The Quality of Cancer Care:Does the Literature Support the Rhetoric? Bruce E. Hillner, M.D. & Thomas J. Smith, M.D. NCPB Report (IOM), 1999 “Literature since 1988 in most areas does not address quality of cancer care to any substantial extent.” “So diffuse and diverse that providers have not had to provide accountability for specific processes or outcomes.” “Quality gaps for all conditions were found in retrospective assessments in process of care.” “GAPS” can be measured by overuse, underuse, misuse (errors) and waste.” Report to the National Cancer Policy Board, Institute of Medicine: April, 1999
Ensuring QualityC A N C E R Care Maria Hewitt and Joseph V. Simone, Editors National Cancer Policy Board INSTITUTE OF MEDICINE and COMMISSION ON LIFE SCIENCES, NATIONAL RESEARCH COUNCIL National Academy Press Washington, D.C., 1999
Agencies Evaluating Cancer Care • INSTITUTE OF MEDICINE • Quality of Healthcare in America Project (1998) • National Cancer Policy Board (1999) • CENTERS FOR MEDICARE AND MEDICAID SERVICES (2003) • Demonstration Projects • AGENCY FOR HEALTHCARE RESEARCH AND QUALITY • NATIONAL INITIATIVE ON CANCER CARE QUALITY (2000) • NATIONAL QUALITY FORUM • Cancer Care Quality Measures Steering Committee (2003) • NATIONAL CANCER INSTITUTE • Cancer Care Outcome Research and Surveillance Consortium (1999) • QUALITY ALLIANCE (2005)
“Environment of Watchful Concern” Quality Research in Radiation Oncology Since 1973 IOM 1998 NCPB 1999 JACHO 2004 LEAPFROG Quality of Cancer Care As a National Issue (1998) NICCQ 2000 Alpha Group 2004 QOPI 2005 Quality Alliance 2005 Since 1998 NCI 1999 CMS 2003 AHRQ 2004
CMS 2005 P4R Demonstration Project Demonstration of Improved Quality of Care for Cancer Patients Undergoing Chemotherapy • Reported levels of nausea or vomiting, pain, and fatigue • $130 payment per report • OIG estimated cost to patient and Medicare @ $300 m • “Unnecessary and fiscally irresponsible to require patients to pay for services that are already covered as part of routine care”
Results of the National Initiative for Cancer Care Quality: How Can We Improve the Quality of Cancer Care in the United States? NICCQ RESULTS • 1998 PATIENTS (Stages I – III) • 5 metro areas (MSA’s) (Atlanta, Cleveland, Houston, Kansas • City, Los Angeles • Total spectrum of care • Less than 85% adherence to 18 of 36 breast cancer measures • Significant variation across MSA’s • JCO 24.(4); Feb, 2006 Jennifer 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, 2006
NICCQ Key Areas for Improvement • Optimizing chemotherapy dosing • Managing treatment side effects • Advising patients about all treatment options, especially when patient choice is a key factor in decision-making • Improving documentation of key information regarding patients’ cancer and treatment, specifically stage and details of chemotherapy planning and delivery • Ensure that patients at highest risk of poor outcomes receive recommended care
Quality Research in Radiation Oncology • PCS conceived — 1969 • Planning grant from NCI — 1971 • Research grant or contract — 1974 - 2004 • Last renewal – June, 2006 • QRRO project – 2006 – 2010 • Kickoff in Milwaukee – Dec. 18, 2006
PCS Disease Site-Specific Surveys Disease SiteSurvey Years 1. Prostate 1973, 78, 83, 89, 94, 99, 07 2. Breast 1983, 89, 94, 99, 07 3. Lung 1999, 07 4. Cervix 1973, 78, 83, 89, 94, 99, 07 5. Esophageal 1994, 99, 07 6. Gastric 07
Determinants of Cancer Care Quality Disease Related Factors Patient Based Factors Provider Characteristics Health System Characteristics a Complex Interplay of
Cancer Care Is a Chain of Events Qualityof cancer care is determined by the weakestlink in the chain. Prevention Detection Staging Treatment Continuing Care QRRO Focus
First Principle of Cancer Treatment Do the right thing - at the right time - and do it right. • Emerging Technology • 3 D conformal (3D) • (IMRT) Intensity Modulated • Radiation Therapy • (PBI) Partial Breast Irradiation • Brachytherapy • Prostate Seed Implants • (HDR) High Dose Rate • (LDR) Low Dose Rate Radiation Dose-Response
QRRO 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 List Average US Facility (1998) # New Patients/year 342 # Treatment machines 1.7 # Linear Accelerators 1.6 # FTE Therapists 4.6 # FTE Dosimetrists1.1 Practice Site (1998)#% Hospital based 1000 63% Free Standing 595 37% Total 1595 100% Inventory of U.S. Radiation Oncology Structure • ADVANCED RADIATION TECHNOLOGY: • Not evenly distributed. • Not readily accessible to all.
Map of all radiation therapy facilities in the United States (2004-2005) N=2,246 Facilities From Ballas et. al: Int. J. Radiation Oncology Biol Phys., Vol. 66, No.4, pp 1204-1211, 2006
Identify Communicate • Patterns of Care • Benchmarks • Appropriateness • Compliance with • Evidence/Standards • Gaps/Disparities • Trend Lines • Professions • Patients • Public • Agencies • Educate • Performance • Feedback • Advocate • Decision support Positively Influence Quality Quality Research in Radiation Oncology Measure Structure Voluntary Cost Effective Multidisciplinary Process Context Outcome
Statistical Design and Analysis Electronic Data Systems and Data Monitoring Task Group Communications Committee Measure Identify Communicate • Patterns of Care • Benchmarks • Appropriateness • Compliance with • Evidence/Standards • Gaps/Disparities • Trend Lines • Professions • Patients • Public • Agencies Structure Multidisciplinary Process Context Outcome
Compliance with Breast-Conservation Standards for Patients with Early-Stage Breast Carcinoma Compliance with selected 22 elements Compliance level# elements > 90% 10 > 80% 16 Poor (< 67%) 6 White, et al: Cancer: February 15, 2003/Vol 97/ No. 4
Impact on Practice • Measured compliance with national standards for Breast Conservation Treatment. • Results cited as evidence justifying changes in Breast Cancer Clinical Guidelines of the National Comprehensive Cancer Network. • Results stimulated changes in the Breast Imaging Reporting and Data System (BIRADS), standardized nomenclature for reporting breast imaging results. • Established benchmark against which practice improvement can be measured.
CDC – NPCRBreast and Prostate Patterns of Care Study (POC-BP) National Program of Cancer Registries Centers for Disease Control and Prevention US Department of Health and Human Services RFA-DP-05-071
WI CaRESpecific 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 Q U A L I T Y Q U A L I T Y Case Load Work Effort Evidence Base Adequate Manpower Reimbursement Cost Effectiveness New Discoveries Destructive Technology Commercialization Healthcare Policy
Opinions • Quality must be evaluated contemporaneously with the care itself. • Requires greatly enhanced electronic data collection systems. • May await a single payer system. • Greater patient centeredness of the entire healthcare system. • QRRO may document individual practice proficiency.