Following a pilot launch in 2002, the Quality Oncology Practice Initiative (QOPI) was opened up to all members of the American Society for Clinical Oncology (ASCO) in 2006 with the objective that ASCO be the international leader in ensuring high-quality cancer care.1,2 The ball was set rolling by the final report, (Ensuring Quality Cancer Care), submitted by the National Cancer Policy Board (NCPB) created by the Institute of Medicine (IOM), with the chair of the NCPB, Joseph Simone, MD, proposing the concept of QOPI.2,3 With more than 973 registered oncology practices across the United States involved in the program as of November 2010,4 QOPI is designed to measure care provided in outpatient oncology practices against evidence-based and expert consensus care recommendations.
Substandard healthcare provided by oncology practices and centers can result in avoidable morbidities and mortalities and accumulate unnecessary healthcare costs. In 2010, Don Berwick, MD, who was then administrator of the Centers for Medicare and Medicaid Services (CMS), expressed interest in partnering with ASCO to raise the quality of service rendered to Medicare and Medicaid beneficiaries.5
Subsequently, the 2014 ASCO annual report announced plans to position QOPI as a model clinical registry with CMS, through a provision made in the American Taxpayer Relief Act of 2012.6
Maintaining high standards for successful treatment requires efficient measures, as well as periodic review to ensure continuing improvement. QOPI was developed by world-renowned practicing oncologists and quality experts, using clinical guidelines and published standards such as the National Initiative on Cancer Care Quality, ASCO/National Comprehensive Cancer Network Quality Measures, and American Society for Radiation Oncology/ASCO/American Medical Association Physician Consortium for Performance Improvement Oncology Measures.7
The program currently lists at least 160 measures, which are updated biannually, but these measures are dynamic and may improve with time and experiences.
From Idea to Reality
Simone, a pediatric oncologist who has served as the director of the University of Florida Shands Cancer Center, is the pioneer of the quality improvement program. In a 2009 commentary, he ascribed his inspiration for developing QOPI to multiple factors:
• the pediatric oncology model
• quality of cancer care recommendations that he was involved in drafting as a member of the NCPB
• the uproar created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which raised the essential question: “Where does the patient stand?”2
Subsequently, Simone initiated a steering committee that laid down a proposed model that was tested (2003) in 25 practices interested in quality-of-care issues. Consequently, QOPI was offered to all ASCO members in 2006.
Program Participation Basics
The program requires that a US-based participating practice have at least 1 active ASCO member in good standing. Currently, international practices can register, but they cannot participate in data collection, although efforts are under way to expand inclusion (iQOPI).
Although participation in QOPI does not entail a fee, data abstraction would cost the practice staff time. Further, practices are encouraged to participate in multiple rounds for rapid quality improvement and to share their data among the entire practice staff. The program necessitates a 1-time registration, and it is recommended that the registration process be initiated at least 1 month prior to data collection.7
QOPI data collection is based on scoring on 7 modules: care at the end of life, symptom/toxicity management, breast cancer, colorectal cancer, and non-small cell lung cancer (Figure), resulting in nearly 160 quality measures. Participation in specific modules is determined by a clinic’s patient population, and data collection measures are evidence-based, process-centric, and are reassessed every 6 months. The core measures include pathology report confirming malignancy, staging documented in the first month of an office visit, pain assessment and pain addressed appropriately, a documented plan for chemotherapy, consent, treatment intent, smoking status with adequate counseling for cessation, and emotional well-being of the patient.
Practices with multiple locations can maintain a single or multiple accounts, with either staff or physician reporting.3,7 According to James Brandman, MD, MS, medical director of Northwestern Medicine Cancer Quality Practice and director of the Robert H. Lurie Clinical Cancer Center, “The Northwestern Medical Faculty Foundation (NMFF) was one of the first practices to enroll with QOPI, after it opened up for enrollment to ASCO members in 2006 Although our practice is well known for palliative care, QOPI assessment identified low pain control scores. This information was relayed back to the physicians and the necessary changes were implemented.” The metrics that formulate QOPI helped design the annual quality projects of the Kellogg Cancer Center according to Thomas Hensing, MD, clinical associate professor at the Kellogg Cancer Center of NorthShore University Health System.
Data Sampling Technique
The sampling protocol is laid out to include patients most recently seen in an out-patient setting, with charts of patients with an invasive malignancy (identified <2 years earlier) who were evaluated in a recent 6-month period being included. Sample size is determined by the number of associated physicians and the number of modules selected.
Registered practices are provided with updated information on data collection, both in the form of training material and webinars, as well as individual training sessions.7
Data can be submitted through a Web-based application and reports are provided within 4 weeks that can help a practice evaluate where it stands compared to the aggregate results of QOPI to improve performance.3 The entire process is compliant with the Health Insurance Portability and Accountability Act.
QOPI Benefits Over and Above Improved Quality of Care
In addition to improving how well a practice functions, physicians can obtain Continuing Medical Education credits for documenting the development and implementation of a performance improvement plan and maintenance of Physician Board Certification.
Additionally, upon request from a participant, ASCO can verify participation or achievement of QOPI certification to health plans that participate in the program (a list of the current participating health plans can be found at http://qopi.asco.org/Health_Plan_Program.htm).3,7 QOPI participation is a means to QOPI certification, which evolved out of the feedback received from oncologists and their staff asking to share their performance information with health plans and in marketing materials.3
When asked about the participation of the North Shore Cancer Center at Massachusetts General Hospital (MGH) in the program, Joel Schwartz, MD, director of oncology services at the cancer center, said in an e-mail response, “We were one of the beta test sites for QOPI, as one of the physicians actively involved in setting up QOPI, Joseph Jacobson, MD, was a member of our practice. We thought it would be a good idea to benchmark ourselves against similar institutions nationally and learn where we could do better in delivering the highest quality care to our patients….It has helped us enormously in understanding areas of practice where we can provide better care for our patients (eg, referral for fertility preservation).”
On future plans of the cancer center with regards QOPI certification, Schwartz added, “In my new role as medical oncology network clinical director of the MGH Cancer Center, I have suggested that all hospitals joining our network apply for QOPI certification, as one of the ways to ensure a higher standard of care across the network.”
The QOPI Certification Program (QCP), initiated in 2008 and promoted in 2010, served as the next step to advancing QOPI in attempts to standardize and improve patient care. QCP, which provides a 3-year certification for outpatient hematology-oncology practices, emerged following feedback provided by registered QOPI members,3 based on the fact that a public recognition of QOPI participation, in the form of certification, would further raise the performance of the participating clinics.
According to the Association of Community Cancer Centers, 80% of all adult cancer patients are treated by community oncology practitioners, and 70% of QOPI-certified practices are community-based.8 For certification, the practice must complete a round of QOPI data abstraction, using the QOPI modules, sampling strategy, and appropriate sample size. The resulting
report would determine eligibility for participation in QOPI certification.
Certification is then achieved based on QOPI medical record abstraction measures selected for certification and QOPI certification site assessment.3 QOPI certification review process includes audits prior to the certification, which confirm results, ensure program integrity, and improve learning opportunities for the program. The audit report is then shared with the practice and they may be awarded a QOPI certification-pending status for 1 year, during which period they can work on improving their shortcomings.3,7 The certification includes 20 standards related to staff training, chemotherapy orders, patient education and consent, chemotherapy planning documentation, drug preparation, chemotherapy administration, patient monitoring and assessment.7 The certification would prove a practice’s commitment to quality to both payers and the patients.
According to Brandman, the certification process “requires a village,” and NMFF brought together the nursing group, the pharmacy group, and the physicians (represented by Brandman) to mobilize resources for the certification. A site visit by 2 oncology nurses ensued in April 2012 following application in fall 2011, and NMFF received certification in July 2012.
For Kellogg, the biggest challenge was documentation of the procedures to adhere to the QOPI metric. “Although electronic medical records were actively in use, the work-flow needed to be ironed out. We went through 2 to 3 cycles of internal auditing before certification," said Hensing. The cancer center registered for QCP in 2011 and were certified in 2012. More than 200 practices are currently QOPI certified.9
QOPI and Health Plans
A number of health plans have been listed on ASCO’s QOPI website as participants in the program,10 and ASCO verifies program participation or successful completion to the listed health plan upon member participation in the QOPI Health Plan Program. However, ASCO does not share performance data with the health plans. Some of the participating health plans include Aetna,
Anthem Blue Cross and Blue Shield, Health Alliance Plan, Humana, UnitedHealthCare.
Although initially frowned upon, health plans are now offering financial incentives to practices for adherence to quality improvement measures. Blue Cross Blue Shield of Michigan (BCBSM) was the one of the first health plans to provide a financial incentive to oncology practices that participate in QOPI.
The Physician Group Incentive Program
oncology initiative was formed in collaboration with ASCO, based on QOPI. BCBSM subsidized participation by practices, expecting that selfassessment and adherence to the QOPI measures would have a positive impact on the quality of life of patients, reduce off-label drug use, and reduce healthcarecosts.1,10 Following participation in QOPI, BCBSM established a new
professional initiative, the Michigan Oncology Quality Consortium (MOQC), to improve performance, implement changes, and guide oncologists who were new to QOPI.11
Other health plans have now caught on with BCBSM. UnitedHealthCare took a different view with the incentives provided to doctors to improve care; by covering the entire cost of treatment upfront, rather than reimbursing later, they disengaged payment from drug selection. The pilot study, published in the journal Health Affairs, experimented with “bundled/episodic payment,” wherein the physician-determined cost of the entire treatment period is paid to cover the standard treatment period of 6 to 12 months. With this practice, the oncologists’ fee does not vary based on the drug selected for treatment, so practitioners can choose a more cost-effective alternate. If the patient later needs treatment with a more expensive drug, the drugs are reimbursed at cost,
mitigating any risk for the practice.
Further, the payer has no say in drug selection,12 thus the oncologist can determine the most cost-effective treatment option. However, considering the huge cost variations between patients, additional studies would be needed to determine the significance of this model. Other practices, including the Northwest Georgia Oncology Centers, are working with UnitedHealthcare to
test the bundled payment model; CMS is also working with payers to adopt the model.13
NMFF has not yet contracted with insurance groups due to internal contracting procedures, but does see an advantage in doing so in the future, says Brandman. According to Hensing, the driver for certification at Kellogg was improving processes to meet the benchmark quality requirements, which is his primary interest, and he was not aware of collaborations with health plans.
Feedback Following Evaluation
Outside of QOPI, cancer clinics are working to achieve quality cancer care based on the IOM recommendations. The Florida Initiative for Quality Cancer Care (FIQCC) is one such initiative: a consortium of 11 medical oncology practices that evaluates the quality of cancer care across Florida.14 FIQCC recently published a report following a reevaluation of 35 quality care indicators
(QCIs) in medical records of colorectal cancer cases in 10 participating practices in 2009. The practices were first evaluated in 2006, and the results of the review were circulated to the relevant clinics to improve adherence.
Despite an overall improvement in QCI adherence, the reassessment in 2009 observed a variability in adherence across practices in addition to lack of adherence to several indicators (accepted regimen of neoadjuvant chemotherapy, receipt of adjuvant radiation treatment), pointing to a need for organized improvement efforts for those specific indicators.
ASCO, in collaboration with the Oncology Nursing Society, published a QCP report early last year evaluating the implementation of chemotherapy administration safety standards in outpatient oncology clinics.8 By the end of November 2012, of the 206 practices that had applied for certification, 156 did get certified, 44 sites were in the process of certification and 6 had withdrawn their application. The study observed that of 111 practices that had completed an on-site review by the end of November 2012, only 2 (1.8%) sites completely met the 17 standard requirements (Table). Individual standard performances varied between 40.4% (qualifications, extravasation management) and 100% (toxicity assessment documentation), with a median of 75.3%.8 QCP is definitely proving to be beneficial in terms of ensuring rigorous adherence to the established standards. The report identified that 98.2% of the practices that received on-site visits failed at some level in adhering to the 17 standards essential for certification. Certain standards seemed more challenging for the practices to meet over others, including qualification of the staff who prescribe, prepare, and administer chemotherapy, medical record documentation, meeting the requirements for the time of administration, and extravasation management (staff were aware of the procedure, but lacked documentation).
Conversely, maximum adherence was observed for ancillary services such as referrals for supportive care and for documentation of toxicity assessment. Following evaluation, practices put in extra efforts to adhere to the standards and improve performance, with 1 clinic obtaining certification within 43 days from the certification-pending date (average time to certification was 4.4 months to 6.9 months over the various rounds).8
Simone, the pioneer of QOPI, said retrospectively in an e-mail, “Since its inception in 2003, I would say one of (QOPI’s) major successes has been engaging a wide array of oncologists from across the country. I believe it was because it was built by and for them. When I had the idea, I had had many experiences of trying to get doctors to do things and the major lesson
was that they must be in on the ground floor. Appealing to their better instincts—do good for patients—was an incentive, but so was curiosity to see how they performed compared to other oncologists. Doctors can be competitive in a good way, rather than just financially or by volume of work. We started small, did lengthy testing, and brought in small test groups before offering it to any ASCO member. This took several years and we managed to keep the commitment and interest of the practices engaged in building the program all that time.”
In terms of where the program could lead the quality of cancer care he added, “QOPI, as it now stands, has only scratched the surface of what should be done. The main challenge, and probably the most important effort, will be to find a way to track outcomes. At the end of the day, that’s all that matters to patients and that is the gold standard to test whether what we are doing i useful as well as informative.”
So where does the patient stand with QOPI and QCP? For an oncology patient, quality of care is most important, but hospitals work on referrals and reputation. “Patients are usually ignorant of a practices’ quality standards and certifications.” said Brandman. “The influence of such accreditations on patient recruitment would be extremely difficult to measure.” However,
in the long run, the reputation of a practice emerges from the standard and quality of care, the ultimate goal of QOPI.References
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