Transcript Clinic Session Assignment and Requests

The Quality Oncology Practice Initiative:
Oncologist Self-Assessment and Improvement
• Disclosures: None
• Outline
• Why measure
• What is quality in oncology
• The ASCO QOPI process
• What difference does it make?
• How do we include patient
reported outcomes?
• How do we adjust for comorbidities?
• How do we consider financial issues?
• Summary: Goldilocks was right
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The Hawthorne Effect: 1924-27
• Sponsored by
• National Academy of Sciences
• Western Electric
• Varied
• Room illumination
• Room temperature
• Breaks and work hours
• Piecework payment
• The measured production of telephone
• relays got better no matter what was
• done to work conditions
F. Roethlisberger, W. Dickson and H. Wright Management and the worker: An account of a research program conducted by
the Western Electric Company Harvard university press Cambridge, MA 1939
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What is Quality Medical Care?
•
American Medical Association: Care which encompasses 8
elements and in doing so contributes to improved outcomes,
including affording improvement in the patients health, (2)
emphasizing promotion o f health and prevention of disease
(3) occur in a timely manner, (4) involve the patient in
decisions and execution, (5) be based on accepted principles
of medical science (6) be sensitive to the patient’s welfare (7)
use technology efficiently and (8) be sufficiently documented
to allow continuity of care
(Council on Medical Service: Quality of care. JAMA
1986;256:1032-1034)
•
Institute of Medicine: “The degree to which health services
for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge”
(Crossing the Quality Chasm, 1996)
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Evaluating the Quality of Medical Care
Avedis Donabedian
• Organizational structure
• Process measures
• Outcome
– Function
• Life
Prominent consideration of cost and “optimality”
defined as “The balancing of improvements in health
against the cost of such improvements.”
Donabedian, A, Evaluating the quality of medical care The Milbank Memorial Fund Quarterly, Vol. 44, (pp. 166–203) 1966
Donabedian A, Bashshur RL An introduction to Quality Assurance in Health Care Oxford University Press, NY, NY 2003
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Institute of Medicine, 1999
• Ensure that patients are treated in
appropriate venues
• Use guidelines for prevention, diagnosis,
treatment and palliative care
• Measure and monitor the quality of care
using a core set of quality measures
• Initial treatment plans should provide
coordinated care with access to
psychosocial support, clinical trials, and
occur with the patients full consent after
honest and full disclosure
• Care at the end of life must be of include
access to palliative and hospice care
Simone J and Hewitt M Ensuring Quality Cancer Care Institute of Medicine, Washington DC 1999
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Quality Oncology Practice Initiative (QOPI)
Founder: Joseph Simone, MD
• Retired Pediatric Oncologist,
former Director of St. Jude’s
Hospital
• Previous Co-chair of the IOM
National Cancer Policy Board
• 2002: “Unless one engages
practicing physicians in the basic
structure, quality will never
become part of the fabric of
practice, the only route to a
sustainable quality effort”
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• Sponsored by
• American Society of Clinical Oncology
• Participating Practices
• Available since 2006
• Practice self reporting, twice annually, web based data
report and secure HIPAA compliant storage and process
• About 20% of US oncology practices regularly participate
• Self examination and improvement, payment premium
M. N. Neuss, C. E. Desch, K. K. McNiff, P. D. Eisenberg, D. H. Gesme, J. O. Jacobson, M. Jahanzeb, J. J. Padberg, J. M. Rainey, J. J. Guo and J. V. Simone A
Process for Measuring the Quality of Cancer Care: The Quality Oncology Practice Initiative: Journal of Clinical Oncology: 23: 6233-6239 2005
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Evolution of QOPI
®
QOPI Certification
Program Launched
(2010)
QOPI offered to full
ASCO membership
(2006)
Measure and content
expansion
(2006-2010)
Joseph Simone, MD
QOPI Pilot Phase
(2002-2005)
Expansion and
design changes
(2013-2015)
“Unless one engages practicing physicians
in the basic structure, quality will never
become part of the fabric of practice…
Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
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Full-time equivalent (FTE) Medical Oncologists
Medical Oncologist
14,000
12,000
10,000
8,000
QOPI Certification
6,000
4,000
2,000
QOPI Participation
QOPI Total Registration
0
Last
Update
11/10/14
Copyright © 2013 American Society of Clinical Oncology. All rights reserved.
9
Quality Oncology Practice Initiative (QOPI)
• Measures
• Five measure criteria
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–
–
–
–
(1)
(2)
(3)
(4)
(5)
applicable to ambulatory oncology practices
intuitively collected
based on chart abstraction
amenable to improvement
relevant and important to care
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Comprehensive library of reliable
and tested measures…
Measures are selected and adapted
by practicing oncologists
Test &
Implementation
More than 160 measures in
use and maintained
Guidelines
1. Evidence-based
2. Consensus
Specification for
Collection [QOPI]
Indicator
Development
Prioritization for
Measure
Development
Ongoing efforts include:
– Radiation Oncology
– Prostate Cancer
– Palliative Care
– Patient Reported
Outcomes
Copyright © 2013 American Society of Clinical Oncology. All rights reserved.
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What We Measure
Core
Measures
®
QOPI
• Care Documentation
• Chemo Administration
• Pain Management
• Smoking Cessation
• Psychological Support
• Breast Cancer
• Colorectal Cancer
• Non-Hodgkin’s
Lymphoma
Disease–
Specific
• Non-small cell Lung
Modules
Cancer
• Ovarian, fallopian tube,
primary peritoneal
(gynonc)
• End of Life Care
Domain–
• Symptom/Toxicity
Specific
Management
Modules
• Palliative Care (2015)
Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
12
Measures showing improvement
Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W.
Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States
JCO Apr 10, 2013:1471-1477; published online on March 11, 2013;
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Measures with very high baseline achievement
Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W.
Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States
JCO Apr 10, 2013:1471-1477; published online on March 11, 2013;
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Measures resistant to change despite gap
Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W.
Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States
JCO Apr 10, 2013:1471-1477; published online on March 11, 2013;
Vanderbilt-Ingram Cancer Center
Model of accounting for varied baseline
Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W.
Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States
JCO Apr 10, 2013:1471-1477; published online on March 11, 2013;
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Adequate node exam in colon cancer
Rate Concordant
Rate of 12 or more nodes examined by time
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0.99
0.97
0.97
0.97
0.96
0.96
1
0.9
0.72
0.8
0.67
0.7
0.61
0.6
0.5
0.4
0.3
0.2
0.1
0
Fall 2006 Spring 2007 Fall 2007 Spring 2008Fall 2008Spring 2009Fall 2009 Spring 2010 Fall 2010
Baseline from literature, 60%
Requires surgery to be correct and node exam to be correct
Medical oncology has little influence over process
Awareness that node recovery had room for improvement, 1990
Awareness that node recovery correlated with survival, 2003
QOPI measure, fall 2006
How long did this take? 3 years, or 20?
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Rate of change in medicine
• An average of about 17 years is required for
new knowledge generated by randomized
controlled trials to be incorporated into
practice, and even then application is highly
uneven
• 6 years from discovery to publication and
dissemination
• 9 further years to get to 50% acceptance
Balas EA and SA Boren Managing clinical knowledge for health care improvement, Yearbook of Medical
Informatics, National Library of Medicine, Bethesda 2000 pp65-70
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How can we facilitate improvement?
• Collaborative improvement networks
• Financial incentives through alternative
payment models
• Public reporting
• Larger acceptance
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Alternative payment models
• Take drugs out- Newcomer et al*
• Pay per bundled episode**
• Pay for populations, reward
efficient care ***
*Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode
Payment Model, Newcomer LN et al JOP Sep 1, 2014:322-326 (published online on July
8, 2014)
**Episode-based payment for cancer care: A proposed pilot for Medicare, Bach PB et
al, Health Affairs 30.3 (2011): 500-509.
***Data-Driven Transformation to an Oncology Patient–Centered Medical Home, Sprandio
JD et al JOP May 1, 2013:130-132.
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What else should we measure?
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Comorbidity adjustment
Patient reported outcomes
Financial factors and value
Real outcomes
– Survival
– Functional days
– ? Survivor’s experience
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Important Issues to Consider
1. Attribution of responsibility
2. Patient comorbidity and social circumstance
3. Randomness and infrequent events
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Patient reported outcomes
• Symptoms, quality of like and functional status
• Choose based on value/meaning to patient
• Standardize methodology, demonstrate
reproducibility, gather benchmark standards
• Examples– Pain
– Nausea
– Satisfaction with healthcare providers
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Value-Based Measures
• ASCO Board of Directors’ directive: priority is
development value-based measures
• Value measurement projects
– ASCO Top Five/Choosing Wisely 2013
• Top Five 2012 implemented in QOPI
– Expanding PQRS Measures
– Policy-led project with Insurers
How do we approach value measurement?
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Total cost of care
Parenteral drug costs per episode
No. of lines of therapy for relapsed patients
Costs in the last 30 days of life
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Diagnostic radiology use
Laboratory service use
Durable medical equipment use
Surgical services, use and cost
Febrile neutropenia occurrence rate
Granulocyte colony-stimulating factor usage rate
Erythropoetin use
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Emergency room and hospitalization rates
Admissions for cancer symptoms
Admissions for treatment-related symptoms
Time to first progression for relapsed patients
Hospice days for patients who died
Days from last chemotherapy to death
Survival from date of condition enrollment
Febrile neutropenia occurrence rate
Granulocyte colony-stimulating factor usage rate
Erythropoetin use
Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model
•Lee N. Newcomer, Bruce Gould, Ray D. Page,Sheila A. Donelan, and Monica Perkins
JOP Sep 1, 2014:322-326; published online on July 8, 2014
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How do we give the right care?
• Not too much, not too little?
– Guidelines, with good
definitions of adherence
– Personalized care
considered
– Appropriate benefit plans
to allow this care
– Appropriate access
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Thank You!
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