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The Development of an Oncology Measure Set
“A Journey of a 1000 miles begins with a step”
Rodger J. Winn MDDirector, Cancer ProjectNational Quality Forum
Interesting Times in Oncology
• New technologies and biologic breakthroughs
• Increasing demand
• Emphasis on quality
• Concern about costs
Transformational times
• 1960-1980
– GROWTH
– AUTONOMY
• 1990-2000
– MANAGED CARE
• 2006
– VALUE-BASED PURCHASING
Value-based Purchasing
Goal: Obtain the Most Value
Value =Qualit
y
Cost
Emerging National Strategy forClosing the Quality Gap
Transparency - Create a marketplace rich in quality information (public reporting)
Payment Alignment - Reward providers for providing safe, effective, efficient care (P4P)
Consumer Engagement - Encourage patients to seek high value providers by having “skin in the game” (HSAs)
Executive Order 8/22/06
• Health Care Transparency: Empowering Consumers to Save on Quality Care
• Orders federal Agencies to:– Increase transparency on pricing– Increase transparency on quality– Encourage adoption of HIT– Provide options that promote quality and
efficiency in healthcare
Ensuring Quality Cancer Care
“The NCPB has concluded that for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.”
Institute of Medicine
National Research Council
1999
The Four Parts of the Quality The Four Parts of the Quality GapGap
OveruseUnderuseMisuse/errorsWaste
Underuse: Adjuvant Tamoxifen for Breast Cancer
Percentage of Postmenopausal Women with Node (+) ER (+) Tumors Who
Received Tamoxifen Minnesota (1993) 59%
Massachusetts (1993-5) 63%
Guadagnoli et al: 1998
Underuse: Pain medication in patients with metastatic cancer
• ECOG survey of 1308 patients• 67% of patients had pain in the preceding week
36% had severe pain (inhibited function)• 42% (250 of 597) were not given adequate
analgesia• 3X more likely to receive inadequate pain
medication if a minority group memberCleeland, NEJM, 1994
Overuse: Chemotherapy use in the last 6 months of life
• 91 patients with metastatic breast cancer– Chemotherapy regimens
None 24%One 46%Two 16 %Three 10Four, five 3Six 1
Misuse: Hospital Surgical Volume and Operative Mortality
30 Day Mortality (%)
Volume Esophagus Pancreas
Very low 23.1 17.6
Low 18.9 15.4
Medium 16.9 11.6
High 11.7 7.5
Very high 8.1 3.8
Birkmeyer, NEJM, 2002
Progress
• When something new is found, people say it’s not true
• When it’s found to be true, people say it’s not important
• When it’s found to be important, people say it’s not new
William James
Quality Measurement
Purposes of measuring quality
• Accountability- public reporting–Drive selection, payment,
accreditation• Quality improvement- private
–Remedial action
• Surveillance- Generate information for policy decisions
Perspectives on quality
• Physicians focus on technical aspects of care
• Patients focus on health status, functional status, access, safety, communication, coordination of care, family inclusion, education, respect
• Purchasers focus on employee satisfaction, time out of work, health costs
IOM/NQF Aims of quality care
• Effective/Beneficial
• Timely
• Safe
• Patient-centered
• Efficient
• Equitable
Evidence linking care to outcomes
Measurement of a degree of adherence
Quality Indicator
Indicators, measurement, and measures
Measure
Types of quality indicators
• Types of indicators relate to realms of quality:
– Structure– Process Output– Outcomes– Patient experience
• Process and structural indicators should relate to outcomes. Outcome measures should loop back to process
Quality measure
• Quality measure: a mechanism to quantify the quality of a selected aspect of care by comparing it to a criterion– Requires a numerator and denominator
– Requires specifications
Surgical wound infection measures
• Assessment of incidence of surgical wound infections in 5804 wounds
• Rate by wound infection definition– CDC 19.2%– NINSS 12.3%– ASEPSIS >20 6.8%
Wilson, BMJ, 2005
Soundness of Measures
• In order to ensure that a measure will accomplish its aim of accurately assessing quality in a way that is meaningful, four areas must be addressed:– Importance– Scientific acceptability– Usability– Feasibility
Quality in the Oncology World:
A Comprehensive Measure Set
Disease Issues
• Multiple tumor types– Big four: Lung, colon, breast, prostate
• Multiple sub-types
• Multiple presentations
• Multiple stages
• Multiple therapeutic approaches
Disease Trajectory• Prevention• Screening• Diagnosis• Staging• Treatment• Surveillance• Survival• Recurrence• End-of-life care
Data Sources
• Administrative database– No staging– Lack of granularity
• Medical records– Multiple sites– Multiple physicians– May require patient contact
• Surveys– Not validated for oncology
Oncology Disciplines• Surgical• Surgical sub-specialties• Radiation• Medical• Pathology• Radiology• Nursing• Social Work• Pharmacy• Etc…….
Longitudinal Care
• To achieve optimal outcomes, i.e. survival, a series of appropriate processes must b e successfully completed:– Pathology reading, surgical procedure,
adjuvant RT, chemotherapy, and hormone therapy.
• Composite measures
– all or none measures
Attribution
• Individual physician• Referring physician• Team• Facility/practice organization• Health plan
• Responsibility beyond currently recognized boundaries
Level of Evidence
• Cardiology: a few trials with thousands of subjects
Oncology: a thousand trials with a few subjects
• High-level evidence not available for most oncology processes
Current Oncology Quality Activities
National Goals and Priorities
Measure Development
NQF Endorsement
Measure selection
Implementation: data selection, aggregation, verification, standard setting
Public ReportingStandard Setting
Accountability QI
Cancer Quality Initiatives• ACoS Commission on Cancer• ASCO
– NICCQ: breast and colon measures piloted in five cities– QOPI
• State Cancer Plans• ACCC Standards for Oncology programs• NCCN Outcomes Project• College of American Pathologists• Kaiser Permanente-IHI-NCQA• NHPCO, National Consensus Project• AUA, AAD
Need for a common set of measures
• If measure development and endorsement not centralized may be counter-productive:
–Fragmented–Duplicative–Contradictory
• Measures require buy-in from all stakeholders: providers, consumers, payers, government
National Quality Forum
• A private, non-profit voluntary consensus standards setting organization
• Membership 350+ • Meets criteria of NTTAA 1995
– Measures acceptable to CMS
• Structured to give voice to all stakeholder constituencies
• Formal review, voting and appeal process
Quality Alliances
• Hospital Quality Alliance (HQA)
• Ambulatory Care Quality Alliance (AQA)
• Cancer Quality Alliance– 12 Founding Members– Promote synergies– Defining role in measure development
• Pharmacy Alliance
• Pediatrics Alliance
NQF-proposed Accountability Measures: Hospital Level
• Breast cancer– Post-breast conserving surgery RT, <70– Adjuvant chemotherapy for Stage I >1cm or
Stage II and III, ER negative, <70– Adjuvant hormone therapy, ER+ or PR+
• Colon cancer– Adjuvant chemotherapy, Stage III, <80– 11 required elements in path report
• Family Evaluation of Hospice Care
NICQQ
Breast Colon
Diagnostic 13 10
Surgery 4 4
Adjuvant Rx 16 10
Toxicity 2 0
Surveillance 1 1
Overall 36 25
NICQQ results: Breast
Adherence (%) Range (%)
Diagnosis 88 88-89
Surgery 87 85-88
Adjuvant RX 82 81-83
Toxicity 73 69-78
Surveillance 94 92-95
Overall 86 86-87
NICQQ Results: Colon
Adherence (%) Adherence (%)
Diagnosis 87 85-89
Surgery 93 91-95
Adjuvant Rx 64 62-67
Toxicity - -
Surveillance 50 46-55
Overall 78 76-79
QOPIQuality Oncology Practice Initiative
Oncology measures:Physician level
• QOPI: Structure
• Path report
• Chemo plan
• Flow sheet
• Patient consent
• QOPI: Process• Pain assessment; 1st, 2nd to last last, visits• Narcotic effectiveness assessed• Chemo intent documented• Smoking• Anti-emetics• EPO or Darbo documentation of Hb <11 g/dl• Adjuvant chemo/hormone recommended and
given: breast, colon, lung• Bisphosphonates given and check renal function• CEA• Growth factors with CHOP or R-CHOP• CD-20 and rituximab
Physician level oncology measures:
Physician level oncology measures
• QOPI- Outcome– None
• QOPI- Patient experience– None
• QOPI- Efficiency– Chemotherapy in last 2 weeks of life
• Clinical trials
Implementation
• Each data collection requires 80 – 150 charts
• Abstractors are usually data manager, nurse, sometimes clerical, not doctors– Trained by ASCO staff
• Data entered directly onto web form
• Takes one or two days of staff time
QOPI Results
• >2000 doctors
• 125 practices currently enrolled
• 10,000 charts abstracted
• Several practices measured 2 – 3 times
Report Card
Chemotherapy recommended for breast cancer patients <50 years with T2 or +ALN
89
96
100
82
84
86
88
90
92
94
96
98
100
Copyright 2004, 2005 American Society of Clinical Oncology. All rights reserved.
RGH
VCI
%
Process
Documented plan for chemotherapy,
including doses and time intervals
15
31
43
6372
80 82 8389
94 95100
0
10
20
30
40
50
60
70
80
90
100
Copyright 2004, 2005 American Society of Clinical Oncology. All rights reserved.
RGH VCI
%
Structure
Was Pain Assessed on One of the Last Two Visits Prior to Death?
30
5664 67 70 73
8087 88 90 93
97 100
0
10
20
30
40
50
60
70
80
90
100
Copyright 2004, 2005 American Society of Clinical Oncology. All rights reserved.
RGH VCI
%
Process
Pain rated (by number) on either visit
08
1319 21 22
27
43
54 5660
7180
90
100
0
10
20
30
40
50
60
70
80
90
100
Copyright 2004, 2005 American Society of Clinical Oncology. All rights reserved.
RGH
VCI
%
Process
Patient enrolled in hospice before death
252733333640
50505353545760606263
7880839193
100
01020304050
60708090
100
Yes
Mean=62%
Copyright 2004, 2005 American Society of Clinical Oncology. All rights reserved.
RGH
VCI
%
Structure/Process
Conclusions• We must instill a culture of quality in
oncology
• All disciplines and stakeholders must be involved
• Measurement of quality is an exacting science and oncology poses special difficulties
• New methods using information technology will be needed
• Physicians and enlightened professional organizations will have to lead the way
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