Ensuring Quality Cancer Care (1999) / Chapter Skim
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6 Cancer Care Quality Assurance
6 Cancer Care Quality Assurance
Pages 144-179
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From page 144... ...
indicators of quality available to help them choose doctors, hospitals, and health plans or to evaluate the merits of alternative courses of treatment. This situation is changing as the science of measuring health care quality matures and begins to focus on consumer-oriented indicators for the treatment of chronic diseases.
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: . · ensure system-wide capacity to evaluate and report on the quality of care, promote and inform consumer choice and further consumer understanding and use of quality measures, enable providers to use data to improve performance, allow meaningful quality comparisons of health care providers and plans, promote competition on the quality of health care services, use broad representation to marshal market forces for quality, and · reduce the burdens on providers and health plans by enabling them to collect consistent data that avoids duplication.
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From page 146... ...
has posted on the internet (www.medicare.gov) some results of these consumer satisfaction ratings for Medicare beneficiaries in health plans, along with comparative plan ratings on indicators such as mammography use.
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If a hospital fails to meet the criteria set forth by professional groups, consumers are justified in searching out more detail about potential problems before agreeing to use the facility. The news media and the popular press may also be sources of consumer information about the quality of health plans and hospitals.
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From page 148... ...
Also, although many Americans perceive great differences in the quality of care among health plans, hospitals, and doctors, relatively few are now using quality data to make health care choices (Kaiser Family Foundation, 1 996~. In many cases, consumer-oriented information is just not available for all of the decisions that a person with cancer may have to make selecting a doctor, choosing among treatments, or finding a home health service, rehabilitation program, or hospice.
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CANCER CARE QUALtTYASSURANCE 149 promote measurement of aspects of care of particular relevance to individuals with cancer and disseminate information to raise awareness of quality issues. The National Coalition for Cancer Survivorship has, for example, published "principles of excellence" in cancer care (Box 6.21.
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Most nonelderly Americans receive their health care insurance through an employer, and employers choose health care plans for their employees on the basis of price benefits' quality' and service. A common metric for quality is
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PBGH collects and analyzes health plan performance data to produce report cards for consumers; promotes shared treatment decision making between providers and consumers; and collects, analyzes, and reports plan-level consumer satisfaction ratings (Castles et al., 1999, President's Advisory Commission, 1998~. PBGH is also developing several disease-specific quality assessment programs, including one for breast cancer.
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From page 152... ...
Many believe that HCFA will lead the effort to converge on a single set of quality measures applicable across delivery systems (Derby, 19981. In 1992, HCFA established the Health Care Quality Improvement Program, which promotes partnerships between PROs and hospitals, health plans, and physicians to improve quality.
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CANCER CARE QUALITYASSURANCE 153 isting evidence supporting performance measures in each of these domains, and identifying multiple sources of performance data (Katherine Kahn and Marge Pearson, RAND, personal communication to Mark Schuster, ~ 998~.
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AHCPR has developed a number of practice guidelines (e.g., a 1994 practice guideline on cancer pain, which wall be updated in 19991. Although no longer developing new practice guidelines, AHCPR in collaboration with the American Medical Association and the American Association of Health Plans has developed a national
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. Joint Commission on Accreditation of Healthcare Organizations The nonprofit Joint Commission on Accreditation of Healthcare Organizations, the oldest and largest standard-setting and accrediting body in health care, has broadened its institutional coverage from solely hospitals to a wide array of delivery systems including health plans, integrated delivery networks, PPOs, home care organizations, nursing homes and other long-term care facilities, behavioral health care organizations, ambulatory care providers, and clinical laboratories.
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National Committee for Quality Assurance The National Committee for Quality Assurance (NCQA) accredits managed care plans and has produced a widely used report card monitoring system called the Health Plan Employer Data and Information Set (HEDIS)
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. FACCT's breast cancer quality measures are the most comprehensive of any of the organizations that currently have breast cancer performance measures and include indicators of the process of care, patient satisfaction, and outcomes.
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CANCER CARE QUALITY ASSURANCE TABLE 6.2 FACCT Breast Cancer Quality Indicators Measure Performance Value Instrument or Data Source 159 Steps to Good Care Mammography Proportion of women age 52~9 who have Doctor's billing or claims records had a mammogram within two years (NCQA's HEDIS 3.0 breast screening measure used) Early-stage de- Proportion of patients whose breast cancer Patient records from cancer reg tection was detected at Stage 0 or Stage ~istry Information Proportion of Stage ~ and lI patients who One question in patient satisfac about radia- indicate that they had adequate informa- tion survey completed three to tion treatment tion about their radiation treatment op- six months after diagnosis options tions before deciding about treatment Breast conserv- Proportion of Stage ~ and [I patients who ing surgery undergo BCS Radiation ther- Proportion of BCS patients who receive apy following radiation treatment after surgery breast con serving sur gery Experience ant' Satisfaction Patient satisfac- Mean score for patients' level of satisfac tion with care tion with breast cancer care, including the technical quality, interpersonal and communication skills of their cancer doctor, their involvement in treatment decisions, and the timeliness of receiving information and services Results Patient records from cancer registry or claims records Patient records from cancer registry or claims records 32-item patient satisfaction survey completed three to six months after diagnosis Experience of Mean score for patients on CARES-SF sur- 59-item CARES-SF patient survey disease vey, which assesses patients' quality of completed 12-15 months after life and experience in living with breast diagnosis cancer Five-year dis- Probability of disease-free survival for a Patient records from cancer regis ease-free sur- group of patients, Stages I-IV' who were try vival (cancer diagnosed during previous five years treatment center meas ure)
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Association of Community Cancer Centers To promote quality improvement among cancer centers, the Association of Community Cancer Centers (ACCC) , a membership organization for cancer centers, has published "Standards for Cancer Programs," a description of an "ideal" cancer program (ACCC.
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Traditional quality assurance programs focus on retraining or removing clinicians who stand out as performing below group norms. By contrast, continuous quality improvement (CQI)
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The best guidelines make explicit the methods used to develop them, including how evidence was used to support recommendations. Clinical practice guidelines can be judged according to several attributes, for example, their validity, reliability, and clarity (Table 6.31.
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; breast cancer management nro~tnte o.~no.f~r m~n~Pmf~nt Anal Pain management (Advisory RnarA 1 99~) ~7 ~'_ ~J~11~ ~ A 7 J Disease management programs incorporate a systematic approach for the management of specific chronic disorders (e.g., asthma, diabetes)
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Hematopoietic growth factors Adopted by the community but no data Outcomes important enough available on compliance or outcomes to justify treatment Likely that all future guidelines will be Antiemetics boundary guidelines for new technolo Surveillance of breast and gies, with overlap of ASCO and NCCN colorectal cancer patients methods and topics Path or algorithm guidelines for specific diseases Management of non-small cell lung cancer Metastatic prostate cancer Society for Surgical Path guidelines for manage- Consensus panels Oncology ment of common surgical problems American Urology As- Path guidelines for common Consensus based on evidence sociation urology problems Localized prostate cancer University of California Path guidelines for most solid PONA did systematic reviews, consulted Cancer Care Consor- tumors with UC faculty for consensus tium (UC and PONA, Inc.) Organizations Whose Guidelines Are not Available (proprietary)
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Breast cancer screening guidelines, for example, differ in the recommended age at which routine mammography screening should begin. That there are differences in practice guidelines is not surprising given the many factors that can affect the ultimate conclusions of a guideline.
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The Community Hospital Oncology Program (CHOP) represents an early attempt to improve oncology by disseminating locally developed practice guidelines.
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As the authors note, these measures were successful but did not require guidelines. The authors conclude that for clinical practice guidelines, "leadership and organizational commitment appear to be the necessary ingredients." Even though the guidelines were developed locally, it is likely that the program failed to change provider behavior because there was no plan for implementation and no system to hold providers accountable for change (Katterhagen, ~ 9961.
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Recent studies suggest that as marry as one in four cancer patients is given inadequate pain relief (Rischer and Childress, 19961. Adherence to the ~ 994 AHCPR guideline on cancer pain management, following its widespread dissemination, was assessed in seven acute care hospitals ire Utah in 1995 and again in 1996 (Rischer and Childress, 1996~.
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Adherence to breast cancer guidelines in British Columbia as assessed in 1991 was very high for radiation therapy, with 95 percent of women receiving radiation therapy following breast conserving surgery. However, only 77 percent of women received adjuvant chemotherapy when indicated, and 6g percent received tamoxifen when indicated (Olivotto, 19971.
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· Implementing critical pathways for cancer care within a managed care organization reduced length of stay and costs for patients treated for respiratory cancer and for those undergoing chest procedures and bowel surgery (Patton and Katterhagen, ~ 9971. In summary, several organizations have developed oncology practice guidelines to promote treatment that conforms to the best medical evidence available.
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Breast Cancer Bilateral mammography Clinical stage Pathological stage Evaluation of axilIary lymph nodes Avoidance of radical mastectomy if T < 2.0 cm Radiotherapy after quadrantectomy Adjuvant chemotherapy started at <4 weeks Polychemotherapy if <50, + lymph nodes Chemotherapy delivered at full dosage Colon Cancer CEA levels and liver ultrasound TNM staging Search for intra-abdominal metastasis Information on resection borders Evaluation of regional lymph nodes Miles resection in lower rectal cancer Radiotherapy in rectal and rectosigmoid cancer No adjuvant chemotherapy in colon cancer If chemotherapy, 5-FU-containing regimen Ovarian Cancer Full information on tumor grading Staging including abdominal echography Histologic type according to standard classifications Chest x-ray Evaluation of residual tumor Disease stage according to standard classification Alkylating agent as part of chemotherapy for early disease Cisplatin-containing regimens for advanced disease Monitoring of toxicity while on chemotherapy Monitoring of nephrotoxicity while on chemotherapy Gold standard: 100 61 37 60 89 84 65 52 71 86 40 78 67 48 66 68 11 79 90 30 75 89 97 45 85 18 34 91 84 NOTE: CEA= carcinoembryonic antigen; 5-FU = S-fluorouracil; node-mestastasis. SOURCE: Grilli et al., 1991.
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By the time a diagnosis of cancer is made and individuals have a clear reason to seek quality cancer care, it is often too late to switch health plans. Even if they could, however, many individuals do not have access to alternative plans.
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_ _ J _ ~O'_ _ _~t _ ~ _ ~ ~_ V ~ ~ it__ _J _ ~ _^ ~ ^ ^~_~^ ~4 ~ ~ . A variety of mechanisms are being used to improve health care from the inside: total quality improvement initiatives, disease management programs, and implementation of clinical practice guidelines all have the potential to improve care.
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1997. Clinical practice guidelines for tile treatment of unresectable non-small-cell lung cancer.
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1990. Clinical Practice Guidelines: Directions for a New Program.
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1997. Compliance with practice guidelines for node-negative breast cancer.
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1998. Ensuring quality cancer care: Clinical practice guidelines, critical pathways, and care maps.
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