The 1999 Institute of Medicine (IOM) report on quality of cancer care highlighted existing gaps in patient care and emphasized the need to develop a core set of measures to assess quality. To Err is Human: Building a Safer Health System stated that errors in American hospitals were responsible for 44,000 to 98,000 deaths each year.1 Although the report spurred debate, with some critics claiming that it channeled resources away from much-needed quality improvement initiatives, a study evaluating the report’s impact at its 5-year anniversary found increased efforts to promote patient safety.2
What started with the IOM report has culminated in organized efforts by groups like the American Society of Clinical Oncology (ASCO) create quality measures that put the patient at the center of treatment regimens. Along with the Quality Oncology Practice Initiative (QOPI), introduced by ASCO in 2006 to measure quality and implement standards that can promote improved patient care,3 ASCO’s annual Quality Care Symposium provides a platform for cost, value, and policy discussions in oncology care.
The Peer Exchange convened by The American Journal of Managed Care in September 2014 as a part of Oncology Stakeholder Summit: Evidence-Based Decisions to Improve Quality and Regulate Costs, witnessed payers and providers deliberating the value proposition of quality measures in oncology.
Participants included John L. Fox, MD, MHA, senior medical director and affairs at Priority Health; Ira M. Klein, MD, MBA, FACP, national medical director, clinical thought leadership, Office of the Chief Medical Officer, Aetna Inc; Michael Kolodziej, MD, national medical director for oncology strategies, Aetna Inc; Bryan Loy, MD, physician lead—cancer at Humana; Irwin W. Tischler, DO, national medical director, oncology, Cigna; and Christopher Sweeney, MBBS, associate professor, Department of Medicine, Harvard Medical School, and medical oncologist, Dana-Farber Cancer Institute. The session was moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and associate director of surgical intensive care at the NewYork-Presbyterian Hospital.
Salgo invited the panel members to identify the key quality measures in oncology and the stakeholders responsible for recognizing them. The participants agreed that 15 years after the IOM report, stakeholders have yet to agree on the most important and relevant measures to improve quality of patient care. While opinions abound, there is no consensus, according to Kolodziej. “Some things are pretty easy to get your hands around—ER utilization, hospitalization rate, end-of-life care—those are fairly harmonious across the platforms, but there’s very little harmony otherwise,” he said, emphasizing that while it would be ideal to measure and report on all aspects of care, accomplishing that is not always feasible.
Sweeney contributed his physician perspective to the discussion, opining that appropriate chemotherapy at the right dose, administered at the right time, with the necessary supportive care, is easy to measure. However, “If the pathways and guidelines suggest that patients with hormone-sensitive prostate cancer should get docetaxel, with the qualification that the patient is docetaxel eligible, the question is how do you define docetaxel eligible? So that quality measure is a lot less clear,” he said.
The Centers for Medicare and Medicaid Innovation (CMMI) recently introduced a preliminary design for an oncology care model, with the “triple aim” of improved health outcomes, higher quality of care, and cost savings, as payers evaluate alternate payment models while transitioning away from the traditional fee-for-service model.4
Patient-centeredness is a very important facet of the quality discussion, according to Klein, especially with the growth of individualized medicine. “It will determine what’s better or what’s worse. We will have to make decisions on toxicity, safety, tolerability, and quality of life. And so if you don’t have that patient-centered component, you’re not going to be able to put it all together,” Klein stressed. He agreed with Salgo that the patient and the family should participate in the discussion on treatment options.
That is the trajectory of the care discussion today—increased communication with the patient to establish treatment regimens. Sweeney said that in addition to establishing if a patient is fit for chemotherapy, he discusses options with the patient after providing all the necessary information on potential complications and side effects of therapy.
Tischler agreed, stating that although the institution of clinical pathways can streamline care and its cost, incorporating a patient-centered approach can cause a practice to make adjustments to improve the quality of care. Emphasizing the importance of an oncology medical home in this context, Klein said that private payers are working to incorporate programs that would improve coordinated, patient-centered care, which is the premise of an oncology medical home.
Quality Care: Key Features and Barriers
The most resounding influence, when it comes to quality initiatives, has been that of ASCO’s QOPI and the American Board of Internal Medicine’s (ABIM’s) Choosing Wisely campaign. Salgo asked the panel members to highlight aspects of care most influenced by these campaigns.
According to Kolodziej, QOPI has had a major influence on end-of-life care. He provided an example of treatment provided to patients during the last 1 to 2 weeks of life at the University of Michigan. “(They) have provided evidence that their chemotherapy administration in the last 7 to 14 days of life was aberrant and it dramatically improved when they started measuring it. So I think getting a process around end-of-life care is extraordinarily difficult, but by using the QOPI measures for end-of-life care, people have looked and said, ‘We’re just not happy with our performance there.’”
For the provider, it’s extremely important that all the relevant information, such as tumor grade and tumor stage, be clearly documented, to help make informed decisions, said Sweeney. Additionally, the ultimate goal of treatment, whether cure or palliative care, should be well defined. This helps all those involved in patient care—primary care physician, medical oncologist, nurses, surgeon, and radiation oncologist—stay on the same page and deliver the optimal treatment path, he added.
However, a consensus around defining quality is much needed, according to Fox, and “There has to be an agreement among the payers who are being asked to pay for quality that we’re going to subscribe to a single standard of quality.” For Fox, the ability to recognize important quality traits and then being able to measure them is crucial. Fulfilling these goals, he said, would be followed by identifying a system to pay for it.
Fox emphasized that discussions on paying for quality care does not mean that insurers were not paying for quality before. The challenge here is to “reengineer practices to improve the quality, and consistency, and reliability of care, (which) takes dollars, and how do we fund that?” he asked. In his opinion, the biggest barrier to widespread implementation of the quality initiatives is incentivizing practices to make the changes and paying them for it.
Loy and Sweeney agreed that ABIM and ASCO have helped bring tremendous value to the quality discussion by their efforts to initiate dialogue alone. The data have always been there—now, instead of deliberating over data credibility, QOPI and Choosing Wisely have steered the discussion toward identifying data gaps and correcting them, and “It’s changed the dialogue,” said Loy.
However, according to Sweeney, implementing these quality measures can place an extra burden on the physician. He echoed what a lot of physicians seem to complain about—the added time spent documenting and filling out paperwork. “Examining and counseling a patient itself is time consuming; but when there’s the extra burden of paperwork, spending time on the computer when you’re already running 20, 30, maybe 50 minutes late in clinic but having to fill out the paperwork, is a competing agenda to delivering the care,” he said. So in Sweeney’s opinion, time is the major barrier for implementing these quality measures, along with finding the resources in this current time of burgeoning healthcare costs.
Ideal Locations for Implementing Quality Measures?
Healthcare practices today vary: they can be private clinics, polyclinics, hospitals, or community health centers. The panelists did not, however, think there would be a difference in implementation based on the site of care. The most important influence, they believe, is the influence of participation by organizations like ASCO.
Loy stated that he’s seen private clinics and academic institutes take the initiative to identify shortcomings within their organizations and introducing improvement measures. Klein agreed, “It’s not as important what the site of care is, though the site of care often determines the operational ability to deploy the metrics, get the metrics back, and have the dialogue.” The rate-limiting step in the business, they all agreed, was identifying the quality metrics to measure.
Can PROs Influence Quality?
Continuing the discussion on patient-centeredness, Salgo asked the experts to comment on the influence of patient-reported outcomes (PROs) on patient and process outcomes.
While Klein believes that PROs are a little early in their development, he believes that the design of these measures plays a very important role in its utility for making quality improvements. Kolodziej added that while PROs are largely a product of aggregate reporting, he believes individual-level reporting would be most important in tying clinical factors to specific outcomes.
“It’s a tremendously exciting time in oncology; the understanding of malignancy and the options for treatment are exploding. If we can come to an agreement that transparency and the concept of process improvement will ultimately lead to better patient care, better patient experience, and better value, then we’ll have really significantly moved the ball.” References
1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000.
2. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The “To Err is Human” report and the patient safety literature. Qual Saf Health Care. 2006;15(3):174-178.
3. Dangi-Garimella S. QOPI, the ASCO initiative, improves compliance and promotes quality of patient care. Am J Manag Care. 2014; 20(SP5):SP153-SP155.
4. The Center for Medicare and Medicaid Innovation: preliminary design for an oncology-focused model. American Society of Clinical Oncology website. http://www.asco.org/sites/www.asco.org/files/cms_innovation_center_oncology_model_preliminary_design_paper_0.pdf. Accessed October 28, 2014.