Delivering High-Quality Cancer Care Charting a New Course for a System in Crisis (2013) / Chapter Skim
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7 Translating Evidence into Practice, Measuring Quality, and Improving Performance
7 Translating Evidence into Practice, Measuring Quality, and Improving Performance
Pages 271-308
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From page 271... ...
Specifically, CPGs translate research results into clinical recommendations for clinicians, and performance improvement initiatives systematically bring about a change in the delivery of care that reflects the best available evidence. Quality metrics evaluate health care clinicians' performance and practices by comparing actual clinical practices against recommended practices, and identifying areas that could be improved.
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Performance improvement initiatives are generally modest, localized efforts, and because they are tailored to unique local circumstances, are difficult to translate to the national level. Similarly, there are many challenges and pervasive gaps in existing measures that impede the development of cancer quality metrics.
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Commission on Cancer (CoC) have developed2 or endorsed3 a number of quality measures specific to or applicable to cancer for use in performance improvement and national mandatory reporting programs in the United States.
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The cases submitted to the NCDB represent approximately 70 percent of all newly diagnosed cancer cases in the United States and are summarized in various clinician-level reports to facilitate performance improvement, create benchmarks for comparative purposes, and identify trends in cancer care, such as survival and cancer incidence. paid under the Prospective Payment System (PPS)
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From page 275... ...
National Quality The Agency for Healthcare Research and Quality Measures Clearinghouse established the NQMC in 2002 to serve as a Web-based (NQMC) repository of evidence-based health care quality measures and to promote widespread access to these measures among health care clinicians, health plans, purchasers, and other interested stakeholders.
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ASCO made the QOPI Program available to its member physicians as a voluntary practice-based program in 2006. This program provides tools and resources to oncology practices for quality measurement, benchmarking, and performance improvement and currently has more than 800 registered member practices.
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Most measures focus on short-term outcomes in care. Thus, there are serious deficiencies in cancer quality measurement in the United States, including (1)
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While NQF-endorsed measures and those included in the National Quality Measures Clearinghouse (NQMC) focus on screening and initial cancer treatment, few measures address post-treatment follow-up and the long-term consequences of care, such as survivorship care, disease recurrence, and secondary cancers.
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From page 279... ...
information that comes directly from the patient (e.g., quality of life, time to return to normal activity, symptom burden) Patients' Measures patients' Gathers data Need to account for Perspective satisfaction with the on patients' patients' limitations on Care health care they experience in assessing technical received throughout aspects of care the health care delivery cycle continued
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. In addition, Cancer Care Ontario conducted a recent performance improvement project that included develop
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. However, management of complex comorbidities and the functional, emotional, and social consequences of the disease, and other high-quality measures, are largely unaddressed by current measures (Bishop, 2013; Spinks et al., 2011)
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From page 282... ...
Challenges Associated with the Measure Development Process Many of the cancer measurement gaps stem from challenges associated with the measure development process. The NQF, AHRQ, and other organizations have adopted stringent guidelines for the evaluation of health care quality measures, such as scientific acceptability, usability, importance, and feasibility.
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From page 283... ...
Efforts by organizations, such as the NQF, to create parsimonious families of quality measures have reduced measure fragmentation to a limited degree. These organizations have prioritized the development of measures that fill crucial gaps in cancer measurement and apply to certain diseases and dimensions of care.
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From page 284... ...
Clinician attribution can also challenge the development of quality measures. Health care quality measures should assess aspects of care that may be influenced by individual clinicians (IOM, 2001)
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In assessing whether appropriate care was received, quality measures should account for the complications of treating asymptomatic disease, inappropriate or inadequate prior care, and patient preferences that differ from clinician recommendations (Kahn et al., 2002)
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Lack of Consumer Engagement in Quality Measurement Publicly reporting health care quality measures has been championed as a means of guiding patients to high-quality and efficient health care. The HHS National Strategy for Performance Improvement in Health Care (or National Quality Strategy)
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The first report in this series -- Best Practices in Public Reporting No. 1: How to Effectively Present Health Care Performance Data to Consumers -- outlined several challenges to consumers' use of health care quality data, including differing definitions of quality among patients and clinical experts, and consumer difficulty with understanding and interpreting quality measures.
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From page 288... ...
By bridging the gulf between patients and measure developers and reporting agencies, patient advocacy groups could play a key role in consumer-driven, patient-centered quality reporting. Meaningful, Timely, and Actionable Performance Data The widespread need for and general absence of meaningful, timely, and actionable performance data to support quality measurement and performance improvement is well documented (Anderson et al., 2012; IOM and NRC, 1999, 2000; MAP and NQF, 2012; Russell, 1998)
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Preliminary assessments of EHR-generated quality measures suggest that major work will be required to ensure the accuracy and validity of quality data obtained from EHRs (Parsons et al., 2012)
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Improved clinician workflow and documentation, together with IT advancements, could promote the availability of meaningful, timely, and actionable performance data for cancer quality measurement and reporting. The Path Forward The current independent efforts to develop cancer metrics have left patients, payers, clinicians, and state and federal agencies without an effective method to assess and improve the quality of cancer care delivery in America.
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From page 291... ...
In order to advance the development of a national quality reporting program for cancer, the committee recommends that HHS work with professional organizations to create and implement a formal long-term strategy for publicly reporting quality measures for cancer care that leverages existing efforts. The long-term strategy should focus on the needs of all individuals diagnosed with or at risk for developing cancer.
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From page 292... ...
A key component of developing a formal long-term strategy for quality measures for cancer will be prioritizing, funding, and directing the development of meaningful quality measures, with a focus on outcome measures, and with performance targets for use in publicly reporting the performance of institutions, practices, and individual clinicians. These measures should target gaps in cross-cutting, nontechnical measures as well as measures for specific types of cancers that have largely been excluded from previous measure development efforts.
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Clinical Practice Guidelines Clinical research leads to improvements in the quality of care only if these research results are translated into practice. Clinicians use CPGs to synthesize research findings into actionable steps for providing care.
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It develops clinical practice guidelines (CPGs) for these radiation oncology clinicians.
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with COI. T • unders should have no role in CPG development.
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4. CPG–Systematic Review Intersection 4.1 PG developers should use systematic reviews that meet standards set C by the IOM's Committee on Standards for Systematic Reviews of Com parative Effectiveness Research.
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In a separate study, Reames and colleagues (2013) scored CPGs and consensus statements addressing the screening, evaluation, or management of the four leading causes of cancer mortality in the United States (non-small-cell lung, breast, prostate, and colorectal cancers)
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Performance Improvement Initiatives Quality measurement and CPGs are essential components of improving performance in health care. As discussed above, quality metrics provide insights into which aspects of health care require improvement and may be used to assess the success of performance improvement initiatives.
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. Performance improvement initiatives, which are conducted at the local level, have been described as "systematic, data-guided activities designed to bring about immediate, positive change in the delivery of health care in a particular setting," as well as across settings (Baily, 2006, p.
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Experts have noted, however, that traditional approaches to performance improvement -- clinician practice peer review, public reporting of quality measures, continuous performance improvement and total quality management, and regulatory and legislatively imposed reforms and penalties -- lack the pace, breadth, magnitude, coordination, and sustainability to transform health care delivery (Chassin and Loeb, 2011; Davies, 2001)
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From page 301... ...
There are currently serious deficiencies in cancer care quality measurement in the United States, including pervasive gaps in existing measures, challenges in the measure development process, lack of consumer engagement in measure development and reporting, and the need for data to support meaningful, timely, and actionable performance measurement. A number of groups representing clinicians who provide cancer care, including ASCO and ACoS, have instituted voluntary reporting programs, through which program participants have demonstrated improvements.
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2012c. National Quality Measures Clearinghouse measures by topic.
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2012a. Clinical practice guidelines.
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2009. Development, implementation, and process evaluation of a regional palliative care quality improvement project.
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2012. Failure of clinical practice guidelines to meet Institute of Medicine standards: Two more decades of little, if any, progress.
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2012. Conflict of interest policies for organizations producing a large number of clinical practice guidelines.
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2011. Improving cancer care through public reporting of meaningful quality measures.
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