Navigating the Quality Landscape in Oncology: Pitfalls and Lessons Learned
Surabhi Dangi-Garimella, PhD
Ensuring access to appropriate data and then using the information to improve healthcare outcomes remains an ongoing challenge—this was the conclusion drawn by panelists participating at the National Comprehensive Cancer Network (NCCN)’s Oncology Policy Summit on Redefining Quality Measurement in Oncology, held September 25 in Washington, DC.
The biggest challenge, the panelists said, was with gathering cutting edge data. “We have limited access to data,” said Andrew York, PharmD, JD, CMS. While CMS has created a registry of what it considers high-quality data, “feasibility is hard, and it’s also hard for us to implement changes.” There are practical and operational challenges.
Ronald Walters, MD, MBA, MHA, MS, The University of Texas MD Anderson Cancer Center, added that the growth of personalized medicine will make the process even more challenging.
“Cross-cutting measures don’t have strong evidence,” said Jason Spangler, MD, MPH, Amgen. Citing the Oncology Care Model (OCM), he said that clinically specific measures provide more information compared with cross-cutting measures, which are usually outcomes measures. According to Mary Lou Smith, JD, MBA, of the Research Advocacy Network, the dearth of a high number of enrollees in adult clinical trials is another issue. “With a 5% adult trial enrollment rale, using real-world evidence to inform drug development is a challenge,” she said.
Physician buy-in, especially when documenting information around things like pain and hospice/palliation is important, according to Jennifer Griggs, MD, MPH, University of Michigan, as is care coordination. “However, it is important to define exactly what needs to be coordinated,” she said.
Spangler highlighted the importance of shared decision making and patient-provider conversation, especially when a patient is receiving precision medicine. “With precision care, patients need to know that quality measurements around their precision treatment may be unique,” he said, explaining the likelihood of a disconnect between standard quality metrics and those used for a patient undergoing precision treatment.
Introducing patient-centricity to the discussion, John Fox, MD, MS, Priority Health, said, “We don’t just have to measure everything, but we do need to understand the accuracy of what we are measuring. We definitely need a quality measure to understand patients’ comprehension of their treatment and disease.”
Matthew Alan Facktor, MD, Geisinger Health, Commission on Cancer, alluded to the fact that most quality metrics in use today are process measures, which he said creates a significant gap in quality measurement. He emphasized the need to pay greater attention to structural measures, such as site of care, and availability of tools to deliver quality care, as well as patient-reported outcomes measures.
When the moderator, Clifford Goodman, PhD, The Lewin Group, asked whether CMS has been thinking about these specific measures, York said that the Center for Medicare & Medicaid Innovation started looking at outcomes measures, but the requirement was for infrastructure changes to ensure ramping up of quality-based programs.
“Our measures were closest to outcomes measures,” he said, adding that while they were process measures, they were geared to collect healthcare utilization metrics. Citing an example of pain as an outcomes measure, he said “We need to include a process measure to ensure [pain medication] was being administered.”
When asked if the existing quality measurement apparatus is suitable for quantifying patient experiences with quality of their treatment, Walters replied in the negative.
Griggs narrated her experience at Michigan with patient interaction: measuring anxiety, stress, and non–cancer-related issues. “The 17 measures that evolved following their patient interaction lined-up well with ASCO [American Society of Clinical Oncology]’s measures submitted under the Merit-based Incentive Payment System.” While these measures have been identified, operationalizing them, is the next step, she said.
“We can actually collect data on switching doctors and the chemotherapy administered in the last 14 days of care … that could be incorporated as a quality measure,” Walters said.
Smith believes that care coordination soon will be included as a quality measure and that precision medicine will help this. Health plans have already been thinking about this. “We have a care management fee in our oncology home model, which is equivalent to the MEOS [monthly enhanced oncology service] payment," under OCM, which helps ensure care coordination receives monetary support.
“We have the medical oncologist targeted as our care coordinator,” York explained, because often the primary care providers aren’t ready to take up that responsibility. He explained though that care navigation can be spread out across the practice to include the nurse navigator, the front office administrator, and the oncologist.
When asked about dealing with patient dissatisfaction when they do not receive the treatment they seek because it may not be supported by evidence, Walters explained that it may not affect quality measurement because “many measures have denominator exclusions that includes documentation on why the patient was refused.”
Explaining the industry’s struggle with sharing real-world evidence that supports the value proposition of their product, Spangler said, “We have limitations on how much of the real-world evidence that we gather can be shared with other stakeholders.” This evidence, he suggested, can definitely be included in the development of quality measures.
“We need a parsimonious tight set of meaningful measures that can be used by both health systems and patients,” said Griggs.
“Collective accountability is vital: everyone needs to work together to improve the quality of care,” added Spangler.