Measuring Quality Indicators to Improve Patient Care 

The Quality of Cancer Care:The Quality of Cancer Care:Does the Literature Support the Rhetoric?Does the Literature Support the Rhetoric?

Bruce E. Hillner, M.D. & Thomas J. Smith, M.D.Bruce E. Hillner, M.D. & Thomas J. Smith, M.D.

Report to the National Cancer Policy Board, Institute of Medicine: April, 1999Report to the National Cancer Policy Board, Institute of Medicine: April, 1999

NCPB Report (IOM), 1999NCPB Report (IOM), 1999

““Literature since 1988 in most areas does not address quality of Literature since 1988 in most areas does not address quality of cancer care to any substantial extent.”cancer care to any substantial extent.”

““So diffuse and diverse that providers have not had to provide So diffuse and diverse that providers have not had to provide accountability for specific processes or outcomes.” accountability for specific processes or outcomes.”

““Quality gaps for all conditions were found in retrospective Quality gaps for all conditions were found in retrospective assessments in process of care.”assessments in process of care.”

““GAPS” can be measured by overuse, underuse, misuse (errors) GAPS” can be measured by overuse, underuse, misuse (errors) and waste.”and waste.”

Ensuring QualityC A N C E R Care

Maria Hewitt and Joseph V. Simone, Maria Hewitt and Joseph V. Simone, EditorsEditors

National Cancer Policy BoardNational Cancer Policy Board

INSTITUTE OF MEDICINEINSTITUTE OF MEDICINE andand

COMMISSION ON LIFE SCIENCES,COMMISSION ON LIFE SCIENCES,NATIONAL RESEARCH COUNCILNATIONAL RESEARCH COUNCIL

National Academy PressNational Academy PressWashington, D.C., 1999Washington, D.C., 1999

Agencies Evaluating Cancer CareAgencies Evaluating Cancer CareINSTITUTE OF MEDICINEINSTITUTE OF MEDICINE

• Quality of Healthcare in America Project (1998)Quality of Healthcare in America Project (1998)• National Cancer Policy Board (1999)National Cancer Policy Board (1999)

CENTERS FOR MEDICARE AND MEDICAID SERVICES (2003)CENTERS FOR MEDICARE AND MEDICAID SERVICES (2003)

• Demonstration ProjectsDemonstration Projects

AGENCY FOR HEALTHCARE RESEARCH AND QUALITYAGENCY FOR HEALTHCARE RESEARCH AND QUALITY

NATIONAL INITIATIVE ON CANCER CARE QUALITY (2000)NATIONAL INITIATIVE ON CANCER CARE QUALITY (2000)

NATIONAL QUALITY FORUMNATIONAL QUALITY FORUM • Cancer Care Quality Measures Steering Committee (2003)Cancer Care Quality Measures Steering Committee (2003)

NATIONAL CANCER INSTITUTENATIONAL CANCER INSTITUTE• Cancer Care Outcome Research and Surveillance Consortium (1999)Cancer Care Outcome Research and Surveillance Consortium (1999)

QUALITY ALLIANCE (2005)QUALITY ALLIANCE (2005)

Quality Research in Radiation Oncology

Since 1973

Quality of Cancer CareQuality of Cancer CareAs a National Issue (1998)As a National Issue (1998)

Since 1998

NCI 1999NCI 1999CMS 2003CMS 2003AHRQ 2004AHRQ 2004

NICCQ 2000NICCQ 2000

Alpha Group 2004Alpha Group 2004

QOPI 2005QOPI 2005

Quality Alliance 2005Quality Alliance 2005

““Environment of Watchful Concern”Environment of Watchful Concern”

IOM 1998IOM 1998

NCPB 1999NCPB 1999

JACHO 2004JACHO 2004

LEAPFROGLEAPFROG

CMS 2005 P4R Demonstration ProjectCMS 2005 P4R Demonstration Project

• Reported levels of nausea or vomiting, pain, and fatigueReported levels of nausea or vomiting, pain, and fatigue

• $130 payment per report$130 payment per report

• OIG estimated cost to patient and Medicare @ $300 mOIG estimated cost to patient and Medicare @ $300 m

• “ “Unnecessary and fiscally irresponsible to require Unnecessary and fiscally irresponsible to require patients to pay for services that are already covered as patients to pay for services that are already covered as part of routine care”part of routine care”

Demonstration of Improved Quality of Care Demonstration of Improved Quality of Care for Cancer Patients Undergoing Chemotherapyfor Cancer Patients Undergoing Chemotherapy

Results of the National Initiative for Cancer Care Quality: Results of the National Initiative for Cancer Care Quality: How Can We Improve the Quality of Cancer Care in the How Can We Improve the Quality of Cancer Care in the

United States?United States?

Jennifer L. Malin, Eric C. Schneider, Arnold M. Epstein, John Adams, Ezekiel J. Emanuel, and Katherine L. KahnJennifer 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, 2006Journal of Clinical Oncology, Vol. 24, No. 4, Feb. 1, 2006

• 1998 PATIENTS (Stages I – III)1998 PATIENTS (Stages I – III)• 5 metro areas (MSA’s) (Atlanta, Cleveland, Houston, Kansas 5 metro areas (MSA’s) (Atlanta, Cleveland, Houston, Kansas City, Los AngelesCity, Los Angeles• Total spectrum of careTotal spectrum of care

• Less than 85% adherence to 18 of 36 breast cancer measuresLess than 85% adherence to 18 of 36 breast cancer measures• Significant variation across MSA’sSignificant variation across MSA’s

JCO 24.(4); Feb, 2006JCO 24.(4); Feb, 2006

NICCQ RESULTSNICCQ RESULTS

NICCQ NICCQ Key Areas for ImprovementKey Areas for Improvement

• Optimizing chemotherapy dosingOptimizing chemotherapy dosing

• Managing treatment side effects Managing treatment side effects

• Advising patients about all treatment options, especially when Advising patients about all treatment options, especially when patient choice is a key factor in decision-making patient choice is a key factor in decision-making

• Improving documentation of key information regarding Improving documentation of key information regarding patients’ cancer and treatment, specifically stage and details of patients’ cancer and treatment, specifically stage and details of chemotherapy planning and deliverychemotherapy planning and delivery

• Ensure that patients at highest risk of poor outcomes receive Ensure that patients at highest risk of poor outcomes receive recommended carerecommended care

Quality Research in Radiation OncologyQuality Research in Radiation Oncology

• PCS conceived — 1969PCS conceived — 1969• Planning grant from NCI — 1971Planning grant from NCI — 1971• Research grant or contract — 1974 - 2004Research grant or contract — 1974 - 2004• Last renewal – June, 2006Last renewal – June, 2006• QRROQRRO project – 2006 – 2010 project – 2006 – 2010• Kickoff in Milwaukee – Dec. 18, 2006Kickoff in Milwaukee – Dec. 18, 2006

PCS Disease Site-Specific SurveysPCS Disease Site-Specific Surveys

Disease SiteDisease Site Survey YearsSurvey Years

1. Prostate1. Prostate 1973, 78, 83, 89, 94, 99, 1973, 78, 83, 89, 94, 99, 0707

2. Breast2. Breast 1983, 89, 94, 99, 1983, 89, 94, 99, 0707

3. Lung3. Lung 1999, 1999, 0707

4. Cervix4. Cervix 1973, 78, 83, 89, 94, 99, 1973, 78, 83, 89, 94, 99, 0707

5. Esophageal5. Esophageal 1994, 99, 1994, 99, 0707

6. Gastric6. Gastric 0707

Determinants of Cancer Care QualityDeterminants of Cancer Care Quality

Disease Related FactorsDisease Related Factors

Patient Based FactorsPatient Based Factors

Provider CharacteristicsProvider Characteristics

Health System CharacteristicsHealth System Characteristics

a Complex Interplay ofa Complex Interplay of

Cancer Care Is a Chain of EventsCancer Care Is a Chain of Events

QualityQuality of cancer care is determined by the of cancer care is determined by the

weakestweakest link in the chain.link in the chain.

QRRO FocusQRRO Focus

Continuing CareContinuing CareTreatmentTreatmentStagingStagingDetectionDetectionPreventionPrevention

First Principle of Cancer TreatmentFirst Principle of Cancer Treatment

Do the right thing - at the right time - Do the right thing - at the right time - and do it right.and do it right.

Emerging TechnologyEmerging Technology• 3 D conformal (3D)3 D conformal (3D)• (IMRT) Intensity Modulated (IMRT) Intensity Modulated

Radiation TherapyRadiation Therapy• (PBI) Partial Breast Irradiation(PBI) Partial Breast Irradiation

BrachytherapyBrachytherapy• Prostate Seed ImplantsProstate Seed Implants• (HDR) High Dose Rate(HDR) High Dose Rate• (LDR) Low Dose Rate(LDR) Low Dose RateRadiation Dose-Response Radiation Dose-Response

QRRO SPECIFIC AIMSQRRO 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 ListFacilities Master List

Practice Site (1998)Practice Site (1998) ## %%

Hospital basedHospital based 1000 1000 63% 63%

Free StandingFree Standing 595595 37% 37%

Total Total 1595 1595

Average US Facility (1998) Average US Facility (1998)

# New Patients/year # New Patients/year 342342

# Treatment machines# Treatment machines 1.71.7

# Linear Accelerators# Linear Accelerators 1.61.6

# FTE Therapists# FTE Therapists 4.6 4.6

# FTE Dosimetrists# FTE Dosimetrists 1.11.1

100% Inventory of U.S. Radiation Oncology Structure100% Inventory of U.S. Radiation Oncology Structure

ADVANCED RADIATION TECHNOLOGYADVANCED RADIATION TECHNOLOGY::

• Not evenly distributed.Not evenly distributed.

• Not readily accessible to all.Not readily accessible to all.

Map of all radiation therapy facilities in the United States (2004-2005)Map of all radiation therapy facilities in the United States (2004-2005)N=2,246 FacilitiesN=2,246 Facilities

From Ballas et. al: Int. J. Radiation Oncology Biol Phys., Vol. 66, No.4, pp 1204-1211, 2006From Ballas et. al: Int. J. Radiation Oncology Biol Phys., Vol. 66, No.4, pp 1204-1211, 2006

Quality Research in Radiation OncologyQuality Research in Radiation Oncology

MeasureMeasure

Voluntary

Cost Effective

ProcessProcess

Outcome

CommunicateCommunicate

• ProfessionsProfessions

• PatientsPatients

• PublicPublic

• AgenciesAgencies

IdentifyIdentify• Patterns of Care

• Benchmarks

• Appropriateness

• Compliance with Evidence/Standards

• Gaps/Disparities

• Trend Lines

• EducateEducate• Performance Performance FeedbackFeedback• AdvocateAdvocate• Decision supportDecision support

Positively Influence QualityPositively Influence Quality

StructureStructure

MultidisciplinaryMultidisciplinary

ContextContext

MeasurMeasuree

IdentifyIdentify CommunicateCommunicate

Statistical DesignStatistical Designand Analysisand Analysis

Electronic Data Systems andElectronic Data Systems andData Monitoring Task GroupData Monitoring Task GroupCommunicationsCommunications

CommitteeCommittee

• Patterns of CarePatterns of Care

• BenchmarksBenchmarks

• AppropriatenessAppropriateness

• Compliance with Compliance with Evidence/StandardsEvidence/Standards

• Gaps/DisparitiesGaps/Disparities

• Trend LinesTrend Lines

• ProfessionsProfessions

• PatientsPatients

• PublicPublic

• AgenciesAgencies

ProcessProcess

StructureStructure

MultidisciplinarMultidisciplinar

yy

Outcome

ContexContextt

Compliance with Breast-Conservation Compliance with Breast-Conservation Standards for Patients with Early-Stage Standards for Patients with Early-Stage

Breast CarcinomaBreast Carcinoma

Compliance with selected 22 elementsCompliance with selected 22 elements

Compliance levelCompliance level # elements# elements

> 90%> 90% 10 10

> 80%> 80% 16 16

Poor (< 67%)Poor (< 67%) 6 6

White, et al: Cancer: February 15, 2003/Vol 97/ No. 4White, et al: Cancer: February 15, 2003/Vol 97/ No. 4

Impact on PracticeImpact on Practice

– Measured compliance with national standards for Breast Measured compliance with national standards for Breast Conservation Treatment.Conservation Treatment.

– Results cited as evidence justifying changes in Breast Cancer Results cited as evidence justifying changes in Breast Cancer Clinical Guidelines of the National Comprehensive Cancer Clinical Guidelines of the National Comprehensive Cancer Network.Network.

– Results stimulated changes in the Breast Imaging Reporting Results stimulated changes in the Breast Imaging Reporting and Data System (BIRADS), standardized nomenclature for and Data System (BIRADS), standardized nomenclature for reporting breast imaging results. reporting breast imaging results.

– Established benchmark against which practice improvement Established benchmark against which practice improvement can be measured.can be measured.

CDC – NPCRCDC – NPCRBreast and Prostate Patterns of Care Study Breast and Prostate Patterns of Care Study

(POC-BP)(POC-BP)

National Program of Cancer RegistriesNational Program of Cancer Registries

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

US Department of Health and Human ServicesUS Department of Health and Human Services

RFA-DP-05-071RFA-DP-05-071

WI CaREWI CaRESpecific AimsSpecific Aims

• 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.

• Determine the proportion of patients in WI who received the recognized standard of care for stages I through III female breast cancer.

• 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.

• 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

Case LoadCase LoadWork EffortWork Effort

Evidence BaseEvidence BaseAdequate ManpowerAdequate Manpower

ReimbursementReimbursementCost EffectivenessCost EffectivenessNew DiscoveriesNew Discoveries

Destructive TechnologyDestructive TechnologyCommercializationCommercializationHealthcare PolicyHealthcare Policy

QQ

UU

AA

LL

II

TT

YY

QQ

UU

AA

LL

II

TT

YY

OpinionsOpinions

• Quality must be evaluated contemporaneously Quality must be evaluated contemporaneously with the care itself.with the care itself.

• Requires greatly enhanced electronic data Requires greatly enhanced electronic data collection systems.collection systems.

• May await a single payer system.May await a single payer system.• Greater patient centeredness of the entire Greater patient centeredness of the entire

healthcare system.healthcare system.• QRRO may document individual practice QRRO may document individual practice

proficiency. proficiency.