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VA did not reveal all veterans' cancer numbers to Congress

The C.W. Bill Young VA Medical Center in Seminole decided to report to Congress only cases where it determined veterans were seriously harmed by delays in receiving consultation for gastro-intestinal cancer.

MELISSA LYTTLE | Times

The C.W. Bill Young VA Medical Center in Seminole decided to report to Congress only cases where it determined veterans were seriously harmed by delays in receiving consultation for gastro-intestinal cancer.

The Department of Veterans Affairs gave Congress a "fact sheet" in April listing the number of patients seriously harmed by long delays in receiving a gastrointestinal cancer diagnosis at VA hospitals across the nation.

It said 76 veterans nationally were harmed by such delays. Of those, 23 died, the VA said.

At the C.W. Bill Young VA Medical Center in Seminole, two patients were harmed but survived, the fact sheet said.

But a November 2012 Young VA email obtained by the Tampa Bay Times reveals what Congress wasn't told by agency officials in Washington, D.C.: In fiscal years 2010 and 2011, 30 Young VA veterans waited "beyond 60 days" for a GI consultation that ultimately found cancer.

Because the VA ruled just two were seriously harmed, that smaller number ended up in the fact sheet, a document that reassured Congress the VA "is committed to a process of full and open disclosure."

The congressional fact sheet may have omitted hundreds of veterans nationwide who endured delays of two months or longer in getting tests that confirmed gastrointestinal cancers, interviews and documents obtained by the Tampa Bay Times indicate.

VA officials, who say delays are often caused by patients canceling appointments, decided to report only cases where veterans were seriously harmed. And who made those determinations?

The VA did.

U.S. Rep. Jeff Miller, R-Pensa­cola, chairman of the House Veterans Affairs Committee, said committee members need all available information as they evaluate problems at the troubled agency. He said Congress did not know the VA review tallied cases where it decided no harm occurred. Those numbers, Miller said, should have been released.

The VA, he said, often denies harm to patients, then clear evidence proves otherwise.

"That's their default position," Miller said. "I don't believe there are many people at all who trust the VA's numbers, nor do they trust the VA to actively report numbers that shine a negative light on the agency. ... We know there are terminally ill patients today who will die because of these delays."

Dr. Gavin West, the VA's special assistant for clinical operations, said the agency is cooperating with Congress and doing its best to identify and fix problems with patient care. He said a rigorous and honest review by physicians determined whether a delay harmed a patient.

"We didn't try to hide anything from anybody," said West, who noted the VA has significantly improved its GI consult system.

He said Congress did not ask for the numbers of veterans who experienced a two-month or longer delay in a GI cancer diagnosis but were unharmed. So the VA did not report those figures.

"We were really going with what Congress wanted," West said.

But Miller disputed that, saying VA lawyers interpret the committee's requests in a way that is most favorable to the agency.

The 2012 VA review of delays in veterans getting GI consultation referrals involved "high interest consults." Those are cases where a patient may have symptoms, such as blood in the stool, that point to the need for cancer screening or tests, such as a colonoscopy.

The agency decided to examine such consultations across the nation after reports of long delays at two VA medical facilities outside Florida.

VA hospitals examined a database of patients diagnosed with GI cancers. They then determined how many of these veterans waited at least 60 days for GI consultation. At the Young VA, the number was 30.

The VA did not respond to requests to disclose the number of veterans nationally it deemed unharmed by such delays.

VA facilities then conducted a two-level review that included cancer doctors to decide which veterans were seriously harmed by delays, documents show.

That review found two Young VA patients who were harmed.

The VA released a summary fact sheet of results to Congress after media reports about the review but did not release underlying documents, Miller said.

The fact sheet only lists cases involving "institutional disclosures." In such disclosures, the VA tells a veteran or family an "adverse" event occurred in the veteran's treatment "that resulted in or is reasonably expected to result in death or serious injury," a VA handbook says.

The VA's response to questions about the fact sheet and its underlying review of delays in the diagnosis of GI cancers is often confusing.

VA officials say a two-month delay in GI cancer diagnosis is unlikely to harm a patient even as they defend their report showing 76 patients were seriously harmed by delays that killed 23. The Young VA denies two of its patients were harmed by GI consultation delays, despite the VA's own fact sheet showing as much.

Jason Dangel, a Young VA spokesman, objected to the use of the term "consult delay" in discussing the facility's patients, though the agency review that identified the 30 Young VA patients who endured a delayed cancer diagnosis was called a "National Consult Delay Review."

Dangel said the two Young VA patients reported in the fact sheet "may have had an advance in disease malignancy" due to a delayed diagnosis unrelated to a delay in a GI consultation.

The two cases were reported in the consult delay report out of an abundance of caution, he said.

Of the 28 other patients at the Young VA who waited "beyond 60 days" for a GI consultation, 17 patients caused the delay by canceling appointments, Dangel said. The remainder, he said, did not face "delays" and were diagnosed within 74 days of the initial request for a consultation."

" 'Consult delay' ... is not the correct terminology," Dangel said in a written statement. " 'Consult delay' ... did not occur in our system. For all cases reviewed, ordered GI consults were acted upon quickly."

Dangel said there is "no scientific benchmark in the medical community" that patients be screened for a GI cancer within 60 days of symptoms, "as colon cancer takes years to develop. It is therefore unlikely that any veteran" at the Young VA experienced an "advanced malignancy" tied to a delay, he said.

But the VA's national review, documents show, may have counted patients who endured delays far beyond 60 days.

Even VA leaders acknowledge the difficulty of determining whether someone is harmed by a delayed cancer diagnosis, raising the question of how the VA can be so certain harm is unlikely.

"Medicine is tough that way," West said. "Medicine's an art, not a science. ... It really is tough. I've reviewed cases like that before and they can take me five and six hours and I still don't know if I've come to the exact right answer. But that is just the way it is with medicine."

Times researcher John Martin contributed to this report. Contact William R. Levesque at levesque@tampabay.com or (813) 226-3432.

The Tampa Bay Times asked a Young VA spokesman how the agency was certain none of its patients were harmed by delays of at least 60 days in getting a gastrointestinal consultation that led to a cancer diagnosis.

Spokesman Jason Dangel emailed the following response, which refers to "institutional disclosures." Such a disclosure by the VA informs a veteran or surviving family member an "adverse" event has occurred in the veteran's treatment "that resulted in or is reasonably expected to result in death or serious injury," according to a VA handbook.

VA STATEMENT

"According to our medical experts, there is no scientific benchmark in the medical community that 60 days is the expected standard, as colon cancer takes years to develop. It is therefore unlikely that any veteran at (the Young VA), outside of the two disclosures included in the report, experienced an advance in disease malignancy.

"Of the 30 patients that were diagnosed more than 60 days after onset of GI symptoms, more than half of the veterans cancelled an earlier GI consult or endoscopy appointment. The remaining veterans were diagnosed within two weeks of the 60 day guidance, with the exception of the two cases where institutional disclosures were made. The disclosure number was included in the findings section of the National Consult Delay report released in April this year.

"In reference to the portion of your question that states — Of the 30 patients at the Young VA who waited 60 days or longer for a GI consult....' — NO cases were identified involving consult delays (time of decision to consult GI specialty to time of consult action), or health care access challenges. However, during the review, two cases were identified by medical experts indicating there may have been an opportunity to diagnose cancer earlier. The (Young VA) Healthcare System disclosed the findings to the two veterans as well as including them in the national report. These two cases were not secondary to a delay in time from consult order to consult action."

A second VA response followed after the Times asked for clarification.

VA STATEMENT

" 'Consult delay' as defined previously (time from consult being entered/ordered by a veteran's primary physician to consult action) is not the correct terminology. 'Consult delay,' as it is defined, did not occur within our system. For all cases reviewed, ordered GI consults were acted upon quickly.

"Delay in reaching a diagnosis within 60 days would be a more accurate statement. As mentioned previously, of the 30 patients that were diagnosed more than 60 days after the onset of GI symptom, more than half cancelled an earlier GI consult or endoscopy appointment. One veteran was too ill to undergo endoscopy. The rest were diagnosed within two weeks of the 60-day period. Institutional disclosures were made for two veterans that may have had an advance in disease malignancy due to a delay in diagnosis. Both of these veterans were seen in the GI clinic within two weeks of the GI consult request."





Tell your story

If you or a family member have experienced a cancer diagnosis that was delayed at a VA facility in the Tampa Bay area, we are interested in speaking to you. Contact reporter William R. Levesque at levesque@tampabay.com or (813) 226-3432.

To see the Young VA's full statement about delays among patients needing gastrointestinal consultations, go to tampabay.com.

VA did not reveal all veterans' cancer numbers to Congress 07/27/14 [Last modified: Sunday, July 27, 2014 11:30pm]
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