The Development of an Oncology Measure Set

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  • From 382 docts in groups from 1 – 200. 120 new pts/doc.
  • --PROCESS ISSUES
  • The Development of an Oncology Measure Set

    1. 1. The Development of an Oncology Measure Set “A Journey of a 1000 miles begins with a step” Rodger J. Winn MD Director, Cancer Project National Quality Forum
    2. 2. Interesting Times in Oncology • New technologies and biologic breakthroughs • Increasing demand • Emphasis on quality • Concern about costs
    3. 3. Transformational times • 1960-1980 –GROWTH –AUTONOMY • 1990-2000 –MANAGED CARE • 2006 –VALUE-BASED PURCHASING
    4. 4. Value-based Purchasing Goal: Obtain the Most Value Value = Quality Cost
    5. 5. Emerging National Strategy for Closing the Quality Gap Transparency - Create a marketplace rich in quality information (public reporting) Payment Alignment - Reward providers for providing safe, effective, efficient care (P4P) Consumer Engagement - Encourage patients to seek high value providers by having “skin in the game” (HSAs)
    6. 6. Executive Order 8/22/06 • Health Care Transparency: Empowering Consumers to Save on Quality Care • Orders federal Agencies to: – Increase transparency on pricing – Increase transparency on quality – Encourage adoption of HIT – Provide options that promote quality and efficiency in healthcare
    7. 7. Ensuring Quality Cancer Care “The NCPB has concluded that for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.” Institute of Medicine National Research Council 1999
    8. 8. The Four Parts of the Quality GapThe Four Parts of the Quality Gap  Overuse  Underuse  Misuse/errors  Waste
    9. 9. Underuse: Adjuvant Tamoxifen for Breast Cancer Percentage of Postmenopausal Women with Node (+) ER (+) Tumors Who Received Tamoxifen Minnesota (1993) 59% Massachusetts (1993-5) 63% Guadagnoli et al: 1998
    10. 10. Underuse: Pain medication in patients with metastatic cancer • ECOG survey of 1308 patients • 67% of patients had pain in the preceding week 36% had severe pain (inhibited function) • 42% (250 of 597) were not given adequate analgesia • 3X more likely to receive inadequate pain medication if a minority group member Cleeland, NEJM, 1994
    11. 11. Overuse: Chemotherapy use in the last 6 months of life • 91 patients with metastatic breast cancer – Chemotherapy regimens None 24% One 46% Two 16 % Three 10 Four, five 3 Six 1
    12. 12. Misuse: Hospital Surgical Volume and Operative Mortality 30 Day Mortality (%) Volume Esophagus Pancreas Very low 23.1 17.6 Low 18.9 15.4 Medium 16.9 11.6 High 11.7 7.5 Very high 8.1 3.8 Birkmeyer, NEJM, 2002
    13. 13. Progress • When something new is found, people say it’s not true • When it’s found to be true, people say it’s not important • When it’s found to be important, people say it’s not new William James
    14. 14. Quality Measurement
    15. 15. Purposes of measuring quality • Accountability- public reporting –Drive selection, payment, accreditation • Quality improvement- private –Remedial action • Surveillance- Generate information for policy decisions
    16. 16. Perspectives on quality • Physicians focus on technical aspects of care • Patients focus on health status, functional status, access, safety, communication, coordination of care, family inclusion, education, respect • Purchasers focus on employee satisfaction, time out of work, health costs
    17. 17. IOM/NQF Aims of quality care • Effective/Beneficial • Timely • Safe • Patient-centered • Efficient • Equitable
    18. 18. Evidence linking care to outcomes Measurement of a degree of adherence Quality Indicator Indicators, measurement, and measures Measure
    19. 19. Types of quality indicators • Types of indicators relate to realms of quality: –Structure –Process Output –Outcomes –Patient experience • Process and structural indicators should relate to outcomes. Outcome measures should loop back to process
    20. 20. Quality measure • Quality measure: a mechanism to quantify the quality of a selected aspect of care by comparing it to a criterion –Requires a numerator and denominator –Requires specifications
    21. 21. Surgical wound infection measures • Assessment of incidence of surgical wound infections in 5804 wounds • Rate by wound infection definition –CDC 19.2% –NINSS 12.3% –ASEPSIS >20 6.8% Wilson, BMJ, 2005
    22. 22. Soundness of Measures • In order to ensure that a measure will accomplish its aim of accurately assessing quality in a way that is meaningful, four areas must be addressed: – Importance – Scientific acceptability – Usability – Feasibility
    23. 23. Quality in the Oncology World: A Comprehensive Measure Set
    24. 24. Disease Issues • Multiple tumor types – Big four: Lung, colon, breast, prostate • Multiple sub-types • Multiple presentations • Multiple stages • Multiple therapeutic approaches
    25. 25. Disease Trajectory • Prevention • Screening • Diagnosis • Staging • Treatment • Surveillance • Survival • Recurrence • End-of-life care
    26. 26. Data Sources • Administrative database – No staging – Lack of granularity • Medical records – Multiple sites – Multiple physicians – May require patient contact • Surveys – Not validated for oncology
    27. 27. Oncology Disciplines • Surgical • Surgical sub-specialties • Radiation • Medical • Pathology • Radiology • Nursing • Social Work • Pharmacy • Etc…….
    28. 28. Longitudinal Care • To achieve optimal outcomes, i.e. survival, a series of appropriate processes must b e successfully completed: – Pathology reading, surgical procedure, adjuvant RT, chemotherapy, and hormone therapy. • Composite measures –all or none measures
    29. 29. Attribution • Individual physician • Referring physician • Team • Facility/practice organization • Health plan • Responsibility beyond currently recognized boundaries
    30. 30. Level of Evidence • Cardiology: a few trials with thousands of subjects Oncology: a thousand trials with a few subjects • High-level evidence not available for most oncology processes
    31. 31. Current Oncology Quality Activities
    32. 32. National Goals and Priorities Measure Development NQF Endorsement Measure selection Implementation: data selection, aggregation, verification, standard setting Public Reporting Standard Setting Accountability QI
    33. 33. Cancer Quality Initiatives • ACoS Commission on Cancer • ASCO – NICCQ: breast and colon measures piloted in five cities – QOPI • State Cancer Plans • ACCC Standards for Oncology programs • NCCN Outcomes Project • College of American Pathologists • Kaiser Permanente-IHI-NCQA • NHPCO, National Consensus Project • AUA, AAD
    34. 34. Need for a common set of measures • If measure development and endorsement not centralized may be counter-productive: –Fragmented –Duplicative –Contradictory • Measures require buy-in from all stakeholders: providers, consumers, payers, government
    35. 35. National Quality Forum • A private, non-profit voluntary consensus standards setting organization • Membership 350+ • Meets criteria of NTTAA 1995 – Measures acceptable to CMS • Structured to give voice to all stakeholder constituencies • Formal review, voting and appeal process
    36. 36. Quality Alliances • Hospital Quality Alliance (HQA) • Ambulatory Care Quality Alliance (AQA) • Cancer Quality Alliance – 12 Founding Members – Promote synergies – Defining role in measure development • Pharmacy Alliance • Pediatrics Alliance
    37. 37. NQF-proposed Accountability Measures: Hospital Level • Breast cancer – Post-breast conserving surgery RT, <70 – Adjuvant chemotherapy for Stage I >1cm or Stage II and III, ER negative, <70 – Adjuvant hormone therapy, ER+ or PR+ • Colon cancer – Adjuvant chemotherapy, Stage III, <80 – 11 required elements in path report • Family Evaluation of Hospice Care
    38. 38. NICQQ Breast Colon Diagnostic 13 10 Surgery 4 4 Adjuvant Rx 16 10 Toxicity 2 0 Surveillance 1 1 Overall 36 25
    39. 39. NICQQ results: Breast Adherence (%) Range (%) Diagnosis 88 88-89 Surgery 87 85-88 Adjuvant RX 82 81-83 Toxicity 73 69-78 Surveillance 94 92-95 Overall 86 86-87
    40. 40. NICQQ Results: Colon Adherence (%) Adherence (%) Diagnosis 87 85-89 Surgery 93 91-95 Adjuvant Rx 64 62-67 Toxicity - - Surveillance 50 46-55 Overall 78 76-79
    41. 41. QOPI Quality Oncology Practice Initiative
    42. 42. Oncology measures: Physician level • QOPI: Structure • Path report • Chemo plan • Flow sheet • Patient consent
    43. 43. • QOPI: Process • Pain assessment; 1st , 2nd to last last, visits • Narcotic effectiveness assessed • Chemo intent documented • Smoking • Anti-emetics • EPO or Darbo documentation of Hb <11 g/dl • Adjuvant chemo/hormone recommended and given: breast, colon, lung • Bisphosphonates given and check renal function • CEA • Growth factors with CHOP or R-CHOP • CD-20 and rituximab Physician level oncology measures:
    44. 44. Physician level oncology measures • QOPI- Outcome – None • QOPI- Patient experience – None • QOPI- Efficiency – Chemotherapy in last 2 weeks of life • Clinical trials
    45. 45. Implementation • Each data collection requires 80 – 150 charts • Abstractors are usually data manager, nurse, sometimes clerical, not doctors – Trained by ASCO staff • Data entered directly onto web form • Takes one or two days of staff time
    46. 46. QOPI Results • >2000 doctors • 125 practices currently enrolled • 10,000 charts abstracted • Several practices measured 2 – 3 times Report Card
    47. 47. Chemotherapy recommended for breast cancer patients <50 years with T2 or +ALN 89 96 100 82 84 86 88 90 92 94 96 98 100 Copyright © 2004, 2005 American Society of Clinical Oncology. All rights reserved. RGH VCI % Process
    48. 48. Documented plan for chemotherapy, including doses and time intervals 15 31 43 63 72 80 82 83 89 9495 100 0 10 20 30 40 50 60 70 80 90 100 Copyright © 2004, 2005 American Society of Clinical Oncology. All rights reserved. RGHVCI % Structure
    49. 49. Was Pain Assessed on One of the Last Two Visits Prior to Death? 30 56 64 67 70 73 80 87 88 90 93 97 100 0 10 20 30 40 50 60 70 80 90 100 Copyright © 2004, 2005 American Society of Clinical Oncology. All rights reserved. RGH VCI % Process
    50. 50. Pain rated (by number) on either visit 0 8 13 19 21 22 27 43 54 56 60 71 80 90 100 0 10 20 30 40 50 60 70 80 90 100 Copyright © 2004, 2005 American Society of Clinical Oncology. All rights reserved. RGH VCI % Process
    51. 51. Patient enrolled in hospice before death 2527 333336 40 50505353545760606263 788083 9193 100 0 10 20 30 40 50 60 70 80 90 100 Yes Mean=62% Copyright © 2004, 2005 American Society of Clinical Oncology. All rights reserved. RGH VCI % Structure/Process
    52. 52. Conclusions • We must instill a culture of quality in oncology • All disciplines and stakeholders must be involved • Measurement of quality is an exacting science and oncology poses special difficulties • New methods using information technology will be needed • Physicians and enlightened professional organizations will have to lead the way

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