Review of Care Coordination for a Patient with Breast Disease at the VA Eastern Colorado Health Care System in Aurora

The VA Office of Inspector General (OIG) initiated an inspection on December 4, 2025, to evaluate concerns identified during a hotline inspection regarding the coordination of care for a patient with breast disease at the VA Eastern Colorado Health Care System (facility) in Aurora. After an abnormal mammogram in late 2023, the patient’s primary care provider placed a breast biopsy consult that was not completed until late spring 2024, raising concerns about the delay. 

The inspection team reviewed care coordination for the patient from mid‑fall 2023 through fall 2024. A virtual site visit was conducted from December 17, 2025, through February 23, 2026.

The OIG found that facility community care staff assigned a basic designation to the breast biopsy consult, consistent with Veterans Health Administration guidance. Despite multiple outreach attempts, the patient did not schedule the appointment, leading to consult cancellation. When later evaluated in a community emergency department, imaging suggested metastatic disease, prompting diagnostic imaging. The OIG noted that including high‑risk conditions, like suspected cancer, to the consult tool’s list of complex/chronic conditions could help ensure clinical assessment for care coordination.

In mid‑winter 2024, the primary care provider assessed the patient for an unrelated pre-op visit but did not document or coordinate follow-up for the incomplete breast biopsy. Additionally, the facility’s breast imaging tracking spreadsheet did not include the patient’s late 2023 test results. The facility hired a breast cancer screening coordinator in June 2025 and implemented a new tracking tool. Given these corrective actions and a parallel recommendation in a previous OIG report, a tracking-related recommendation was not made.

The OIG made one recommendation. In response, the Under Secretary for Health shared plans to review the current list of complex/chronic conditions and assess the feasibility of expanding the list to include additional conditions, such as suspected cancer.