National Academies Press: OpenBook

Ensuring Quality Cancer Care (1999)

Chapter: 6 Cancer Care Quality Assurance

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Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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6
Cancer Care Quality Assurance

Individuals with cancer (or at risk of cancer) have relatively few direct or indirect ("surrogate") 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. No national comprehensive quality monitoring system exists in the United States, but there is a patchwork of federal and private efforts to assess quality, each with different purposes, perspectives, and audiences. Much of the recent impetus for quality assessment stems from the desire of large employers, business groups, and government programs to purchase managed care products for employees on the basis of quality, as well as cost.

An important aspect of quality is accountability, which can be applied to many aspects of health care. Providers can, for example, be held accountable for professional competence, legal and ethical conduct, financial performance, accessibility of services, public health promotion, and community benefit (Emanual and Emanual, 1996). There have also been calls to hold managed care organizations and other insurers publicly accountable for the "reasonableness" of their decisions by making rationales for limit-setting decisions (e.g., decisions regarding coverage for new technologies) explicit and publicly available (Daniels and Sabin, 1997; 1998a). Many parties may wish to hold providers accountable, and "accountors" may at the same time be "accountees" (Darby, 1998). A hospital, for example, may require physicians to adhere to clinical practice guidelines, while the hospitals themselves, in turn, are subject to oversight from government regulators and professional groups. At least three types of forces exert pressure on the health care system to foster accountability (although the degree to which they influence the system is quite variable) (Darby, 1998; Donaldson, 1998):

  1. The public sector relies on the regulatory, oversight, and purchasing actions of government at the federal, state, and local levels to ensure quality. Government health agencies also conduct disease surveillance to monitor public health and develop tools to assess quality, often in partnership with the private sector. The courts are often the final arbitrators in disputes about possible medical negligence and the appropriateness of care.
Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×
  1. The market relies on the use of quality data by health care purchasers and consumers in choosing plans and providers. The underlying assumption is that quality is a market force on a par or nearly so—with cost.
  2. The professional community relies on the actions of private-sector accreditation groups, trade associations and health plans, hospitals, and other providers to ensure quality. The profession assumes leadership for policing itself and demonstrating quality to outside parties.

Although these categories are convenient for describing the forces at work, they are not entirely independent, and in fact, the number of public and private collaborative efforts is increasing. For instance, the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998) recommended that two complementary bodies be formed on health care quality one lodged in the public sector to promote interagency coordination among federal agencies (Quality Interagency Coordination Health Care Task Force), and the other in the private sector to improve health care quality measurement and reporting (National Forum for Health Care Quality Measurement and Reporting). The goals of the Quality Forum are to (http://www.uhfnyc.org/intro/qfpc.htm):

  • 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.

This chapter first considers the individual consumer's point of view in describing the strengths and weaknesses of the tools and information available to help understand accountability in cancer care and the quality of such care. Next, the forces that affect accountability are described, using the three categories listed above. Finally, some of the specific activities that are in place to try to measure and improve the quality of health care (and cancer care, specifically) are described.

Quality Assurance: an Individual Consumer Perspective

Choosing Insurers

Most people are healthy when they first select a health plan or source of care and so do not focus specifically on the quality of cancer care. Then too, even if consumers wanted to comparison shop for a health plan on the basis of quality, many have no real choice of health plan. Most individuals under age 65 are insured through their employer, and less than half of employees (41 percent) who are offered insurance at work can choose among two or more plans (Long and Marquis, 1998). Furthermore, most new cases of cancer occur among those age 65 and older

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

who receive care within Medicare's fee-for-service (FFS) system, where consumer-oriented quality measures are generally less available.

Consumer-oriented quality initiatives have focused largely on helping people choose among managed care plans. For those with the opportunity to opt into managed care or switch plans, there is a wealth of information that, over time, is beginning to address meaningful issues for those with chronic illnesses such as cancer (see descriptions of the National Committee for Quality Assurance [NCQA] and the Foundation for Accountability [FACCT] later in this chapter).

A new generation of consumer surveys about health plans is now available that go beyond simple ratings of satisfaction (Cleary et al., 1997). Consumers are asked to report on specific experiences in obtaining health care, for example, difficulty in obtaining referrals. If a plan is large enough, cancer-specific ratings or at least the experience of individuals with chronic illness or functional limitations—could be provided to those making health plan choices. Here too, standardized measures are being developed to allow managed care and FFS comparisons (http://www.ahcpr.gov/qual/cahpfact.htm). The Health Care Financing Administration (HCFA) 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. HCFA plans to survey those who have disenrolled from health plans to provide information to beneficiaries on why people leave health plans (Medicine & Health, 1999).

Most individuals with a new diagnosis of cancer find themselves in an insurance system that they must live with, at least in the short term. At this point, many people have little flexibility in terms of their insurance plan, although they are usually able to choose among physicians within their plan and among institutions covered by their insurer.

Choosing Physicians and Hospitals

In choosing a physician, one basic piece of information is whether the physician is certified by a cancer specialty board, which requires completion of an approved training program and passing a rigorous written and oral exam about cancer care. Other potential indicators of physician quality of relevance to consumers might include: history of disciplinary action, hospital admitting privileges, volume of cancer patients treated, number and credentials of support staff, and the personality and demeanor of the provider and staff. Not all of this information is readily available, and as described in Chapter 5, good evidence is lacking to support the link between these indicators and outcomes of care. There are, for example, very few studies of the effects of physician specialization on outcomes of care, so although board certification has some intuitive appeal as a quality measure, the effect of certification on outcomes of care is virtually unknown.

For hospitals, there are several indicators of the range of services available (e.g., research programs), structure (e.g., size as indicated by annual hospital discharges), and to a limited extent, the quality of cancer-related services (e.g., appropriate use of diagnostic tests):

  • The American College of Surgeons' Commission on Cancer (see below) has standards for approving hospitals.
  • The National Cancer Institute (NCI) designates cancer centers for support of cancer research, and these centers are affiliated with a wide range of small and large hospitals. Treatment at participating hospitals means patients could have access to clinical trials (see Chapter 3).
Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×
  • The Joint Commission on Accreditation of Heathcare Organizations (JCAHO) is the lead organization in accrediting hospitals in the United States. JCAHO has recently instituted an outcomes-based performance system that includes specific oncology measures and may, over the coming years, improve the relevance of JCAHO certification to individuals with cancer (see below).

Although various organizations collect information related to the quality of hospital-based cancer care, the consumer usually can find out only whether or not a hospital is approved or accredited. The overwhelming majority of hospitals that voluntarily submit to an inspection or review are approved or accredited, but the details of hospital performance on various indicators are not yet publicly available. Even if the information were available, it would be difficult for consumers to evaluate a particular hospital's quality because there are few established links between hospital attributes and quality (see Chapter 5). Standards can, however, help to ensure that hospitals meet minimum infection control, safety, and security standards. 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. A few widely circulated magazines have sponsored national surveys of consumers regarding their satisfaction with care, and of providers regarding their assessments of the quality of sites of care, that they have used to rank services on the basis of quality. Consumer Reports has, for example, evaluated managed health care plans, and each year U.S. News & Worm Report ranks hospitals, including hospital-based cancer centers (Box 6.1), a feature that has been very popular with consumers and has been used by the high-ranking centers in marketing (Memorial Sloan-Kettering Cancer Center, 1998). While the U.S. News & Worm Report ranking includes indicators for which there is some evidence linking them to good health outcomes (i.e., volume of services, nurse to patient bed ratio), the ranking system itself has not been validated externally and the methodology has been criticized (Teasley, 1996).

BOX 6.1 U.S. News and World Report Annual Ranking of Cancer Centers

With a circulation of more than 2 million, the U.S. News & World Report annual ranking of hospital-based cancer programs is perhaps the most widely read source of information on the quality of cancer care. In 1997, 998 hospital-based cancer care programs were ranked according to measures of structure, process, and outcome:

  • reputation score among board-certified oncologists;
  • severity-adjusted cancer mortality rate;
  • membership in the Council of Teaching Hospitals;
  • availability of cancer-related technology;
  • number of cancer discharges; and
  • nurse to patient bed ratio.

The authors of the ranking system concluded that there are a few extremely ''good'' hospitals, many hospitals providing "competent" care, and a few hospitals at the bottom of the curve.

SOURCE: Comarow, 1997; Ehrlich et al., 1997.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

Choosing Treatment Options

Most consumers do not have the scientific background to evaluate their treatment options, but they can still participate intelligently in decisions about their care. Specifically, they can

  • seek independent second opinions;
  • use information resources such as the patient-oriented version of the NCI's Physician Data Query (PDQ) system, which can be accessed by computer and describes (in nontechnical language) treatment options by type of cancer. Information is also available through telephone services operated by both NCI and the American Cancer Society (ACS) (Murphy et al., 1997);
  • enter systems of care that employ a comprehensive approach to cancer treatment and management. (Programs that emphasize patient education, adherence to evidence-based protocols, and use of multidisciplinary teams of providers have been shown to contribute to greater patient satisfaction and better health outcomes (Wagner et al., 1996); and
  • make use of an array of available consumer-oriented products that enable individuals with cancer to electronically access health educational materials, communicate with their providers and with individuals with cancer, and make more fully informed treatment decisions (CancerDesk, 1999; Gustafson et al., 1993).

Use of Quality Information by Consumers

There is evidence that the available quality information is not viewed by many consumers as relevant to their decision making (Hibbard and Jewett, 1997b). In one national survey, three-quarters of Americans said that they would opt to see a surgeon they know rather than one they do not, even if the alternative had much higher quality ratings. 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, 1996). 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. The type of information needed about the quality of cancer care services can vary greatly by individual. The services important to the high-risk patient or person who has not yet been diagnosed are quite different from those important to a long-term cancer survivor.

Barriers to the use of quality information include the complexity of the task of evaluating health care quality, difficulties in understanding such information (e.g., high rates of functional illiteracy, non-English speakers), a lack of familiarity among the public with the workings of the health care system (e.g., most Americans do not understand the concept of managed care) and the way in which the organization of care might influence quality, and importantly, a paucity of user-friendly information (Hibbard et al., 1997b).

If large numbers of consumers do not use quality information directly, decisions at the intermediary level may offer important guidance to consumers (Hibbard et al., 1997c). Having a "thumbs-up" or "thumbs-down" rating from an influential group such as the American Association of Retired Persons (AARP) might be more useful for some consumers than detailed quality report cards. Awareness of quality issues in cancer care will likely increase as cancer advocacy groups

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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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 6.2).

BOX 6.2 National Coalition for Cancer Survivorship: Imperatives for Quality Cancer Care

Principle 1

People with cancer have the right to a system of universal health care. This access should not be precluded because of preexisting conditions, genetic or other risk factors, or employment status.

Principle 2

Quality cancer care should be available in a health care system whose standards and guidelines are developed in consideration of treating the whole person with cancer. Health care plans must regard the cancer patient as an autonomous individual who has the right to be involved in decisions about his or her care.

Principle 3

Standards of cancer care should be driven by the quality of care, not only by the cost of care, and should include participation in clinical trials and quality-of-life considerations.

Principle 4

All people diagnosed with cancer should have access to and coverage for services provided by a multidisciplinary team of care providers across the full continuum of care. Health care plans should be held accountable for timely referral to appropriate specialists when symptoms of cancer or its recurrence may be present.

Principle 5

People with cancer should be provided a range of benefits by all health care plans that include primary and secondary prevention; early detection; initial treatment; supportive therapies to manage pain, nausea, fatigue, and infections; long-term follow-up; psychosocial services; palliative care; hospice care; and bereavement counseling.

Principle 6

People with histories of cancer have the right to continued medical follow-up with basic standards of care that include the specific needs of long-term survivors.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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Principle 7

Long-term survivors should have access to specialized follow-up clinics that focus on health promotion, disease prevention, rehabilitation, and identification of physiologic and psychosocial problems. Communication with the primary care physician must be maintained.

Principle 8

Systematic long-term follow-up should generate data that contribute to improvements in cancer therapies and decreases in morbidity.

Principle 9

The responsibility for appropriate long-term medical care must be shared by cancer survivors, their families, the oncology team, and primary care providers.

Principle 10

The provision of psychosocial services must be safeguarded and promoted. Persons diagnosed with cancer should receive psychosocial assessments at critical junctures along the continuum of cancer care to determine the availability of needed support and their ability to seek information and advocate on their own behalf.

Principle 11

Psychosocial research is integral to comprehensive cancer care, and as such, psychosocial outcome measures should be included in all future clinical trials. The importance of this research and its application and transfer to oncology care plans should be recognized and encouraged.

Principle 12

Cancer survivors, health care providers, and other key constituency groups must work together to increase public awareness; educate consumers, professionals, and public policy makers; develop guidelines and disseminate information; advocate for increased research funding; and articulate for and promote survivors' rights.

SOURCE: NCCS, 1995.

Quality Assurance: a Market Approach

Although individual consumers may not yet wield much clout in the health care marketplace, large private-sector purchasers are already doing so. Most nonelderly Americans recieve 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

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

essential if health plans are to compete on the basis of value. Information on the quality of care provided in managed care plans is sometimes made available to employers, consumers, and other purchasers in the form of report cards, using a standardized format to make comparisons possible across health plans.

Most employers currently make health care purchasing decisions on the basis of price, not quality (Darby, 1998). When quality enters the decision-making process, some evidence suggests that employers are more likely to consider consumer satisfaction and accreditation status than clinical performance measures (Hibbard et al., 1997a). Some very large employers (e.g., Digital, Xerox) have been addressing quality of care concerns for years, and employers are increasingly banding together increasingly to form large coalitions to gain purchasing clout and to push for uniform quality assessment among health plans. Purchasers may use quality information to identify high-value plans with which to contract, to steer employees into higher-performing plans, or as leverage when establishing rates for premiums (Darby, 1998).

The Pacific Business Group on Health (PBGH), for example, is a nonprofit coalition of large health care purchasers in California and Arizona representing, as of 1996, 2.5 million insured individuals employed by 33 private-and public-sector organizations. 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. PBGH was the first purchasing coalition to impose a condition on contracting plans whereby it would withhold 2 percent of the premium until the plans achieved specific goals for improving customer satisfaction and quality of care. The Alliance, a health insurance purchasing cooperative in Denver, subsequently adopted a similar approach (Darby, 1998).

An informal group of large employer organizations including PBGH, called the Leapfrog group, is promoting "evidence-based hospital referral," the channeling of patients to certain hospitals for selected conditions and procedures (e.g., coronary angioplasty, bypass surgery) for which clear evidence exists that a higher volume of procedures or teaching status is associated with better outcomes. The PBGH is asking California HMOs with whom it has contracts to use new performance standards for physician groups, hospital precertification, and enrollee education to advance "evidence-based hospital referral" (Bodenheimer, 1999).

Quality Assurance: the Public-Sector Approach

Oversight through accreditation and licensing is one of the oldest systems of quality assurance employed by the federal government (e.g., accrediting hospitals providing care for Medicare beneficiaries) and states (e.g., licensing physicians). Although traditionally focused on regulation and oversight to ensure at least a minimal level of acceptable quality, government bodies are increasingly turning to market-based approaches. State-sponsored initiatives in Minnesota, Maryland, and Pennsylvania, for example, publish reports that allow consumers to compare health plans on various aspects of quality (Darby, 1998).

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

Health Care Financing Administration

Many of the federal health care accountability systems are housed within the Health Care Financing Administration (HCFA), the principal payer for health care. HCFA has two main quality-of-care strategies: (1) As part of its certification activities, it requires fee-for-service providers, HCFA-contracting health maintenance organizations (HMOs), and clinical laboratories to meet Medicare standards; (2) it undertakes quality improvement initiatives in cooperation with its peer review organization (PRO) programs.

On the regulatory front, HCFA is revising its rules to certify Medicare providers in four areas: home health, hospital care, hospice care, and end-stage renal disease, placing more emphasis on clinical performance and patients' experience with care. The proposed home care rule, for example, would require Medicare home health agencies to use a standard system called the Outcomes and Assessment Information Set (OASIS) to measure quality and patient satisfaction with care (Darby, 1998). HMOs contracting with HCFA must now report clinical performance data (i.e., Health Plan Employer Data and Information Set [HEDIS] data) and information on patients' experience and satisfaction with plans (i.e., results from a new Consumer Assessment of Health Plans Survey). HCFA is also implementing the Quality Improvement System for Managed Care to require participating health plans to show improvement in the health care they provide. Minimum service levels for improvement measures such as mammography will be set, along with targets specific to a geographic region. Initially, the focus will be on preventive and acute care services. A similar system is being developed for fee-for-service care (Voelker, 1997).

Relatively few Medicare beneficiaries are enrolled in managed care plans (13 percent as of 1997), and efforts are underway to gather performance information from providers in the FFS environment. Medicare beneficiaries are beginning to have more choices in type of health coverage beyond fee-for-service and HMOs. With the Medicare+Choice program, beneficiaries will be able to select new insurance options including preferred provider organizations (PPOs) and medical savings accounts. Many believe that HCFA will lead the effort to converge on a single set of quality measures applicable across delivery systems (Darby, 1998).

In 1992, HCFA established the Health Care Quality Improvement Program, which promotes partnerships between PROs and hospitals, health plans, and physicians to improve quality. Each state has a PRO that evaluates whether care given to Medicare patients is reasonable, necessary, and provided in the most appropriate setting. Funding for PROs in 1997 was $183 million. HCFA maintains a quality-of-care surveillance system to provide information to PROs about Medicare health care utilization, patterns, and trends to help PROs target their quality improvement activities. Among the indices tracked are rates of radical prostatectomy among men 70 years or older (see examples of PRO activities in Box 6.3). As of 1998, more than 700 quality improvement projects were underway, some of which were national in scope and disease specific. The Cardiovascular Cooperative Project, for example, is a national, data-based effort to improve care for Medicare patients hospitalized for heart attacks (President's Advisory Commission, 1998). PROs appear to have been effective in improving the care of patients with acute myocardial infarction, according to a recent quasi-experimental assessment (Marciniak, 1997).

HCFA is also actively involved in the development of clinical performance measures to assess quality. As part of HCFA's Outcomes Project, for example, it is identifying multiple domains of processes and outcomes of care for breast cancer, collecting and summarizing the ex-

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

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, 1998).

BOX 6.3 HCFA's Peer Review Organizations—Examples of Cancer Care Quality Monitoring

Radical Prostatectomy (RP) in Men 70 and Older. RP should generally not be used for men 70 and older, given the risks and benefits of the procedure. The PRO overseeing Medicare quality assurance in Kentucky and Indiana identified five "outlier" hospitals in each state with high rates of RP for older men (20-22 percent of prostate cancer admissions among elderly males). Provider education and monitoring of RP led to significant declines in RP in outlier hospitals, and in Kentucky, the rate of RP among older men was reduced to statewide norms (ML Daffron, personal communication to Maria Hewitt, February 18, 1998).

Breast Conserving Surgery. The PRO overseeing Medicare quality in Delaware found that rates of breast conserving surgery (BCS) rose from 16 to 80 percent from 1993-1994 to 1996-1997 among Medicare beneficiaries with Stage I or II breast cancer. Among women eligible for BCS for whom mastectomy was performed, documentation of patient choice of mastectomy rose from 50 to 72 percent of cases (Cochran, 1997).

Cancer Pain Management. The Minnesota PRO evaluated hospital adherence to the Agency for Health Care Policy and Research and American Pain Society guidelines on pain management. According to a review of 271 charts of patients admitted for specific cancers (e.g., metastasis to bone and spinal cord, liver, intestine, peritoneum), hospitals excelled at documenting some form of a patient's initial self-assessment of pain (93 percent of patients). Most hospitals, however, did not utilize effective means of communicating pain intensity (26 percent of patients). Pain reassessment was found to be inconsistent among hospitals. The PRO is planning interventions to improve compliance with pain management guidelines (Stratis Health, 1997).

Determinants of Use of Adjuvant Cancer Therapy. The Colorado PRO matched cancer registry data with Medicare A and B claims data to assess factors associated with the use of adjuvant therapy for Stage I or II breast cancer and Stage III colon cancer. Underuse of adjuvant therapy was found among those age 65 and older, particularly for chemotherapy following Stage III colon cancer. The principle factor associated with failure to use adjuvant therapies was advancing age, which did not appear to be explained by comorbidities (Byers et al., 1998).

Satisfaction with Breast Cancer Treatment. The Colorado PRO conducted focus groups among minority and non-minority group women and a telephone survey of women age 65 and older regarding their care for breast cancer. Women's satisfaction with cancer care was high, but areas in which doctors could provide more information to their patients were in the discussion of what to expect from surgery and the potential physical and emotional outcomes of surgery (Crane et al., 1997).

SOURCES: Byers et al., 1998; Cochran, 1997; Crane et al., 1997; Daffron, 1998; Stratis Health, 1997.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

Most state Medicaid agencies monitor utilization, outcomes, consumer satisfaction, and disenrollment, through either chart review or client survey. Some have engaged in collaborative quality improvement initiatives with health plans, providers, public health agencies, and community organizations in areas such as pediatric immunization and prenatal care. Medicaid agencies are also beginning to incorporate quality-based performance indicators and specifications into their contracting strategies. Some use quality information to assess potential contractors, whereas others (e.g., Massachusetts) hold contractors accountable for measurable service improvements that are spelled out in a set of contractual terms and purchasing specifications (e.g., provision of member satisfaction data, clinical indicator data from HEDIS, and voluntary disenrollment rates) (Darby, 1998).

Public Health Monitoring

Another set of important quality assurance activities involves public health monitoring. Here, cancer registries, surveillance systems, and national survey data are used to monitor the epidemiology of cancer, the prevalence of risk factors, and the use of preventive health services. The adequacy of the nation's public health programs and services is, in part, judged by whether or not public health goals are met—for example, those established as part of the Centers for Disease Control and Prevention's (CDC's) Healthy People 2000 initiative, which highlights cancer as a priority area. The cancer objectives call for decreases in site-specific death rates (e.g., breast, colorectal); improved primary preventive health practices (e.g., reducing cigarette smoking, reducing dietary fat intake); improved early cancer detection (e.g., increased use of breast, colorectal, and cervical cancer screening); and ensuring that cancer screening and diagnostic tests meet quality standards (i.e., Pap tests, mammograms). As of 1997, progress had been made for 12 of the 17 cancer objectives, but in many cases the improvements have been slight (NCHS, 1997).

State public health agencies are building links with local health plans and providers to monitor public health goals. Plans for the Missouri Health Indicator Set, for example, include integrating public health records on births, deaths, hospital discharges, and cancer (Darby, 1998). Some States (e.g., New York, Pennsylvania) track hospital admissions and outcomes associated with certain procedures in an effort to monitor quality. New York, for example, has since the late 1980s collected standardized clinical data for coronary artery bypass surgery (CABS) patients, producing and publishing risk-adjusted mortality rates for hospitals and surgeons, and using these data to facilitate quality improvement efforts. The program has led to declines in statewide mortality (Chassin et al., 1996, 1998; Hannan et al., 1994).

Agency for Health Care Policy and Research

The Agency for Health Care Policy and Research (AHCPR) is the lead agency within the federal Department of Health and Human Services (DHHS) charged with supporting research on health care quality, cost, financing, and access (see Chapter 7). AHCPR has developed a number of practice guidelines (e.g., a 1994 practice guideline on cancer pain, which will be updated in 1999). 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

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

guideline clearinghouse accessible by Internet (www.guideline.gov). The website contains information on available guidelines, compares and contrasts the recommendations of guidelines, and allows communication among those involved in guideline development and dissemination (Stephenson, 1997).

Quality Assurance: The Health Care Professional Approach

Health care providers have established systems to monitor themselves and to demonstrate quality to parties outside the profession. Several organizations have incorporated quality measures into their voluntary accreditation programs (e.g., the JCAHO), developed quality monitoring systems (e.g., the National Committee for Quality Assurance), or have published standards with which to judge cancer care providers (e.g., American College of Surgeons' Commission on Cancer).

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. JCAHO evaluates and accredits more than 16,000 health care organizations in the United States. Application for JCAHO accreditation is voluntary. About 80 percent of U.S. hospitals participate, representing about 96 percent of all inpatient admissions.

For accreditation, JCAHO conducts an on-site quality assessment every three years. It covers such topics as patient rights, patient care, patient education, continuity of care, ongoing efforts to improve quality, safety plans, information management, and infection control. Although JCAHO (and other accrediting organizations) has traditionally focused on structural measures of quality—such as whether a hospital has appropriate capacity for the covered patient population—it now incorporates process and outcomes measures into its accreditation criteria.

JCAHO instituted the ORYX system in 1997, which requires organizations seeking JCAHO accreditation to select from among 60 performance measurement systems and two specific indicators on which they will report their care. Hospitals and long-term care facilities are being instructed to begin reporting with these indicators during early 1999. One of the systems is JCAHO's Indicator Measurement System (IMS), which has specifications for 42 quality-of-care indicators (including 5 for cancer care; Table 6.1), and others are being developed. About 40-50 hospitals currently use the IMS reporting system (Chris McCravy, IMSystem, personal communication to Maria Hewitt, 1998). With institutions choosing their own indicators, making comparisons across institutions will be challenging. It should allow for comparisons with prior years within the same institution, benchmarks, and goals. JCAHO will soon rely on the American College of Surgeons' Commission on Cancer survey findings for cancer programs within JCAHO-accredited organizations (see below).

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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TABLE 6.1

Oncology Indicators of the JCAHO's IMSystem

 

Data

Staging

Breast Cancer

Lung Cancer

Colon or Rectum Cancer

Focus

Availability of data for diagnosis and staging

Use of staging by managing physicians

Use of tests critical for prognosis and clinical management of female breast cancer

Effectiveness of preoperative diagnosis and staging

Comprehensiveness of diagnostic workup

Numerator

Patients undergoing resection for primary cancer of the lung, colon or rectum, or female breast for whom a surgical pathology consultation report is present in the medical record

Patients undergoing resection for primary cancer of the lung, colon or rectum, or female breast with stage of tumor designated by a managing physician

Female patients with Stage I or greater primary breast cancer who, after initial biopsy or resection, have estrogen receptor analysis results in the medical record

Patients with non-small-cell primary lung cancer undergoing thoracotomy with complete surgical resection of tumor

Patients undergoing resection for primary cancer of the colon or rectum whose preoperative evaluation by a managing physician included examination of the entire colon

Denominator

Patients undergoing resection for primary cancer of the lung, colon or rectum, or female breast

Patients undergoing resection for primary cancer of the lung, colon or rectum, or female breast

Female patients with Stage I or higher primary breast cancer undergoing initial biopsy or resection

Patients with non-small-cell primary lung cancer undergoing thoracotomy

Patients undergoing resection for primary cancer of the colon or rectum

 

SOURCE: IMSystem, 1997.

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). As the name implies, HEDIS measures were initially designed to provide information to large purchasers about the quality of care offered to employees. More recently, the audience for results from HEDIS has broadened, and HEDIS indicators are often reported in consumer-oriented report cards.

HEDIS is a performance measurement tool designed to assist purchasers and consumers in evaluating managed care plans and holding plans accountable for the quality of their services. Because HEDIS has standard measures and uniform data reporting requirements, comparisons can be made across various health plans and their organizational structures (e.g., staff-model HMOs, point-of-service plans). The most recent iteration, HEDIS 3.0, assesses plans in eight domains: (1) effectiveness of care, (2) accessibility and availability of care, (3) satisfaction with care, (4) cost of care, (5) stability of the health plan, (6) informed health care choices, (7) use of services, and (8) descriptive information about the plan. In addition to the standard set of measures, a set of measures not used in current scoring is being tested for future iterations of HEDIS (Box 6.4). NCQA has appointed an Oncology Measurement Advisory Panel to review quality measures relevant to cancer care.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

BOX 6.4 Selected Cancer-Specific (or Cancer-Relevant) HEDIS 3.0 Measures

Effectiveness of Care

  • Advising smokers to quit
  • Cervical cancer screening
  • Breast cancer screening
  • Number of people in the plan who smoke*
  • Smokers who quit*
  • Colorectal cancer screening*
  • Follow-up after an abnormal Pap smear.*
  • Follow-up after an abnormal mammogram (within 60 days)*
  • Stage at which breast cancer was detected*
  • Assessment of how breast cancer therapy affects the patient's ability to function*

Access to or Availability of Care

  • Adults' access to preventive ambulatory health services
  • Problems in obtaining care*

Satisfaction with the Experience of Care

  • Member satisfaction
  • Disenrollment*
  • Satisfaction with breast cancer treatment*

Health Plan Stability

  • Provider turnover

Health Plan Descriptive Information

  • Provider board certification or residency completion
  • Arrangements with public health, educational, and social service organizations

*  

Denotes testing set measures.

SOURCE: NCQA, 1998a.

The HEDIS cancer quality indicators have targeted early detection and diagnosis, not care received after cancer is diagnosed. NCQA's focus on early detection in cancer quality assessment appears to be related to its belief that ''early detection remains the most effective way of improving the outcomes of breast cancer'' (McGlynn, 1996). Treatment-related indicators are being evaluated—for example, assessment of the effect of breast cancer therapy on a woman's ability to function and patients' satisfaction with breast cancer treatment. NCQA has halted further work on the indicator related to the stage at which breast cancer is detected, because the incidence of breast cancer cases in most health plans is too low to make meaningful comparisons of stage at diagnosis across health plans (Schuster et al., 1998).

HEDIS is a voluntary system, although managed care plans are finding it increasingly necessary to participate to compete for patients. Some evidence suggests that most large employers are

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

using HEDIS data to evaluate the managed care plans with which they contract (Hibbard et al., 1997a). In 1996, more than 330 plans—more than half of the plans in the United States, representing more than three-quarters of all commercial managed care enrollees—reported HEDIS measures on their enrollees. NCQA produces Quality Compass, a CD-ROM-based system that makes it possible for consumers to obtain comparative HEDIS ratings for HMOs in communities throughout the United States. A subset of Quality Compass measures appears on the World Wide Web. A health plan can refuse to disclose its HEDIS profile to the public. In 1997, less than half of plans (45 percent) permitted public reporting of the data (Bodenheimer, 1999).

American Accreditation Health Care Commission, Inc./URAC

The American Accreditation Health Care Commission, Inc./URAC (AAHC/URAC) accredits PPOs, point-of-service plans, and other open-panel plans. These plans represent a large segment of the private insurance market, yet they have relatively little in the way of a quality measurement infrastructure (Darby, 1998).

Foundation for Accountability

Although many indicators of quality that are relevant to purchasers are also relevant to consumers, the perspective of consumers is gaining a separate voice in several quality initiatives. The nonprofit Foundation for Accountability's (FACCT's) principal mission is to ensure that information on quality is effectively communicated to and used by consumers. FACCT has developed a quality assessment framework that uses categories designed to be descriptive of issues of concern to consumers: the basics, staying healthy, getting better, living with illness, and changing needs (www.facct.org; Lansky, 1998). FACCT has been developing new measures and selecting existing measures for use by others in assessing quality. One of the areas for which FACCT has been compiling a set of measures is breast cancer (Table 6.2). 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. These measures are currently being field-tested to determine the feasibility of their use.

American College of Surgeons' Commission on Cancer

Although not a formal accreditation program, The American College of Surgeons' Commission on Cancer surveys and approves hospitals, treatment centers, and other facilities according to established standards. The goal of the program is to improve the quality of patient care through multidisciplinary cancer programs that are concerned with prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, surveillance, psychosocial support, and the hospice concept (http://www.facs.org). The Commission on Cancer has approved 1,500 programs, which are estimated to provide care for 80 percent of the nation's newly diagnosed patients (Carol Cook, Administrative Coordinator, American College of Surgeons, personal communication to Maria Hewitt, February, 1999).

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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TABLE 6.2

FACCT Breast Cancer Quality Indicators

Measure

Performance Value

Instrument or Data Source

Steps to Good Care

Mammography

Proportion of women age 52-69 who have had a mammogram within two years

Doctor's billing or claims records (NCQA's HEDIS 3.0 breast screening measure used)

Early-stage detection

Proportion of patients whose breast cancer was detected at Stage 0 or Stage I

Patient records from cancer registry

Information about radiation treatment options

Proportion of Stage I and II patients who indicate that they had adequate information about their radiation treatment options before deciding about treatment

One question in patient satisfaction survey completed three to six months after diagnosis

Breast conserving surgery

Proportion of Stage I and II patients who undergo BCS

Patient records from cancer registry or claims records

Radiation therapy following breast conserving surgery

Proportion of BCS patients who receive radiation treatment after surgery

Patient records from cancer registry or claims records

Experience and Satisfaction

Patient satisfaction with care

Mean score for patients' level of satisfaction 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

32-item patient satisfaction survey completed three to six months after diagnosis

Results

Experience of disease

Mean score for patients on CARES-SF survey, which assesses patients' quality of life and experience in living with breast cancer

59-item CARES-SF patient survey completed 12-15 months after diagnosis

Five-year disease-free survival (cancer treatment center measure)

Probability of disease-free survival for a group of patients, Stages I-IV, who were diagnosed during previous five years

Patient records from cancer registry

NOTE: CARES = Cancer Rehabilitation Evaluation System.

SOURCE: Foundation for Accountability, 1998.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

An approved cancer program must provide specific state-of-the art diagnostic and treatment services in all medical disciplines that a person with cancer may need. The standards applied to institutions are not limited to surgery. Adherence to accepted clinical practice guidelines (e.g., AHCPR's Management of Cancer Pain) and the provision of discharge planning are, for example, among the standards used to evaluate programs.

A major initiative of the Comission on Cancer, in collaboration with the American Cancer Society, is the National Cancer Data Base (NCDB), which currently collects data routinely from 1,600 hospitals in all 50 states on all the patients with cancer they treat. With the program now in its sixth year, more than half of U.S. patients newly diagnosed with cancer are included. Basic demographic information about the patient, type and stage of cancer, and nature of the treatment given are reported electronically. Aggregate data from the country are available publicly. In addition, each hospital is given back its own data in summary form, which it can use to compare with national data ("benchmarking"). The national data allow problem areas to be pin-pointed (e.g., widespread use of an inappropriate treatment for a particular type of cancer) and the observation of trends over time in such characteristics as stage at diagnosis, percentage of patients who have complete staging information, and type of treatment given. Results of NCDB analyses are published regularly in professional journals (NCDB, 1999).

In addition to routine data collection, each year two Patient Care Evaluation (PCE) studies are carried out, focusing on specific cancer types or general treatment issues. More extensive data are collected for these special studies, allowing a more detailed analysis of how patients are treated, with the data again fed back to hospitals so that they can see how they compare in the national spectrum. Specific information on each disease is included. For example, the breast cancer section of the report featured quality benchmarks such as completeness of disease staging according to the American Joint Committee on Cancer (AJCC), percentage utilization of breast conservation surgery for early breast cancers, and percentage of patients undergoing BCS who also received adjuvant radiotherapy. The NCDB expects an increase in hospital participation in the coming years, and it will make outcomes data available on-line. NCDB estimates that three out of every four U.S. patients with cancer will be reported on by the year 2000 (American College of Surgeons, 1999).

The findings of the American College of Surgeons' Commission on Cancer survey will soon be used as part of JCAHO' s accreditation process for JCAHO-accredited organizations that house a cancer center. The collaboration is an attempt to increase the visibility of approved cancer programs, share information on standards and survey process, and increase consumer access to health care organization performance information. Reports will allow approved programs to benchmark their performance with that of other programs (ACS/CoC, 1998).

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, 1997) (see Box 6.5). The standards are based on expert opinion rather than a systemic review of evidence. ACCC has not undertaken a study of the extent to which these standards have been met.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

BOX 6.5 Association of Community Cancer Centers--Standards for Cancer Programs

Program Leadership

  • Administrative structure is in place to ensure efficient, appropriate, and effective management of the cancer program and services.

Cancer Committee

  • An interdisciplinary standing Cancer Committee provides program leadership.

Medical Director

  • The program has a designated medical director on a part or full-time basis.
  • The authority of the medical director is defined and documented by the sponsoring organization of the program.
  • The medical director is subject to a minimum of annual performance review.

Cancer Registry

  • A cancer registry will be maintained to meet and preferably exceed the minimum requirements of the Commission on Cancer of the American College of Surgeons.

Continuous Performance Improvement

  • Patient care is monitored and evaluated for the quality of services. Continuous performance improvement (CPI) plans are generated from quality review data, including attributes of timeliness, appropriateness of care, clinical outcomes of disease-free survival, and effective management of disease and treatment sequelae.

Staff Support

  • A structured program for staff support is available (e.g., educational and professional skill development opportunities).

Multimodality Treatment

  • Multimodality and interdisciplinary cancer case reviews are conducted on a regular basis to ensure patients' access to consultative services by all disciplines.
  • Tumor conference case review is prospective in nature. Prospective is defined as prior to treatment or any time a clinical treatment plan is reviewed for further evaluation.

Patient Advocacy and Survivorship

  • Information and programs specific to patients' advocacy and survivorship issues are available to cancer patients and their families.

Cancer Education and Resource Program

  • Education and resource programs are developed and provided for primary care providers, cancer patients and families, and the community.
Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

Cancer Prevention and Detection

  • Cancer prevention and detection programs are available to reduce the risk of developing cancer, teach self-examination and symptom identification techniques, provide screening guidelines, and communicate the availability of community resources (e.g., screening mammography) for early detection.

Clinical Research

  • Cancer patients are provided access to clinical research programs including treatment and cancer prevention and control trials.

Ethics

  • Oncology professionals will uphold a professional code of ethics and conduct as defined by the appropriate governing professional organization.
  • Oncology professionals will uphold a professional code of ethics, conduct, and confidentiality as defined by the policies and procedures of their respective employers.
  • A mechanism for ethics consults should be available.

Interdisciplinary Team

  • There is an interdisciplinary team approach to planning, implementing, and evaluating the care of cancer patients and their families.

Nutritional Support Services

  • A clinical dietitian is available to work with patients and their families, especially those identified as at risk for having nutritional problems or special needs. The dietitian provides dietary guidelines on reducing cancer risk through program materials and services to the community.

Oncology Nursing Services

  • Nursing care of the cancer patient is provided by nurses with specialized knowledge and skill in oncology.

Pastoral Care

  • Pastoral care services are available to meet the needs of patients and their families.

Pharmacy Services

  • Pharmacy services will purchase, store, and prepare cytotoxic agents in a safe and efficient manner.
  • The dispensing of investigational drugs will meet all federal regulations.
  • Pharmacy services will store and maintain all investigational cytotoxic agents in a safe and efficient manner.
  • Pharmacy and oncology nursing services will prepare extravasation guidelines and drug kits for use by the nursing department.
  • Pharmacy services will maintain current information on the safe handling of cytotoxic agents and prepare information for employees involved in preparation and administration of these agents.
Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

Rehabilitation Services

  • Comprehensive rehabilitation services are available to cancer patients and their families.

Psychosocial Services

  • Social work services are provided by licensed social workers prepared at the master's level and experienced in meeting the psychosocial needs of patients and their families.
  • Psychosocial services are directed by written policies and procedures.

Pain Management

  • Acute and chronic cancer pain management guidelines are available to assist professional staff in alleviating patient suffering and improving quality of life.

Oncology Unit

  • An inpatient oncology unit is designed for the care of patients with cancer and their families.

Ambulatory Oncology Services

  • An outpatient facility or office is available and dedicated to outpatient cancer care.
  • A radiation oncology facility is available for treatments.
  • Integration of oncology services for optimal treatment planning, evaluation, and follow-up.

Home Care

  • A home health agency or referral relationship exists to provide professional services to cancer patients and their families in the home.

Hospice

  • A hospice program exists to provide professional and volunteer services to patients with cancer in the terminal stage of disease and their families. Bereavement for families is provided for a minimum of six months.

SOURCE: Association of Community Cancer Centers, 1997.

Quality Improvement Within Health Care Organizations

Several techniques are available for using internal quality assessments to improve quality within an organization. Ideally, information on quality shows where to focus efforts for improvement. Traditional quality assurance programs focus on retraining or removing clinicians who stand out as performing below group norms. By contrast, continuous quality improvement (CQI) programs (also known as total quality management [TQM] programs) focus on improving the quality of care delivered by all clinicians, with the goal of raising the average level of quality

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

in an organization. CQI assumes that most examples of poor quality are due to correctable systematic problems rather than to individual incompetence or irresponsibility. It often incorporates routine collection and monitoring of information to assess quality so that the organization can identify and respond to problems in a timely fashion. CQI generally uses interdisciplinary teams both to identify inefficiencies that increase errors and to institute checks that make errors easier to prevent and catch (Berwick, 1989; Kritchevsky and Simmons, 1991). For example, a group of cardiothoracic surgeons practicing in three states used CQI and other techniques to improve their practices and found a 24 percent reduction in their combined mortality rates (O'Connor et al., 1996).

A hospital that finds medication errors might review the many steps involved in the process by which physicians, nurses, pharmacists, and others provide medications to patients. Solutions might include having nurses and pharmacists double-check doses, using standardized doses for patient weight ranges to reduce calculation errors, and having a standard location for documentation of all drug allergies (Leape et al., 1995). Prevention of medication errors is particularly important for cancer chemotherapy, and efforts have been initiated to improve safeguards (Cohen et al., 1996).

While there are concrete examples of the success of some CQI efforts, some health care experts do not believe that the movement has made a sizable impact on the U.S. health care system (Blumenthal et al., 1998).

Practice Guidelines

Practice guidelines are systematically developed recommendations about some or all aspects of decision making for a particular condition or clinical situation (IOM, 1990). The development of guidelines usually involves a review of the relevant research and clinical literature. 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 6.3).

TABLE 6.3

Institute of Medicine List of Desirable Attributes of Clinical Practice Guidelines

Attribute

Description

Validity

Lead to health and cost outcomes projected for them

Reliability/reproducibility

Given the same evidence and methods, another set of experts would produce essentially the same statement

Applicability

Explicitly state the population to which they apply

Flexibility

Identify specific exceptions

Clarity

Use unambiguous language and precise definition of terms

Multidisciplinary process

Involve participation by representatives of key affected groups

Scheduled review

Indicate when they should be reviewed

Documentation

All procedures, participants, evidence, assumptions, and analytic methods must be documented and described

 

SOURCE: IOM, 1990.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

There are two general types of guidelines: path or algorithm guidelines, which include branch points and if-then statements to guide decision-making according to a standard of care, and boundary guidelines, which are used to define the appropriate use of a new (and generally expensive) technology. Guidelines are not intended to dictate a rigid approach to care; rather, they give options that clinicians should be aware of, even if they choose a different strategy for a particular patient. Guidelines are partly an outgrowth of the boom in scientific information that makes it difficult for individual physicians to keep up with medical advances.

Practice guidelines have been developed by government agencies (e.g., AHCPR), specialty organizations (e.g., American Society of Clinical Oncology), and cancer centers. The National Comprehensive Cancer Network (NCCN), a consortium of 15 leading cancer centers, has assembled expert panels to review evidence and develop guidelines on the treatment of 15 of the most common cancers (Marwick, 1997; McGivney, 1998). Many other hospitals and health care systems have developed their own guidelines (e.g., use of antiemetics, use of single daily dose antibiotics for infection), but they are generally not available to other institutions (see Table 6.4—for this review, cancer screening guidelines were not considered).

The Advisory Board Company, a private consulting group, has launched an Oncology Roundtable to provide cancer centers with information on "best" practices in the following areas: patient-focused oncology (i.e., ensuring convenient access, informed decision making, compassionate care, quality service); breast cancer management; prostate cancer management; and pain management (Advisory Board, 1998).

Disease management programs incorporate a systematic approach for the management of specific chronic disorders (e.g., asthma, diabetes), which often include adherence to clinical guidelines. The goal of these programs is to improve quality of care and outcomes, integrate and coordinate care, and track and manage costs associated with chronic illnesses. Memorial Sloan-Kettering Cancer Center has, for example, established 17 disease management teams to develop treatment pathways, track resource consumption, and identify appropriate patient education materials for cancers (McDermott, 1997). Nearly 100 clinical paths have been developed at the M.D. Anderson Cancer Center as part of its disease management program (Morris, 1996; Morris et al., 1996).

Practice guidelines are available for only a small fraction of oncology practice, but for some cancers, several guidelines are available. When to create a practice guideline can be difficult to gauge. The impetus to create a guideline often comes from evidence of widespread variation in practice; however, this is often a sign that there is little evidence upon which to construct a guideline. Guidelines based on sound evidence rather than expert opinion are most likely to succeed in influencing provider practice. Sometimes practice guidelines can be issued too late, after providers have already changed behavior in light of new evidence. A major recommendation of the 1979 National Institutes of Health (NIH) Consensus Development conference on treatment of primary breast cancer—that few Halsted radical mastectomies should be done—was found in subsequent reviews of medical practice to be moot since the procedure was being performed very infrequently (Kanouse et al., 1989). If the intent of a guideline is to inform and possibly change physician behavior, priority should be given to developing guidelines for which there is practice variation, despite good evidence to support a standard set of practices (U.S. Congress, 1994).

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

TABLE 6.4

Selected Oncology Guidelines, by Sponsoring Group

Group

Guidelines

Comment

National Comprehensive Cancer Network (NCCN)

Path or algorithm guidelines for all common cancers

Evidence-based, with consensus; when no consensus possible, options listed

Intended for mandatory use for all participating cancer centers

No set date for implementation

No set benchmarks for care

Adopted in the community for use outside of NCCN cancer centers No data yet on compliance or outcomes

American Society of Clinical Oncology (ASCO)

Boundary guidelines for new technologies

Hematopoietic growth factors Outcomes important enough to justify treatment

Antiemetics

Surveillance of breast and colorectal cancer patients

Path or algorithm guidelines for specific diseases

Management of non-small-cell lung cancer

Metastatic prostate cancer

Evidence-based with consensus demanded before approval

Adopted by the community but no data available on compliance or outcomes

Likely that all future guidelines will be boundary guidelines for new technologies, with overlap of ASCO and NCCN methods and topics

Society for Surgical Oncology

Path guidelines for management of common surgical problems

Consensus panels

American Urology Association

Path guidelines for common urology problems

Localized prostate cancer

Consensus based on evidence

University of California Cancer Care Consortium (UC and PONA, Inc.)

Path guidelines for most solid tumors

PONA did systematic reviews, consulted with UC faculty for consensus

Organizations Whose Guidelines Are not Available (proprietary)

Kaiser Permanente

Salicknet, Inc.

Value Health Science, Inc.

Multiple others

Path guidelines for management of common oncology problems

Consensus based on evidence; not available outside the corporation

 

SOURCE: Smith and Hillner, 1998.

Variation in practice often reflects uncertainty and points to a need for rigorous clinical research. There are, for example, no randomized clinical trials comparing best supportive care versus second-line chemotherapy for patients with non-small-cell lung cancer. (There are limited Phase II data from single institutions.) An American Society of Clinical Oncology (ASCO)

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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guideline on this topic noted that no benefit could be proven in either survival or quality of life, so no recommendation could be made for or against second-line chemotherapy (ASCO, 1997). Without evidence to discourage it, the aggressive use of chemotherapy is common. In a survey of practices for dying patients, more than 50 percent of ASCO members stated that they would give second-line chemotherapy to a 43-year-old woman with progressive non-small-cell lung cancer, nearly 20 percent would give third-line chemotherapy, and a substantial number would give fourth-line chemotherapy (Ezekiel Emanuel, personal communication to Tom Smith, 1998).

Multiple guidelines on the same topic are not always consistent. 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. Guideline recommendations may vary because of differences in the composition of guideline panels, the way evidence from the literature is reviewed, the interpretation of evidence, and the procedures to reach agreement on recommendations. The interpretation of data depends on values and perspectives. Some patients and practitioners will think that a small and statistically non-significant improvement in six-month disease-free survival associated with the use of high-dose chemotherapy in lymphoma is sufficient evidence of clinical benefit, whereas others will not.

Guideline panel membership appears to have a strong effect on shaping recommendations. There is, for example, evidence of a user bias in which physicians who perform a given intervention are more likely to judge it as beneficial. When faced with the same evidence from the literature on the effectiveness of carotid endarterectomy, a panel of surgeons rated 70 percent of indications as appropriate, whereas a multidisciplinary group found only 38 percent of indications to be appropriate (Leape et al., 1992). Panels in the United Kingdom and the United States with the same physician mix came to different conclusions when assessing the appropriateness of treatment for coronary disease, in part because the U.K. panelists seemed to require a higher standard of scientific evidence than did their U.S. counterparts (Brook et al., 1988).

One of the hallmarks of a good guideline is having clear documentation of the methods used to arrive at recommendations. The ASCO text that supports the guideline on the provision of follow-up services for patients with breast cancer can be critiqued for not documenting the basis of the guideline's recommendations. Evidence from a well-designed randomized clinical trial indicated that outcomes for women with breast cancer were similar whether follow-up care was provided by a general practice doctor or a specialist surgeon, but the ASCO guideline reinforced the ASCO board's policy that all patients with cancer have the right to see a cancer specialist at all times (Grunfeld et al., 1996). In this case, group opinion and a desire to be consistent with ASCO policy took precedence over the available literature in framing the recommendation, but the guideline does not make this explicit.

The guideline process is a dynamic one, which must incorporate new information as it becomes available. New evidence from the largest clinical trial on follow-up care for individuals with colorectal cancer will, for example, have to be considered as available guidelines are revised. The current NCCN guidelines, for example, recommend annual chest x-ray, annual colonoscopy, and regular computed axial tomography scans, all strategies that do not improve survival according to new evidence (Schoemaker et al., 1998).

How successful guidelines are in informing and changing practice depends in large part on how they are developed, disseminated, and implemented. Personal involvement in the process of change encourages adherence, and evidence suggests that physicians are more likely to ascribe

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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credibility to information from sources they know and respect (U.S. Congress, 1994). Guidelines with greatest likelihood of success include those with internal development, specific educational intervention, patient-specific reminders at the time of consultation, and a system to hold the provider accountable for adherence (Table 6.5) (Grimshaw and Russell, 1993; Smith and Hillner, 1998). Guidelines that have a lower chance of success are those issued by a national group with no ties to local practitioners, those that rely on publication in a journal to disseminate findings, and those that limit implementation to general reminders about the recommendations. In general, changes in practice are more likely if implementation efforts are more active and intensive, if they involve multiple-rather than single-pronged approaches, and if the efforts are tailored to the specific context and problems addressed by a particular guideline (U.S. Congress, 1994). Clear benchmarks, or targets, for good practice are needed to implement and evaluate guidelines (Schoenbaum et al., 1995).

Some clinical practices are more amenable to change than others. Cancer screening practices, for example, can be increased by using computer and manual reminders, as well as a variety of other administrative mechanisms. Guidelines for the use of x-rays, blood tests, and pharmaceuticals have also been implemented successfully. Interventions to change practice have been less successful for more complex clinical decisions, such as choosing between medical and surgical treatments or managing complex medical problems (U.S. Congress, 1994).

TABLE 6.5

Framework for Analysis of Clinical Practice Guideline Success

Likelihood of Success

Development

Dissemination

Implementation

Accountability

High

Internal

Specific educational intervention

Patient-specific reminder at time of encounter

Practice monitored, feedback given

Above average

Intermediate

Continuing education

Patient-specific feedback

Practice monitored

Below average

External/local

Mailing targeted groups

General feedback

None

Low

National/external

Publication in journal

General feedback

None

 

SOURCE: Grimshaw and Russell, 1993, modified by Smith and Hillner, 1998.

What Evidence is There That Cancer Practice Guidelines Have Been Successful?

There have been a modest number of successful clinical practice guideline efforts, as well as a number of documented failures. In some areas, improvements in guideline compliance have been demonstrated, but often the improvement in practice has not been substantial.

The Community Hospital Oncology Program. The Community Hospital Oncology Program (CHOP) represents an early attempt to improve oncology by disseminating locally developed practice guidelines. From 1982 to 1984, 17 CHOP programs located throughout the country im-

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
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plemented site-specific guidelines for staging, medical management, nursing, and rehabilitation. Community practice for breast, rectal, and small-cell lung cancer was evaluated in 1985-1986 after the program had been fully implemented. There was no evidence of diffusion of guideline principles to the majority of practicing physicians, even those who were involved in their development (Table 6.6).

TABLE 6.6

Conformance to Accepted Standards of Care

Cancer

Standard (%)

Conformance (%)

Breast

Clinical staging

100

33

Medical oncology consultation if node-positive

100

73

Radiation oncology consultation

100

27

Rectal

Staging

100

67

Radiation therapy consultation

100

27

Small-Cell Lung Cancer

Radiation oncology consultation

100

50

 

SOURCE: Ford et al., 1987.

Some CHOPs developed more intense programs to encourage compliance that included tumor boards, educational efforts, peer pressure, and administrative action. The CHOPs that were able to ensure staging did so by requiring completion of forms before specimens were submitted to pathology or denying privileges if forms were not completed. 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, 1996).

ASCO Guideline on Use of Hematopoietic Growth Factors. Hematopoietic growth factors are effective when administered to prevent or treat neutropenia (an abnormally small number of a type of blood cell), which may occur following chemotherapy, but they do not improve outcomes for those with febrile neutropenia (fever associated with neutropenia). The growth factors are expensive to use ($200 to $300 per dose), but there is little harm to patients if they are administered inappropriately. Their administration can be a significant source of income to a physician. Guidelines issued by ASCO in 1994 on the use of hematopoietic growth factors led to some reduction in their inappropriate use, but serious overuse of these substances persisted. This finding was based on physicians' self-reported use of hematopoietic growth factors on surveys conducted before, and shortly after, the 1994 guideline was issued and again following the publication of a guideline update in 1996. Response rates to the surveys were roughly 60 percent. Inappropriate

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

use of hematopoietic growth factors was sharply reduced in one managed care organization by the institution of a simple accountability system. Before administering growth factors, physicians had to call the administrator and report the indication for its use (J.E. Katterhagen, personal communication to Thomas Smith, 1998).

AHCPR Cancer Pain Management Guidelines. Recent studies suggest that as many as one in four cancer patients is given inadequate pain relief (Rischer and Childress, 1996). Adherence to the 1994 AHCPR guideline on cancer pain management, following its widespread dissemination, was assessed in seven acute care hospitals in Utah in 1995 and again in 1996 (Rischer and Childress, 1996). On most process measures, care improved, but outcomes (e.g., pain scores) were not assessed (Table 6.7). A limitation of this study is the absence of a concurrent control group that was not exposed to the guideline dissemination intervention. Without such a group, one cannot attribute improvements to the guidelines. The program to improve pain management according to the AHCPR guideline has been implemented throughout Utah.

TABLE 6.7

Compliance with Core Guidelines

Guideline

Prea

Postb

p Value

Opioids Prescribed

99

100

1.000

Initial Pain Assessment

Rating Scale Used

64

79

.090

Ongoing Pain Assessment

Pain rating scale repeated at regular intervals

27

74

<.001

Efficacy reported

83

97

.011

Analgesic Use

Pain medicines on regular schedule

70

91

.003

Bowel Treatment Plan

Laxatives ordered

66

69

.857

Education of Family or Patient

Education about cancer pain

6

34

<.001

Written education

16

26

.238

Patient Satisfaction Evaluated (not actual patient satisfaction)

24

97

<.001

NOTE: Ten patients were assessed at each of seven hospitals; n = 70.

a Pre = before guideline was issued.

b Post = after guideline was issued.

SOURCE: Rischer and Childress, 1996.

American Urologic Association Early Prostate Cancer Guideline. The American Urologic Association recommended in 1995 that patients with localized prostate cancer be offered surgery, radiation, or surveillance as treatment options. To assess compliance with the guideline in the

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

military health system (i.e., those covered by CHAMPUS), men who had received radical prostatectomy before and after the guideline was published were asked in a survey to report whether or not they had been offered treatment options. The guideline was mailed to each practitioner within the system. The average number of treatments offered increased following publication of the guideline (Thompson et al., 1995). A limitation of this study is that it included only men undergoing radical prostatectomy, not all men with prostate cancer.

Evidence on The Impact of Guidelines in Canada and Europe

Canada. 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 68 percent received tamoxifen when indicated (Olivotto, 1997). Adherence to guidelines was higher at cancer centers than among community oncologists. Improvements in disease-free and overall survival coincided with implementation of the guidelines, but other factors such as the regionalization of cancer care services and the presence of strong opinion leaders may account for good outcomes.

Italy. In an effort to improve community-based cancer care in Italy, guidelines on the treatment of breast, colorectal, and ovarian cancer were sent to practitioners in 1977. The effects of the educational program were evaluated in 1987 (Grilli et al., 1991). The familiarity of practitioners with the breast cancer guidelines was poor: roughly one-half knew of the breast cancer guideline, one-third knew of the colon cancer guidelines, and one-quarter knew of the ovarian cancer guidelines (estimates are weighted averages of respondents to a survey of providers). Compliance with the recommendations of the guidelines was poor in several areas as shown by chart audit. For women with breast cancer, for example, only 37 percent had full staging, and only 61 percent had a bilateral mammogram at the time of surgery (Table 6.8). Better compliance was observed among physicians with high-volume practices. The authors note that the results were "disappointing" and that efforts to improve cancer care with a "guidelines diffusion" approach appear to have had a negligible effect on cancer treatment.

France. Cancer care guidelines developed and disseminated through a regional cancer center in Lyon, France, appear to have succeeded in improving cancer care. Guidelines on breast and colon cancer were developed by a task force in 1993 and then reviewed by all practitioners in the region. In 1994, the guidelines were widely available via different media—paper, computer disk, and on-line at the cancer center. A comparison of randomly selected patients with breast and colon cancer treated in 1993 and 1995 showed marked improvements in care. From 1993 to 1995, adherence to the recommended overall treatment sequence increased from 19 to 54 percent for breast cancer and from 50 to 70 percent for colon cancer (Table 6.9). The guidelines were reviewed again in 1995 and disseminated to a wider network of hospitals and providers through continuing education meetings and mailed reminders to physicians. Compliance measured from 1994 to 1996 also improved (Ray-Coquard et al., 1998). The success of the guideline program was attributed in part to the local development of the guidelines, their wide dissemination, and

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

the reliance on peer pressure to change practice behavior (Ray-Coquard et al., 1997). The studies lacked a concurrent control group that was not exposed to the guideline intervention, so it is unclear whether improvements were due to the guideline program or to a generally increased awareness in the medical community.

Scotland. As part of its national health plan, Scotland has initiated comprehensive efforts to improve cancer care. On a national basis, it has limited reimbursement for cancer services to practitioners who agree to use evidence-based guidelines and submit their results to external scrutiny. Full results of the first three years of this program will be available in 1999 (Smith et al., 1998).

Effects of Local Guideline Implementation on Costs

Whether implementing guidelines increases or decreases costs depends on the medical interventions involved. Guidelines aimed at currently overused services will likely reduce some spending, whereas those aimed at underused services could increase spending. Some guidelines might shift spending from inappropriate to more appropriate care, leading to better value but not necessarily lower costs (IOM, 1992). Although the intention of guidelines is usually to improve care, an added benefit may be increased efficiency and cost savings. There are several anecdotal accounts of cost savings associated with local implementation of practice guidelines, often with attendant improvements in care:

  • Implementing surgical care guidelines for patients with gynecologic cancer in one surgical practice improved clinical outcomes, decreased hospital length of stay, decreased costs, and kept patient satisfaction high. A team approach to guideline development and accountability systems accounted for the program's success (Morris et al., 1997).
  • Implementing surgical care guidelines for patients undergoing radical prostatectomy in hospital practice decreased length of stay, while maintaining high scores on patient satisfaction and quality of life (Litwin et al., 1996).
  • Implementing clinical pathways and treatment protocols in one cancer group practice led to greater efficiency (increases in number of patient encounters, decreases in costs) and increased participation in clinical research (Feinberg and Feinberg, 1998).
  • Implementing a clinical practice guideline for endoscopic sinus surgery at an academic medical center led to improved short-term outcomes (i.e., fewer unplanned admissions) and lower costs (Stewart et al., 1997).
  • 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, 1997).

In summary, several organizations have developed oncology practice guidelines to promote treatment that conforms to the best medical evidence available. Guidelines for many aspects of cancer care are not available, in part because the evidence base upon which to judge best practice does not exist. The oncology guidelines that have been put into practice have not been uniformly successful in changing physician behavior or clinical outcomes. Aspects of guideline development and

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

implementation affect success, and the most successful guidelines are those with internal development, specific educational interventions, patient-specific reminders at the time of consultation, and a system to hold providers accountable for adherence. Studies of the impact of oncology guidelines have often not included a concurrent control group that was not exposed to the guideline intervention, which makes it difficult to attribute change to guideline implementation.

TABLE 6.8

Compliance with National Guidelines in Italy as Measured by Chart Audit, 1987

Recommendation

Compliance (%)

Breast Cancer

Gold standard: 100%

Bilateral mammography

61

Clinical stage

37

Pathological stage

60

Evaluation of axillary lymph nodes

89

Avoidance of radical mastectomy if T < 2.0 cm

84

Radiotherapy after quadrantectomy

65

Adjuvant chemotherapy started at <4 weeks

52

Polychemotherapy if <50, + lymph nodes

71

Chemotherapy delivered at full dosage

86

Colon Cancer

CEA levels and liver ultrasound

40

TNM staging

78

Search for intra-abdominal metastasis

67

Information on resection borders

48

Evaluation of regional lymph nodes

66

Miles resection in lower rectal cancer

68

Radiotherapy in rectal and rectosigmoid cancer

11

No adjuvant chemotherapy in colon cancer

79

If chemotherapy, 5-FU-containing regimen

90

Ovarian Cancer

Full information on tumor grading

30

Staging including abdominal echography

75

Histologic type according to standard classifications

89

Chest x-ray

97

Evaluation of residual tumor

45

Disease stage according to standard classification

85

Alkylating agent as part of chemotherapy for early disease

18

Cisplatin-containing regimens for advanced disease

34

Monitoring of toxicity while on chemotherapy

91

Monitoring of nephrotoxicity while on chemotherapy

84

NOTE: CEA = carcinoembryonic antigen; 5-FU = 5-fluorouracil; TNM = tumor-node-mestastasis.

SOURCE: Grilli et al., 1991.

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

TABLE 6.9

Compliance Rates of Medical Decisions with Guidelines, Lyon, France

 

Compliant with Clinical Practice Guidelines (%)

Type of Procedure

1993

1995

p Value

Breast Cancer

Initial evaluation

75

86

.09

Surgery

96

92

.26

Chemotherapy

71

85

.01

Radiotherapy

72

93

<.001

Hormonal therapy

83

94

.01

Follow-up

31

80

<.001

Overall treatment sequence

19

54

<.001

Colon Cancer

Initial evaluation

100

100

 

Surgery

100

99

.56

Chemotherapy

56

78

.02

Follow-up

62

54

.69

Overall treatment sequence

50

70

.009

 

SOURCE: Ray-Coquard et al., 1998.

Key Findings

Information about quality cancer care is becoming more available to individuals with cancer (or at risk for cancer), but it is not yet easily accessible to or understandable for consumers. A number of potential quality indicators can be listed, but most have not been evaluated to assess their ultimate value to consumers. It is unclear, for example, how the following indicators affect an individual's experience of care or health care outcomes:

  • a physician's board certification,
  • a hospital's approval status determined by the American College of Surgeons' Commission on Cancer, and
  • a health plan's accreditation status and HEDIS scores.

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. Individuals may use available quality indicators to choose doctors and hospitals within their plans, and perhaps to choose alternative courses of treatment, but evidence suggests that individual consumers can exert only a modest market pressure for quality improvement through access to better information about the quality of cancer care.

Quality assurance systems are often not apparent to consumers, but they have the potential to greatly affect care. Some large employer groups are beginning to hold health plans to

Suggested Citation:"6 Cancer Care Quality Assurance." Institute of Medicine. 1999. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press. doi: 10.17226/6467.
×

quality performance goals. HCFA is requiring health plans, hospitals, and other providers to produce standardized quality reports, and state Medicaid programs are beginning to include quality provisions in their contracts with providers. The development of better standards and performance measures for cancer care could provide a way for large employers or groups of purchasers to exert influence on the quality of cancer and other health care.

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. The experience with oncology practice guidelines has been mixed, with some examples of success but others of ineffectiveness in changing provider behavior or outcomes. Many guideline efforts have failed because of limitations in the way they were developed or implemented.

There are numerous health care accountability systems in place, but they fail to constitute a coordinated system for ensuring quality health care in general, and they do not yet embody a comprehensive, organized effort for cancer care. Given the diversity of the U.S. health care system, such fragmentation is not unexpected, but it could be remedied through a combination of public regulation and cooperation between public-and private-sector purchasers of care. Although much of the impetus for quality accountability has come from the private and professional sectors, government-sponsored programs have promoted public health accountability by maintaining cancer surveillance systems and monitoring the use of cancer screening tests among the U.S. population. The elderly are disproportionately affected by cancer, and cancer care quality indicators have in some areas been integrated into programs designed to ensure appropriate treatment for Medicare beneficiaries. The Agency for Health Care Policy and Research has assumed an important convening role in tracking clinical practice guidelines and supporting the basic health services research needed to form the basis of future guidelines.

Comprehensive improvements in health care quality and in the ability of consumers to make health care decisions that are fully informed on the basis of quality will likely occur only through collaborative efforts of the public and private sectors (President's Advisory Commission, 1998). As large health care purchasers, both sectors have a stake in improving the quality of care, and both sectors have knowledge and experience concerning quality measurement and reporting. Each sector has unique strengths. Private-sector organizations have the capacity to act quickly in response to rapid changes in the health care system. The public sector can provide established channels and safeguards to ensure representative action and open proceedings. Such an approach has recently been recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and some initial steps have being taken to implement a public-private collaborative effort (President's Advisory Commission, 1998). A concerted public-private collaboration on the development and reporting of performance standards for cancer and other care could provide a framework for changing incentives in the system so that they aim at publicly accountable measures of quality.

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Ensuring Quality Cancer Care Get This Book
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We all want to believe that when people get cancer, they will receive medical care of the highest quality. Even as new scientific breakthroughs are announced, though, many cancer patients may be getting the wrong care, too little care, or too much care, in the form of unnecessary procedures.

How close is American medicine to the ideal of quality cancer care for every person with cancer? Ensuring Quality Cancer Care provides a comprehensive picture of how cancer care is delivered in our nation, from early detection to end-of-life issues. The National Cancer Policy Board defines quality care and recommends how to monitor, measure, and extend quality care to all people with cancer. Approaches to accountability in health care are reviewed.

What keeps people from getting care? The book explains how lack of medical coverage, social and economic status, patient beliefs, physician decision-making, and other factors can stand between the patient and the best possible care. The board explores how cancer care is shaped by the current focus on evidence-based medicine, the widespread adoption of managed care, where services are provided, and who provides care. Specific shortfalls in the care of breast and prostate cancer are identified. A status report on health services research is included.

Ensuring Quality Cancer Care offers wide-ranging data and information in clear context. As the baby boomers approach the years when most cancer occurs, this timely volume will be of special interest to health policy makers, public and private healthcare purchasers, medical professionals, patient advocates, researchers, and people with cancer.

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