Quality measurement—how we assess cost and effectiveness of cancer care—cannot be separated from policy decisions that have a profound influence on the overall health-care system. At the recent ASCO Quality Care Symposium, Jennifer L. Malin, MD, PhD, Medical Director for Oncology at WellPoint, Inc, Thousand Oaks, California, noted that many in the oncology community first began thinking about quality measurement with the release of IOM’s 1999 report on the quality of cancer care.1
“The IOM report highlighted the gaps in quality of cancer care for our patients. Although the extent wasn’t fully know, the report underscored the need for us to use a core set of quality measures to assess quality,” said Dr. Malin.
“Now some 14 years later, with IOM’s new report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis” we see an increased urgency on this issue with the call for a national quality reporting program with meaningful quality measures including patient outcomes,” said Dr. Malin.
She commented that one component of the reporting program should be aligning reimbursement to reward affordable, patient-centered care. “Foremost to this discussion, it’s important to understand that patient-centered care establishes a partnership among practitioners, patients, and their families to ensure that the decisions respect patients’ wants, needs, and preferences and that patients have the education to make and participate in their own care,” said Dr. Malin.
She explained, “Quality improvement centers around the science and application of measures to get better outcomes. And then there is accountability and transparency, the way that we ensure that our patients have access to the highest quality of care possible,” said Dr. Malin, adding, “But the most important aspect of improving the cancer care system is the implementation of rigorous quality measurement instruments and payment systems that are associated with quality as opposed to volume. A number of initiatives have changed the overall ecosystem, bringing us to a place where most of us are fluent in the language of quality measurement.”
Quality Measurement Initiatives
Dr. Malin looked at the results of several quality measurement initiatives such as ASCO’s Quality Oncology Practice Initiative (QOPI®). “QOPI probably gives us the broadest view of today’s quality measures. On some metrics, such as adherence to adjuvant therapy, there’s very high compliance, but we don’t see much change over time, which most likely indicates a ceiling effect,” said Dr. Malin.
The measures in supportive care showed a different picture. “We see more variation in supportive care in terms of how we’re treating symptoms, but again, there is little variation over time that shows an upward trend of quality. So we must ask ourselves why there is such little change in the clinical outcomes we measure,” said Dr. Malin.
She pointed to the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely® campaign as another initiative to cull ineffective radiologic strategies from oncology practice. ASCO joined the ABIM Foundation’s initiative in 2012 and recently released its list of top recommendations for 2013.
“They advise against using cancer-directed therapy for solid tumor patients with low-performance status. They recommend not performing [positron-emission tomography (PET), computed tomography (CT)], and radionuclide bone scans in staging patients with early prostate cancer at low risk of metastases. And they advocate not using PET, CT, and radionuclide scans in early breast cancer, also at low risk for metastases,” said Dr. Malin.
She used a study led by Bruce E. Hillner, MD,1 to highlight the QOPI report. “The data in Bruce Hillner’s study underscore the top Choosing Wisely recommendations on overuse of imaging. They looked at scanning patterns in patients across five cancer groups, running the gamut from diagnostic to surveillance. It’s hard to imagine that in some tumor types, more than 50% to 70% of patients received multiple imaging tests within a very short period of time,” said Dr. Malin.
“We tend to think of unnecessary imaging in terms of costs, but I would argue that this is not very patient-centered care because it places a burden on patients and caregivers to go back and forth for imaging studies that for the most part are unnecessary,” said Dr. Malin.
“Moreover, looking at some of the outcomes and issues that current measurement strategies have identified, we see a lack of adaptability to discriminate variations in quality, which limits their utility for public reporting or pay-for-performance,” said Dr. Malin.
“Quality measurement is an iterative process, but the end goal is improving outcomes. You can have a measure indicating that 60% of cancer patients have their pain needs addressed, but the question becomes, how do you move that needle so that 100% of patients are as pain-free as possible? So the hard work that takes us from where we are to where we want to go is using a measure and then initiating quality improvement strategies,” noted Dr. Malin.
She concluded, “We need measures that take into account the waste in the system. Not doing things that are unnecessary is as important for the system as doing the things that are necessary. And to enable accountability and transparency, we have to report our quality measures in a way that our stakeholders can best use the data. Measures need to be specific enough to distinguish high-quality care from mediocre or poor care. Most important, they need to capture the patient experience.” ■
Disclosure: Dr. Malin reported no potential conflicts of interest.
2. Hillner BE, Tosteson AN, Song Y, et al: Growth in the use of PET for six cancer types after coverage by Medicare: Additive or replacement? J Am Coll Radiol 9:33-41, 2012.