Journal of Oncology Practice, Vol 5, No 6 (November), 2009: pp. 284-286
© 2009
American Society of Clinical Oncology.
DOI: 10.1200/JOP.091051
Improving the Quality of Cancer Care: Crossroads or Convergence?
Eric C. Schneider, MD, MSc
RAND Corporation; Division of General Medicine, Brigham and Women's Hospital; and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
Corresponding author: Eric C. Schneider, MD, MSc, 20 Park Plaza, Suite 720, Boston, MA 02116; e-mail: eschneid{at}rand.org
Many practicing physicians are struggling to make sense of a tangled quality improvement agenda. Insurers and payers are demanding performance measurement for accountability, report cards, and pay-for-performance programs. Professional boards and others are urging physicians to participate in practice-based quality improvement projects. The relationship between these two streams of activity is unclear. Will they improve the day-to-day practice of medicine or simply add administrative burden to already challenging patient care schedules?
A decade ago, the Institute of Medicine report Ensuring Quality Cancer Care raised profound questions about the quality of care for patients with cancer in the United States.1 Despite formidable advances in biomedical science, studies suggested that a worrisome number of patients were failing to receive timely and complete treatment. In the wake of the report, ASCO, under the presidency of Joseph Bailes, MD, initiated two projects. First, it took leadership of the National Initiative for Cancer Care Quality (NICCQ), developing and evaluating approximately 100 measures of the quality of care in breast and colorectal cancers. Second, it implemented the Quality Oncology Practice Initiative (QOPI), which was developed by practicing oncologists.2 Creating an electronic registry for a selected set of quality measures (some derived from the NICCQ list), these oncologists voluntarily submitted data and received results, allowing them to compare their own practices with others. NICCQ addressed the call for widespread, standardized quality monitoring. QOPI addressed the need to engage professionals directly in improvement.
For a while, these two roads ran in parallel. NICCQ was a large-scale study involving the American College of Surgeons National Cancer Database (a registry), more than 60 hospitals in five metropolitan areas, and a sample of approximately 5,000 patients. The results were mixed.3 The quality of care was found to be better than might have been expected, considering prior studies cited in the report by the Institute of Medicine1 (suggesting the limitations of insurance claims for quality measurement). However, even with more accurate measurement methodology, care still fell short of the standard of high reliability. More to the point, NICCQ demonstrated the challenges of creating a national quality monitoring system for cancer care.4 NICCQ was an unprecedented accomplishment, but it revealed weaknesses in the data infrastructure required for affordable routine public reporting and pay-for-performance programs.
Since its inception, QOPI has expanded and matured, taking its place alongside other key quality improvement collaboratives.2,5–7 In the 1990s, a group of cardiac surgeons from northern New England, using a simple outcome metric (ie, risk-adjusted mortality), examined operating room practice, observing and learning from one another regarding local best practices and producing a dramatic reduction in mortality resulting from cardiac bypass surgery.8 Another collaborative of cystic fibrosis treatment centers used voluntary quality measurement and feedback to improve care for patients.9 A statewide collaborative of intensive care units reduced central line–associated bloodstream infections to zero.10
Surprisingly, these successful professional quality improvement collaboratives have remained almost invisible to the public, little appreciated by key policymakers, and, until recently, rarely replicated. Instead, purchasers and the public seem focused on collecting data for accountability so that the public can compare providers and offer them carrots or sticks. The fixation on accountability frequently provokes feuding between physicians and insurers and tends to discredit the quality measurement enterprise in the eyes of many physicians. Worse yet, a debate about the utility of public reporting and pay for performance has displaced a conversation about how to mount a comprehensive, integrated quality improvement program of the type represented by QOPI and the other initiatives described.
At the current crossroads, I believe two steps could bring about a convergence of measurement for reporting and measurement for quality improvement. First, professional programs like QOPI must be made visible to the public as evidence that professionals are engaged in improving quality. Professionals involved in quality collaboratives invariably demand better data to guide decision making rather than attempting to avoid measurement. Second, professionals need to promote investment in an electronic health information infrastructure that includes electronic clinical registries or health information exchange for quality improvement. Voluntary reporting will continue to be limited by the costs of data entry. This barrier could be overcome by electronic health records and health information exchange that would permit the use of routine clinical data for performance measurement.
Some results will inevitably be made available to the public. Participants in the cystic fibrosis project9 ultimately agreed to make their results public. However, the more productive purpose of measurement is to provide feedback that physicians can use to improve care. The technical knowledge necessary to build an electronic quality monitoring system has been demonstrated by NICCQ. The use of an electronic registry for routine quality monitoring to improve care has been demonstrated by QOPI. ASCO has been a key leader in both these efforts. If resources can be found to merge these two roads—quality improvement collaboratives and quality measurement through electronic clinical registries—then physicians, patients, and the public will benefit.
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Author's Disclosures of Potential Conflicts of Interest
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The author indicated no potential conflicts of interest.
accepted September 3, 2009.
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References
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- Ensuring Quality Cancer Care in Hewitt M Simone JV (eds.).Washington, DC, National Academies Press, 1999
- Neuss MN, Desch CE, McNiff KK, et al: A process for measuring the quality of cancer care: The Quality Oncology Practice Initiative. J Clin Oncol 23:6233-6239, 2005[Abstract/Free Full Text]
- Malin JL, Schneider EC, Epstein AM, et al: Results of the National Initiative for Cancer Care Quality: How can we improve the quality of cancer care in the United States? J Clin Oncol 24:626-634, 2006[Abstract/Free Full Text]
- Schneider EC, Malin JL, Kahn KL, et al: Developing a system to assess the quality of cancer care: ASCO's national initiative on cancer care quality. J Clin Oncol 22:2985-2991, 2004[Free Full Text]
- Blayney DW, McNiff K, Hanauer D, et al: Implementation of the Quality Oncology Practice Initiative at a university comprehensive cancer center. J Clin Oncol 27:3802-3807, 2009[Abstract/Free Full Text]
- Jacobson J, Neuss M, McNiff K, et al: Improvement in oncology practice performance through voluntary participation in the Quality Oncology Practice Initiative. J Clin Oncol 26:1983-1988, 2008
- McNiff K, Neuss M, Jacobson J, et al: Measuring supportive care in medical oncology practice: Lessons learned from the Quality Oncology Practice Initiative. J Clin Oncol 26:3832-3837, 2008[Abstract/Free Full Text]
- O'Connor GT, Plume SK, Olmstead EM, et al: A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. JAMA 275:841-846, 1996[Abstract/Free Full Text]
- Schechter MS, Margolis P: Improving subspecialty healthcare: Lessons from cystic fibrosis. J Pediatr 147:295-301, 2005[CrossRef][Medline]
- Pronovost P, Needham D, Berenholtz S, et al: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355:2725-2732, 2006[Abstract/Free Full Text]
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