United States20. We chose the NCDB for several reasons including that it does not exclude patients based on age; it captures readmission data; it collects several quality metrics specific to lung cancer surgery; and – while not truly “population-based” – it is still highly representative of the US population21. Patients in the NCDB cohort were identified using the 2017 Participant User File (PUF) (released 2020) using the same inclusion and exclusion criteria as the VHA. Study dates were limited to operations occurring between 2006 and 2016. Notably, VHA and DoD facilities are excluded from the NCDB PUF files22.

Covariates

Covariates that were common between the two databases were extracted for further analysis. All NCDB variables were extracted as coded23. For variables in the VHA that required creation or additional cleaning by our group, we defined these using the same criteria as the NCDB (using the American College of Surgeons Facility Oncology Registry Data Standards coding manual23). The extracted demographic information from the VHA included age, sex, race, year of diagnosis, and residential zip codes at the time of surgery. Zip codes were then linked to obtain county-level median household income and education level (the proportion of adults with at least high school diploma). Distance from facility to residence was estimated from the center of patient zip code to the facility address. Comorbidities (measured from 5 years prior to surgery to 1 month after surgery) were determined using ICD 9/10 codes in order to calculate a composite Charlson/Deyo score24,25. Treatment-related characteristics included tumor size, wait time to surgery, histology, grade, year of operation, surgical approach type (video-assisted thoracic surgery, VATS, or thoracotomy), type of resection (lobectomy, segmentectomy, wedge resection, or pneumonectomy), and number of lymph nodes examined. The NCDB did not collect data on surgical approach until 2010, hence only available data are presented.

Outcomes

Our primary outcome of interest was overall survival. The NCDB assigns each patient record a date of last contact with an associated vital status (alive or dead). Participating hospitals are expected to provide follow-up on at least 90% of all living patients annually26. Despite this, we anticipated that the consistency and fidelity of follow up would be greater in the VHA since it is an integrated, national health-care system, which could confound our analysis. We employed several methods to address this difference. First, we limited follow up in both cohorts to that of the NCDB (June 30, 2019). Second, we censored patients in the VHA using comparable methods to those used in the NCDB. In the NCDB, failure to find a patient in a death record does not constitute that a patient is alive23; therefore, patients are censored based on “date of last contact” (annually). To manage this similarly in our VHA dataset, alive patients were censored if they had not been seen within the VHA for more than 12 months (i.e., date of last contact). Finally, to further ensure the consistency of follow up and censoring in our propensity analysis (below), patients were matched exactly for year of diagnosis.

Secondary outcomes of interest included length of stay, pathologic upstaging, positive margin status, 30-day readmission, 30-day mortality, and 90-day mortality. We were also interested in comparing several quality metrics for clinical stage I lung cancer resection (previously described by Samson and colleagues)4. These quality-of-care metrics include timely surgery, minimally invasive surgical approach (VATS), anatomic resection (lobectomy), and adequate lymph nodes examination (≥10 lymph nodes)4, in line with several national treatment guidelines.

Propensity Matching

Due to differences in sociodemographic characteristics and comorbidities between the NCDB and VHA cohorts, propensity score matching was employed to create balanced populations for comparing treatment-related outcomes. Propensity scores were based on age, sex, race, income, educational level, Charlson/Deyo score, distance to hospital, and tumor size. Year of diagnosis was exactly matched to eliminate differential follow up between matched pairs. We generated covariate balanced propensity scores with ATT (average effect of treatment on the treated) weighting using the Covariate Balancing Propensity Score (CBPS) package in R studio (version 1.3). The calculated propensity scores were used to match the two cohorts using the Matchit package. Patients were greedy matched 1:1 with no replacement using a caliper of 0.1. Differences between matched groups were displayed with standard mean differences (SMD), with a goal SMD of less than 0.15 based on prior literature27,28.

Statistical Analysis

Baseline cohort descriptive statistics were reported. For continuous variables, means (standard deviations) were presented with two-tailed, t-test statistics. For categorical variables, frequencies (proportions) were presented with χ2 test statistics. Observations with missing values were excluded (except for VHA tumor size, lymph node collection, and surgical approach where an “unknown” variable was created). Overall survival was estimated using the Kapan-Meier method with log-rank tests to determine differences in survival. All tests are two sided. P-values of less than 0.05 were considered statistically significant. Analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC).

Results

Between 2006 and 2016, 9,981 patients in the VHA and 176,304 patients in the NCDB with clinical stage I NSCLC undergoing resection were identified. Median follow up was 4.4 years and 4.1 years in the VHA and NCDB cohorts, respectively. Supplementary Table 1 displays demographics, treatment-related characteristics, and outcomes between the unmatched cohorts. Patients from the VHA were younger and more likely to be male and non-white. VHA patients were less educated but had higher median incomes. VHA patients tended to live further from the hospital performing surgery. Comorbidity burden was significantly higher among VHA patients, with 86.5% having a Charlson/Deyo score of at least 1 (compared to only 50.1% in the NCDB). In terms of disease-related characteristics, tumors were larger, higher grade, and more likely to exhibit squamous histology among VHA patients. VHA patients were slightly more likely to undergo lobectomy and had a higher proportion of minimally invasive operations.

In the unmatched comparison, VHA patients had longer lengths of stay (8.3 vs 6.3 days, p<0.001) and were more likely to be readmitted (8.2 vs 6.7%, p<0.001). Pathological upstaging and positive surgical margins were less common among VHA patients. Finally, VHA patients had higher unadjusted 30-day mortality (2.1% vs 1.7%, p=0.011), 90-day mortality (4.0% vs 3.2%, p<0.001) and shorter median overall survival (69.0 vs 88.7 months, p<0.001, Figure 1).

Figure 1.

Figure 1.

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Kaplan-Meier survival curve of unmatched patients undergoing resection for clinical stage I NSCLC in the VHA versus NCDB

Propensity score matching yielded 6,792 matched pairs. These groups were comparable in age, sex, race, income, education level, distance from the hospital, Charlson/Deyo comorbidity score, tumor size, and year of diagnosis (Table 1). VHA patients were slightly less likely to receive a lobectomy (70.1% vs 70.7%, p=0.023, Table 2) but were more likely to have a minimally invasive operation (60.0% vs 39.6%, p<0.001). Adequate lymph node sampling (defined as ≥10 nodes4) was performed in a minority of patients in either group (VHA 33.3% vs NCDB 36.4%, p<0.001).

Table 1.

Demographics of propensity matched patients with clinical stage I NSCLC undergoing resection in the VHA and NCDB

VHA 2006–2016 N=6,792 NCDB 2006–2016 N=6,792 SMD
Age (SD) 67.55 (8.04) 67.08 (9.30) 0.053
Sex (%) 0.060
 Male 6,471 (95.6) 6,314 (93.0)
 Female 321 (4.7) 478 (7.0)
Race (%) 0.053
 White 5,887 (86.7) 5,767 (84.9)
 Black 743 (10.9) 842 (12.4)
 Other 105 (1.5) 127 (1.9)
 Unknown 57 (0.8) 56 (0.8)
Income category (%) 0.070
 <$30,000 212 (3.1) 251 (3.7)
 $30,000 - $34,999 507 (7.5) 467 (6.9)
 $35,000 - $45,999 2,626 (38.7) 2,440 (35.9)
 $46,000 + 3,447 (50.8) 3,634 (53.5)
Did not graduate high school (%) 0.094
 29% or More 1,131 (16.7) 1,341 (19.7)
 20% - 28.9% 2,131 (31.4) 2,174 (32.0)
 14% - 19.9% 1,809 (26.6) 1,616 (23.8)
 Less than 14% 1,721 (25.3) 1,661 (24.5)
Distance, miles (SD) 56.73 (62.07) 36.94 (180.78) 0.146
Charlson/Deyo Score (%) 0.037
 0 1,134 (16.7) 1,180 (17.4)
 1 2,011 (29.6) 2,079 (30.6)
 2 1,643 (24.2) 1,555 (22.9)
 3+ 2,004 (29.5) 1,978 (29.1)
Tumor Size, mm (SD) 23.32 (10.69) 23.03 (10.39) 0.028
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Table 2.

Treatment-related characteristics and outcomes of propensity matched patients with clinical stage I NSCLC undergoing resection in the VHA and NCDB

VHA 2006–2016 N=6,792 NCDB 2006–2016 N=6,792 P-Value
Tumor/Operative Characteristics
Median wait time to surgery, days 46 29 <0.001
Surgical resection (%)a 0.023
 Lobectomy 4,748 (70.1) 4,611 (70.7)
 Pneumonectomy 104 (1.5) 125 (1.9)
 Segment 382 (5.6) 302 (4.63)
 Wedge 1,538 (22.7) 1,486 (22.8)
Surgical approach (%)a,b <0.001
 Thoracotomy 1,616 (40.0) 2,655 (60.4)
 VATS 2,429 (60.0) 1,739 (39.6)
Histology (%) 0.232
 Adenocarcinoma 3,631 (53.5) 3,724 (54.8)
 Squamous cell carcinoma 2,299 (33.9) 2,255 (33.2)
 Other 860 (12.7) 813 (12.0)
Grade (%) <0.001
 I 785 (12.52) 893 (14.12)
 II 3,324 (53) 3,107 (49.11)
 III 2,069 (32.99) 2,227 (35.2)
 IV 94 (1.5) 99 (1.56)
 Unknown 520 (7.66) 466 (6.86)
Lymph nodes
Median (IQR) 6 (2–12) 7 (3–13) <0.001
≥10 Collected (%) 2,113 (33.3) 2,472 (36.4) <0.001
Outcomes
Length of stay, days (SD) 8.12 (6.59) 7.08 (7.54) <0.001
Pathologic upstage (%)a <0.001
 I 5,712 (87.5) 5,109 (85)
 II 520 (8) 584 (9.7)
 III 268 (4.1) 285 (4.7)
 IV 27 (0.4) 35 (0.6)
Pathologic upstage (%)a 815 (12.5) 904 (15.0) <0.001
Surgical margins (%)a 0.376
 Negative 6,214 (96.8) 6,427 (96.6)
 Positive 203 (3.2) 229 (3.4)
30-D readmission (%) 523 (7.70) 470 (7.02) 0.132
30-D mortality (%) 128 (1.9) 188 (2.8) <0.001
90-D mortality (%) 250 (3.7) 331 (5.0) <0.001
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a

Excluding unknown or missing data.

b

NCDB collected incision data beginning in 2010. Only available data (post-2010) in both groups is shown.

In the matched cohorts, VHA patients still had longer lengths of stay (8.1 vs 7.1 days, p<0.001). VHA patients were less likely to be pathologically upstaged (12.5% vs 15.0%, p<0.001) and the likelihood of a positive surgical margin was similar between the two cohorts (3.2% vs 3.4%, p=0.376). Readmission rates were statistically equivalent between the two matched cohorts (7.7% vs 7.0%, p=0.132). VHA patients had significantly lower 30-day mortality (1.9% vs 2.8%, p<0.001) and 90-day mortality (3.7% vs 5.0%, p<0.001). VHA patients also experienced longer median overall survival (71.4 vs 65.2 months, p<0.001, Figure 2).

Figure 2.

Figure 2.

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Kaplan-Meier survival curve of propensity matched patients undergoing resection for clinical stage I NSCLC in the VHA versus NCDB

Discussion

This study examined quality of care and outcomes among Veterans undergoing clinical stage I NSCLC resection at the VHA compared to the general population. We found that Veterans had a significantly higher comorbidity burden at baseline which likely accounted for inferior unadjusted outcomes in this group. After controlling for appropriate covariates, however, Veterans received high-quality care, with superior rates of minimally invasive surgery compared to the general population. Furthermore, VHA patients had significantly better short-term outcomes and overall survival in the matched comparison. These findings demonstrate that the VHA delivers acceptable if not superior lung cancer care compared to non-VHA institutions.

There is a widespread perception that Veterans receive inferior care through the VHA system. The VHA is the nation’s largest integrated healthcare system, providing care to nearly 10 million Veterans across over 1,000 different facilities29. Perhaps due to this enormous complexity and its vulnerable population of patients, the VHA has faced significant scrutiny related to the quality of care that it provides9–11,30. These concerns, which have been widely circulated in the lay media, have resulted in policy changes. For example, Congress established the 2018 MISSION Act to provide more flexible care to Veterans, including the option to seek care outside of the VHA altogether31. This has led some experts to fear that the VHA may become less relevant in supplying healthcare of Veterans and severely weaken the system12.

Our study directly contradicts this negative perception and instead highlights that Veterans receive appropriate and guideline-based lung cancer care through the VHA with good – if not superior – perioperative and long-term outcomes. Our study joins a growing body of evidence in which the VHA has been found to outperform civilian hospitals13,32,33. Several quality measures specific to lung cancer surgery are worth noting in our study. For example, Veterans are more likely to receive minimally invasive operations; this is compared to the high number of patients in the civilian population who receive open operations34. Additionally, VHA patients received similar rates of anatomic resections and resections with negative margins, another indication of high-quality care35. These findings highlight the exemplary lung cancer care that is provided through the VHA. Our study suggests that instead of discarding the VHA-centered paradigm of care (with which recent policies have flirted), the aim should be to improve the system that already is performing quite well.

There are several potential explanations for why Veterans may receive superior care through VHA medical centers. First, VHA hospitals are largely staffed by surgeons from nearby academic medical centers; academic hospitals have been associated with superior outcomes in lung cancer surgery4. Second, the VHA is a closed system, reducing several of the access to care barriers that a civilian population may face. Better access to care should result in improved outcomes especially in the setting of early-stage lung cancer36. Third, specific to lung cancer, the VHA has experienced more robust adoption of lung cancer screening programs37. Early detection of disease likely contributes further to favorable outcomes. Finally, Veterans experience longer lengths of stay. While this is generally disapproved of in civilian literature, this metric may be a surrogate marker of the superior out-of-hospital social support that the VHA supplies. While we did not explicitly examine discharge location, it is likely that VHA centers have more short-term care options for rehabilitation, further enhancing recovery and outcomes after surgery.

Another notable finding is the significant smoking prevalence among VHA patients. While smoking data is not available in the NCDB, it is available in other national lung cancer databases. For example, the Society of Thoracic Surgery (STS) General Thoracic Surgery Database captures most surgical lung cancer care at academic hospitals in this country38. Prior studies have shown that, even in this complex patient population, only 23.7% of STS patients smoke at the time of surgery (measured at 4 weeks before surgery)39. Conversely, we found that 50.3% of VHA patients in our cohort smoked at the time of surgery (data not shown, measured at 2 weeks before surgery). Given the well-established detrimental effects of smoking at the time of lung cancer surgery, especially on short-term outcomes, it is quite remarkable that VHA patients seem to do paradoxically well compared to both the STS and NCDB40,41. Due to the lack of smoking data in our matched analysis, it is likely that our study underestimates the superiority of short-term outcomes in the VHA.

The VHA was not superior in all aspects of care, however. In particular, VHA patients had less extensive lymph node sampling, although this metric was poor in both populations. Inadequate lymph node sampling is associated with worse survival following resection42,43. This is likely a result of occult mediastinal disease going unrecognized in a group of patients who would otherwise benefit from adjuvant therapy44. As such, systematic lymph node sampling is broadly recommended45,46. VHA patients also waited longer for their operations. This is consistent with prior work which demonstrated that Veterans wait significantly longer for most cancer operations6. In our analysis, Veterans waited approximately 6.5 weeks from diagnosis until surgery (2.5 weeks longer than patients in the NCDB). Importantly, prior work from our group has shown that operative wait times less than 8 weeks are not associated with worse outcomes15. Therefore, a vast majority of Veterans are still receiving timely care by modern definitions. Additionally, it is unclear what the cause of this delay is. For example, are these delays due to inherent inefficiencies of the VHA system or are they rather due to a sicker patient population that requires more prolonged medical optimization? In the context of the latter scenario, Veterans may wait longer for surgery but they also have lower rates of both short- and long-term mortality. A marginal delay of roughly 2 weeks – if used to optimize sick patients – seems to be a reasonable trade-off for such favorable outcomes. Further research into this is required.

This study has several strengths. First, it is a robust cohort of patients from two well-maintained clinical databases allowing for a powerful comparison of Veteran and civilian populations with early-stage lung cancer. Second, the VHA and NCDB share similar coding standards which reduces potential bias23. Third, we employed rigorous statistical methods to control for demographic and tumor-related differences between the two populations. Conversely, this study also has several limitations. First, we cannot control for inherent differences between the two databases, particularly in relation to follow-up. We addressed this through propensity matching and standardized follow-up criteria. Second, the NCDB does not afford the same granular detail as the VHA medical record. For example, variables like smoking status are not available in the NCDB. Similarly, comorbidities may be coded more accurately in the VHA33. Our findings may change if additional variables were available upon which to match the two cohorts. Finally, any study involving the VHA is limited by the patient population: almost exclusively male, heavy smoking histories, significant comorbidities. While we controlled for this in the present study through propensity score matching, this fact should be remembered anytime VHA data is applied to the larger US population.

In conclusion, Veterans receive quality of care that is comparable to or better than the general population, including high rates of minimally invasive operations. Overall, Veterans have favorable short- and long-term outcomes including significantly longer overall survival compared to the general population. Policy makers should be aware of these strengths when considering future VHA reforms.

Supplementary Material

Supplementary Table 1.

Baseline demographics, treatment-related characteristics, and outcomes of unmatched patients with clinical stage I NSCLC undergoing resection in the VHA and NCDB

Acknowledgements

This study is funded in part through a cardiothoracic surgery NIH 5T32HL007776–25 grant (BTH) and a VA 1I01HX002475-01A2 grant (VP).

Source of Funding: Funded in part by NIH 5T32HL007776-25 (BTH), 1 I01 HX002475-01A2 (VP)

Classifications: Non-small cell lung cancer; surgery; quality of care; outcomes

Footnotes

Conflict of Interest: None

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table 1.

Baseline demographics, treatment-related characteristics, and outcomes of unmatched patients with clinical stage I NSCLC undergoing resection in the VHA and NCDB

NIHMS1697518-supplement-Supplementary_Table_1.docx (23.1KB, docx)

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