Veterans With Cancer Died After Delays at VA Hospital

Watchdog: New Mexico VA put patients with colorectal cancer at ‘unnecessary risk for adverse outcomes’

VA Medical Center in Albuquerque, N.M.
VA Medical Center in Albuquerque, N.M. / AP
September 29, 2016

Patients at a Department of Veterans Affairs hospital in New Mexico who were eventually diagnosed with cancer experienced delays in care that put their health at risk, according to the agency’s inspector general.

Dozens of veterans who tested positive for colorectal cancer at the New Mexico VA Health Care System in Albuquerque were not notified of their results in a timely manner, according to the inspector general report released this week, which faulted a lack of oversight from the system’s leadership.

Colorectal cancer is the second-leading cause of cancer deaths in the United States. Screening can detect the cancer in its early stages, making it easier to beat.

Nine veterans who sought care at the New Mexico VA hospital in fiscal years 2013 and 2014 and who were eventually diagnosed with colorectal cancer "experienced delays and, in some instances, significant delays that may have affected the patients’ clinical outcomes," investigators found.

These patients represented 38 percent of the veterans serviced by the hospital who were diagnosed with colorectal cancer during the two-year period reviewed.

For three of the veterans, mismanagement at the hospital resulted in them waiting three, eight, and nine months respectively before being notified of their positive colorectal screening; another veteran was never notified, only to be diagnosed with cancer after approaching his doctor with pain nine months later. VA policy at the time of the review mandated that hospital staffers notify patients of results within 14 days, meaning that the veterans’ delays were as much as 20 times the acceptable wait period.

Two of the four veterans who were put at risk by care delays died after undergoing chemotherapy and other procedures.

Through a review of electronic health records, the inspector general identified an additional 133 veterans who also may not have received "appropriate notification" of their positive tests or follow-up colonoscopies, which are mandated by VA policy.

The watchdog knocked facility management for not having a process in place to make sure that staffers were properly handling colorectal cancer screening in fiscal years 2013 and 2014. The hospital had a designated nurse in 2012 who followed up with patients and regularly reported to management, but the employee transferred out of the facility and the position was left vacant for more than two years.

"Delays in cancer screenings have been a problem at VA for years, and this report is proof the department still has a long way to go in order to solve this problem," said Rep. Jeff Miller (R., Fla.), chairman of the House Committee on Veterans Affairs. "Right now, it’s incumbent upon New Mexico VA Health Care System leaders to outline who will be held accountable for these mistakes as well as the steps they are taking to fix them."

The New Mexico VA system, which serves veterans in the state as well as those in southwest Colorado and Nevada, was one of several facilities investigated over allegations of wait time manipulation, after staffers at the Phoenix VA were found keeping secret wait lists in 2014.

The report summarizing the review, made public this past June, documented evidence of staffers entering available dates for appointments as veterans’ desired dates in patient records, resulting in the appearance of a zero-day wait time.

"A long-standing practice of misreporting desired appointment dates was occurring," the review found. "Two VA officials—a nurse manager and a business manager—were identified as having played an active role in encouraging this activity."

The New Mexico hospital was also the subject of a 2012 inspector general review, which concluded that leaders needed to improve the process of notifying patients who screen positive for colorectal cancer and giving them timely follow-up care.

A spokesman for the VA told the Free Beacon that the hospital is improving its process of colorectal cancer screening and adding a new full-time position to assist this and other cancer screening practices.

"We have worked diligently to not only satisfy OIG’s recommendations, but also to continue providing the highest quality care for our Veterans," the spokesman said.

A flurry of investigations has spotlighted mismanagement, insufficient care, and persisting wait times across the VA’s network of hospitals, despite congressional efforts to reform the agency. An independent assessment released one year ago found the VA’s problems to be systemic, precipitating recommendations to transform the federally run health care system.

A local director for Concerned Veterans for America, a veterans’ advocacy group pushing for reform at the VA, pointed to legislation recently passed by the House with bipartisan support that would expand the agency’s firing powers to more easily hold employees accountable for failings such as those displayed at the New Mexico facility.

"This is usually how problems at the VA start—one bad state IG report, then another, then another," said Tom Greer, the New Mexico state director for Concerned Veterans for America. "If top VA officials won’t hold their employees accountable, Congress must. The VA Accountability First and Appeals Modernization Act would go a long way toward making these regular reports on VA incompetence a thing of the past."

The White House has criticized the legislation.

Update 10:42 A.M.: A previous version of this story said the White House threatened to veto the VA Accountability First and Appeals Modernization Act. The White House has been critical of the legislation but has not threatened a veto.

Published under: Veterans Affairs