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Determining what to measure, and how best to measure it, can be surprisingly complex-and appropriate metrics can vary between cancer types and patient populations.
The rates at which cancer patients receive recommended care vary between cancer centers, contributing to avoidable disparities in patient outcomes. Cancer care quality metrics are under ongoing development and refinement to better measure and compare the quality of care at different cancer centers, and to identify and correct problems in a timely manner.
However, determining what to measure, and how best to measure it, can be surprisingly complex-and appropriate metrics can vary between cancer types and patient populations.
During the American Society of Clinical Oncology (ASCO) 2016 Annual Meeting in Chicago, attendees heard more about metrics for assessing quality of cancer care during the June 5 session, “Defining and Measuring Quality.”
HassettSession presenter Michael Hassett, MD, MPH, a physician at Dana-Farber Cancer Institute and assistant professor, Medicine, Harvard Medical School, recently spoke with Managed Healthcare Executive (MHE) about the top challenges associated with developing appropriate quality metrics.
MHE: You have been closely involved in cancer care quality and the promulgation of cancer care-quality metrics. What are the most important challenges in measuring quality of cancer care today?
Hassett: I think that the first challenge I would highlight is deciding what exactly we want to measure. There is a lot of stuff that we can measure, and the resources we have to measure those things are unlimited. Trying to figure out where our focus should be is tricky. There are a lot of efforts underway to come up with measures, put together by professional societies like ASTRO [the American Society for Radiation Oncology] and ASCO and efforts to correlate measures by organizations like AHRQ [the U.S. Agency for Healthcare Research and Quality]. But we’re still facing some difficult choices about what we want to measure.
The second challenge is to really understand why we’re measuring something-what is the purpose of that measurement. That seems simple but I think there are different reasons why we want to measure quality.
Let me give you an example: a hospital may be very interested in doing a quality-improvement program. And that quality-improvement program is designed to get from one level of quality performance to another level. Then the healthcare system as a whole may be interested in reducing disparities in healthcare-trying to reduce the likelihood that a particular sociodemographic group is less likely to receive a recommended treatment than other groups.
The way that you measure, and the priorities that you set, really influence the choices that are made at those organizations. I think we want to be clear about how and why we’re using particular measures.
The third one is the technical challenge of making sure we have the data that we need to really assess quality of care.
So it comes down to choosing what to measure, figuring out why we are measuring it, and then getting the data we need to measure.
MHE: Is the expansion of electronic health records (EHRs) and meaningful use under the Affordable Care Act, creating new opportunities to do that-to get the data needed for measuring quality?
Hassett: Yes, but-certainly, having more data in the electronic record is helpful. But I think we have to be wide-eyed in the way that we look at those data. Information that goes into the medical record or information that’s used for billing claims purposes, those pieces of information are the information that are most commonly used to evaluate quality.
But they weren’t collected to measure quality. They were collected to pay a bill or to provide clinical care. So we have to be cognizant of some of the limitations of what they can provide. They may be incomplete; they may be entered through nonstandardized mechanisms such that one doctor may enter data one way, and another, another way.
Having online records is great and helps you get data and increases data capture. But there are still things that aren’t present in medical records. There’s a lot we’d like to measure that we don’t capture as our routine practice of medicine. I think if we really want to measure these things, then we have to think about how to do a better job of capturing that kind of information.
MHE: What is an example of something you’d like to measure but that isn’t captured in EHRs?
Hassett: I think the best example I can give is patient-reported outcomes. Those are not captured for claims. They are not captured in most routine medical records. But if we want to evaluate patient-reported outcomes as part of our quality-assessment efforts, how do we go about doing that?
MHE: How is ASCO trying to advance or promulgate quality-of-cancer-care measures?
Hassett: I’m part of the ASCO efforts. ASCO has a Quality of Care Committee that oversees a number of projects in the quality space. Under that committee is a measures workgroup, and QOPI-the Quality Oncology Practice Initiative.
The Quality of Care Committee has a series of sub-workgroups to tackle different issues in breast cancer, and overuse, and colorectal cancer-a variety of different teams are working on quality measures development for ASCO.
The QOPI program identifies measures and asks individual physician practices to review their patient care to determine if they’re providing care with those recommendations, or not. That information is reported back to ASCO on a regular basis. Some sites can petition for accreditation through that program if they meet certain standards of practice performance.
There has also been a fair amount of interest in establishing collaborative efforts across different professional societies, to develop quality measures. ASCO and ASTRO have done some of this work, and the NCCN [National Comprehensive Cancer Network] has been involved as well, where groups get together to promulgate quality measures as a group overall.
The new wave or push on the ASCO side is an informatics push. They have a program called CancerLINQ to try to bring together available health information to measure quality and improve care.
There are also efforts to develop what are affectionately termed “e-measures” or electronic measures that can be applied to CancerLINQ or similar large databases.
MHE: Are quality measures specific to different cancer types?
Hassett: Some quality measures are unique to a type of cancer and some cut across cancer types. For example, breast cancer is sometimes treated with a medication that blocks estrogen, and there are measures regarding administration of estrogen-blocking treatment. But not all cancers are responsive to that hormone, so we don’t include that measure in cancers like lung cancer.
Contrast that to recommendations about the use of anti-nausea medications for patients receiving chemotherapy. It doesn’t matter if they have breast, or lung, or colorectal cancer.
So we should have cross-cutting measures such as that, and then cancer-specific measures.
MHE: How can quality metrics help manage cancer care costs?
Hassett: There is certainly a lot of interest in this space. The simplest way is using “overuse” measures. Historically, measures were developed to address underuse of recommended treatments, such as hormones in breast cancer: of all the patients with this type of cancer, what proportion get the recommended treatment? That is where most quality measures have been, historically.
But we’re now starting to develop overuse measures for people who should not be getting a treatment. For example, ASCO has participated in the Choosing Wisely campaign, with the goal of identifying treatments that are widely regarded as unnecessary. ASCO identified a set of treatments that are generally not recommended. ASCO has identified 10 such practices so far. They’re straightforward things; for example, in people who have just been diagnosed with early breast cancer or prostate cancer at low risk of metastasis, we do not recommend full-body [PET or radionuclide bone] scans because the chances of detecting something in those scans is just very low. ASCO recommends against doing these high-cost exams because we don’t think they are necessary.
MHE: How big a factor is patient health insurance in achieving quality-of-cancer-care goals?
Hassett: That’s a great question and the answer is complicated. I think the first way health insurance plays a role is by providing access to care. We know from many years of analysis that patients who are socioeconomically disadvantaged and do not have healthcare coverage are much less likely to receive recommended care when they are diagnosed with cancer. And they are much more likely to be diagnosed at a later stage, with more advanced cancers. Those are critical problems for our healthcare system. The patients who have health insurance, in general, have access to services.
There is some concern still-questions are being asked about what role the insurers should be playing in measuring quality of care and limiting access to costly treatments. Sometimes health insurers limit access to treatments they see as costly. That can be a good thing for reducing costs. But it can also introduce more barriers to the healthcare system and make it harder for patients to receive care. Prior authorization is one example. I sometimes have to get authorization from an insurer before I can get a patient on an expensive medication.
MHE: What does the future hold for measuring quality in cancer care?
Hassett: Our ability to measure quality of care is growing and having more information is a huge help. I think the potential is huge. The more we measure, the better we understand-and the better job we can do for our patients. But we can’t rely just on electronic health records.
The other piece of this is what roles do different people have in the process of measuring quality? We talked about the fact that electronic health records can only do so much for us. But if we believe that measuring quality is important, that there are things that we want to measure, but that we can’t measure with the information that’s currently available-then, who is responsible for making that happen? Who is in charge of that process?
Is it the managed healthcare organization? Is it their job to say, we want to collect patient-reported outcomes?
We should look to national organizations like ASCO and ASTRO to try to develop what standards we want, and then we should look to physician organizations and managed care networks to implement those standards. We don’t want every practice going their own way because it becomes very difficult to compare outcomes if every health system chooses a different measure of, say, patient-reported outcomes.
The whole purpose of quality metrics is comparing outcomes. ASTRO and ASCO can define the standards, and healthcare providers can implement those standards.
Selecting measures is a process that ideally happens in a more centralized way, and implementation, more locally. There are exceptions to that, though. There are also situations where a given hospital just wants to know how they are doing over time. In that case, there’s a stronger case for hospitals playing a bigger role in developing measures because hospitals know where their weaknesses are in a way the national organizations may not.
Having a set of measures to compare hospitals is important but giving hospitals the flexibility and mandate to look into their own structures to find where the problems exist, is also important.