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Measuring Quality Indicators to Improve Patient Care
The Quality of Cancer Care:
Does the Literature Support the Rhetoric?
Bruce E. Hillner, M.D. & Thomas J. Smith, M.D.
NCPB Report (IOM), 1999
“Literature since 1988 in most areas does not address quality of
cancer care to any substantial extent.”
“So diffuse and diverse that providers have not had to provide
accountability for specific processes or outcomes.”
“Quality gaps for all conditions were found in retrospective
assessments in process of care.”
“GAPS” can be measured by overuse, underuse, misuse (errors)
and waste.”
Report to the National Cancer Policy Board, Institute of Medicine: April, 1999
Ensuring Quality
C A N C E R Care
Maria Hewitt and Joseph V. Simone, Editors
National Cancer Policy Board
INSTITUTE OF MEDICINE
and
COMMISSION ON LIFE SCIENCES,
NATIONAL RESEARCH COUNCIL
National Academy Press
Washington, D.C., 1999
Agencies Evaluating Cancer Care
INSTITUTE OF MEDICINE
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Quality of Healthcare in America Project (1998)
National Cancer Policy Board (1999)
CENTERS FOR MEDICARE AND MEDICAID SERVICES (2003)
•
Demonstration Projects
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
NATIONAL INITIATIVE ON CANCER CARE QUALITY (2000)
NATIONAL QUALITY FORUM
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Cancer Care Quality Measures Steering Committee (2003)
NATIONAL CANCER INSTITUTE
•
Cancer Care Outcome Research and Surveillance Consortium (1999)
QUALITY ALLIANCE (2005)
“Environment of Watchful Concern”
Quality Research in Radiation Oncology
Since 1973
IOM 1998
NICCQ 2000
Quality of Cancer Care
As a National Issue (1998)
JACHO 2004
Since 1998
LEAPFROG
Alpha Group 2004
QOPI 2005
Quality Alliance 2005
NCI 1999
CMS 2003
AHRQ 2004
NCPB 1999
CMS 2005 P4R Demonstration Project
Demonstration of Improved Quality of Care
for Cancer Patients Undergoing Chemotherapy
• Reported levels of nausea or vomiting, pain, and fatigue
• $130 payment per report
• OIG estimated cost to patient and Medicare @ $300 m
• “Unnecessary and fiscally irresponsible to require
patients to pay for services that are already covered as
part of routine care”
Results of the National Initiative for Cancer Care Quality:
How Can We Improve the Quality of Cancer Care in the
United States?
NICCQ RESULTS
• 1998 PATIENTS (Stages I – III)
• 5 metro areas (MSA’s) (Atlanta, Cleveland, Houston, Kansas
City, Los Angeles
• Total spectrum of care
• Less than 85% adherence to 18 of 36 breast cancer measures
• Significant variation across MSA’s
JCO 24.(4); Feb, 2006
Jennifer L. Malin, Eric C. Schneider, Arnold M. Epstein, John Adams, Ezekiel J. Emanuel, and Katherine L. Kahn
Journal of Clinical Oncology, Vol. 24, No. 4, Feb. 1, 2006
NICCQ Key Areas for Improvement
• Optimizing chemotherapy dosing
• Managing treatment side effects
• Advising patients about all treatment options, especially when
patient choice is a key factor in decision-making
• Improving documentation of key information regarding
patients’ cancer and treatment, specifically stage and details of
chemotherapy planning and delivery
• Ensure that patients at highest risk of poor outcomes receive
recommended care
Quality Research in Radiation Oncology
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PCS conceived — 1969
Planning grant from NCI — 1971
Research grant or contract — 1974 - 2004
Last renewal – June, 2006
QRRO project – 2006 – 2010
Kickoff in Milwaukee – Dec. 18, 2006
PCS Disease Site-Specific Surveys
Disease Site
Survey Years
1. Prostate
1973, 78, 83, 89, 94, 99, 07
2. Breast
1983, 89, 94, 99, 07
3. Lung
1999, 07
4. Cervix
1973, 78, 83, 89, 94, 99, 07
5. Esophageal
1994, 99, 07
6. Gastric
07
Determinants of Cancer Care Quality
a Complex Interplay of
Disease Related Factors
Patient Based Factors
Provider Characteristics
Health System Characteristics
Cancer Care Is a Chain of Events
Quality of cancer care is determined by the
weakest link in the chain.
Prevention
Detection Staging Treatment
QRRO Focus
Continuing Care
First Principle of Cancer Treatment
Do the right thing - at the right time and do it right.
Emerging Technology
• 3 D conformal (3D)
• (IMRT) Intensity Modulated
Radiation Therapy
• (PBI) Partial Breast Irradiation
Radiation Dose-Response
Brachytherapy
• Prostate Seed Implants
• (HDR) High Dose Rate
• (LDR) Low Dose Rate
QRRO SPECIFIC AIMS
1. To define a core set of process measures for selected major cancers in which radiation oncology
plays a major role, based on best available evidence that these measures affect outcomes
important to patients and providers and, thus measure quality of care. To collect data on those
measures from a sample of patients in a survey designed to allow calculation of national averages
for all patients treated with RT for the selected cancers. To examine practice setting, treatment
technology, patient and disease factors that may influence these measures.
2. To define process of care measures for important emerging advanced technologies based on the
best available evidence including expert consensus. To conduct surveys that will allow
documentation of process of care and quality assurance in emerging technologies, such as seed
implant treatment for prostate cancer, 3D Conformal Radiation Therapy (CRT) and Intensity
Modulated Radiation Therapy (IMRT) treatment for prostate, lung, gastric, and breast cancer, and
High Dose rate (HDR) brachytherapy for cervical and breast cancer.
3. To document the penetration of results of clinical trials and widely promulgated practice
guidelines and appropriateness criteria into use in the national practice providing an overview of
quality of care for treatment of each disease.
4. To describe patient and practice-based parameters, such as age, race, ethnicity, geographic
region, practice setting, and insurance status in relation to processes of care, disease
presentation, disease evaluation, treatment, compliance, and structure of treating facilities.
5. To disseminate information and educate the target audiences, radiation oncologists and other
oncologic physicians, health professionals, patients and the public regarding the findings.
Facilities Master List
100% Inventory of U.S. Radiation Oncology Structure
ADVANCED RADIATION TECHNOLOGY:
• Not evenly distributed.
• Not readily accessible to all.
Average US Facility (1998)
Practice Site (1998)
#
%
Hospital based
1000
63%
# Treatment machines
1.7
595
37%
# Linear Accelerators
1.6
# FTE Therapists
4.6
# FTE Dosimetrists
1.1
Free Standing
Total
1595
# New Patients/year
342
Map of all radiation therapy facilities in the United States (2004-2005)
N=2,246 Facilities
From Ballas et. al: Int. J. Radiation Oncology Biol Phys., Vol. 66, No.4, pp 1204-1211, 2006
Quality Research in Radiation Oncology
Measure
Identify
Communicate
• Patterns of Care
Structure
Voluntary
Multidisciplinary
Cost
Effective
Process
Context
• Benchmarks
• Appropriateness
• Compliance with
Evidence/Standards
• Gaps/Disparities
Outcome
• Trend Lines
Positively Influence Quality
• Professions
• Patients
• Public
• Agencies
• Educate
• Performance
Feedback
• Advocate
• Decision support
Statistical Design
and Analysis
Electronic Data Systems and
Data Monitoring Task Group
Measure
Identify
Communications
Committee
Communicate
• Patterns of Care
Structure
Multidisciplinary
Process
Context
Outcome
• Benchmarks
• Appropriateness
• Compliance with
Evidence/Standards
• Gaps/Disparities
• Trend Lines
• Professions
• Patients
• Public
• Agencies
Compliance with Breast-Conservation
Standards for Patients with Early-Stage
Breast Carcinoma
Compliance with selected 22 elements
Compliance level
# elements
> 90%
10
> 80%
16
Poor (< 67%)
6
White, et al: Cancer: February 15, 2003/Vol 97/ No. 4
Impact on Practice
– Measured compliance with national standards for Breast
Conservation Treatment.
– Results cited as evidence justifying changes in Breast Cancer
Clinical Guidelines of the National Comprehensive Cancer
Network.
– Results stimulated changes in the Breast Imaging Reporting
and Data System (BIRADS), standardized nomenclature for
reporting breast imaging results.
– Established benchmark against which practice improvement
can be measured.
CDC – NPCR
Breast and Prostate Patterns of Care Study
(POC-BP)
National Program of Cancer Registries
Centers for Disease Control and Prevention
US Department of Health and Human Services
RFA-DP-05-071
WI CaRE
Specific Aims
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Assess the completeness and quality of the stage and first course of treatment
data collected by the WI Cancer Reporting System (WCRS) for prostate and
female breast cancer.
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Determine the proportion of patients in WI who received the recognized
standard of care for stages I through III female breast cancer.
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Determine the tumor, patient, provider, and health system characteristics that
are associated with different cancer treatments for female breast and prostate
cancer patients in WI.
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Based on these studies and assessments, make recommendations for
enhancements to data collection that would expand the capabilities of the
WCRS.
Evolution of Cancer Care Quality:
Dynamic Factors
Q
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Y
Case Load
Work Effort
Evidence Base
Adequate Manpower
Reimbursement
Cost Effectiveness
New Discoveries
Destructive Technology
Commercialization
Healthcare Policy
Q
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Opinions
• Quality must be evaluated contemporaneously
with the care itself.
• Requires greatly enhanced electronic data
collection systems.
• May await a single payer system.
• Greater patient centeredness of the entire
healthcare system.
• QRRO may document individual practice
proficiency.