NcXHF

LAWRENCE N. SHULMAN
will never be eliminated altogether. All members of a team
must be free and willing to speak up when something seems
wrong, and each team member must respect and encourage
this approach. Hierarchical systems in which some team
members are viewed as subservient add considerably to system
vulnerabilities. An organizational structure that continually
assesses culture and processes, with clear leadership and
accountability, is essential in any cancer practice.
However, as important as safety is, it does not consider
quality of cancer care in regard to appropriateness of treatment
that is designed to provide optimal patient outcomes. It
is possible for a medical oncologist to order a regimen correctly,
to have it prepared and administered as intended with
optimal safety, but if it is not the ideal regimen for the patient’s
particular type of cancer, the patient outcome is likely
to be less than it might be.
KEY POINTS
Cancer care providers have an obligation to measure the
quality of their treatment to be certain they understand its
current state and can design interventions to continually
improve performance and patient outcomes.
Cancer care quality encompasses the safety of care
delivered, process measures assessing whether appropriate
treatments were administered, and outcome measures that
include survival and quality of life.
Cancer care is complex, provided by medical, radiation, and
surgical oncologists, and oncology nurses, with key support
from pathologists and radiologists, and spans in-patient and
out-patient venues, which makes quality assessment and
improvement challenging.
The Commission on Cancer’s Quality program using the
National Cancer Data Base and the American Society of
Clinical Oncology’s Quality Oncology Practice Initiative are
examples of broad-based national quality programs.
The use of health information technology will play a key
role in future measurement of cancer care quality.
PROCESS QUALITY
Much of current cancer care quality measurement is focused
on process measures. Based on a high level of evidence from
randomized clinical trials, a patient with stage III colon cancer
should receive adjuvant chemotherapy. Most quality
programs, however, only determine if the patient received
chemotherapy. They do not assess whether the patient received
the right chemotherapy, whether it was given in appropriate
doses and schedule, and they do not assess patient
toxicity, quality of life, or survival. There is an implication
that if the patient received chemotherapy in this circumstance,
appropriate therapy was given, and, by inference, outcomes
would be ideal. These are big assumptions.
Additionally, much of what oncology providers deal with on
a day-to-day basis involves decisions where no high-level evidence
exists, which narrows the number of important clinical
decisions that can be assessed for quality.
Process measures are used for many reasons. They can be
defıned, measured, and assessed on recently treated patients.
There is an assumption that receiving the right therapy will
result in optimal ultimate outcomes. This assumption, however,
can be variably defıned. Did the patient with stage III
colon cancer receive chemotherapy? Do we know what chemotherapy
he or she received? Do we know if dosing and
schedule was appropriate? Do we know if toxicities were
managed appropriately? Care processes can be evaluated on a
small random sample of patients or on all patients meeting
defıned criteria. ASCO’s QOPI assesses a random subset of
patients with a particular diagnosis and stage for appropriate
therapy. For example, patients who have stage III colon cancer
should receive adjuvant chemotherapy. 3 The Commission
on Cancer (CoC) uses the National Cancer Data Base
(NCDB), which will be described in more detail later in this article,
to assess all patients treated at a CoC-accredited hospital
for this same metric. 5 Process measures are most useful for a
practice or hospital when data from other practices and hospitals
are available to compare performance. This is true for both
the QOPI program and the CoC quality program. In neither
case, though, are the specifıc chemotherapeutic agents assessed,
nor are the appropriateness of dosing and schedule.
Process measures can assess the current state of practice for
a particular physician group or hospital. They also can be
used as a quality improvement tool if performance is suboptimal.
The QOPI program examined chemotherapy given
during the last 2 weeks of life as a quality metric for end-oflife
care. A group in Michigan realized that its rates of utilization
of chemotherapy during the last 2 weeks of life were
much higher than other QOPI programs. The group then designed
interventions to influence practice and their performance
quickly improved substantially. 6
Some process measures derived from very high-level evidence
represent relatively low bars to which excel. Both
QOPI and CoC examine hormone therapy rates for women
with certain stage, hormone receptor–positive breast cancer.
Most programs rate very high on this metric. As such, most
programs have little room for improvement and the measure
does not represent a good approach to comparing performance
across programs.
OUTCOMES MEASURES
Patient outcomes, such as overall survival, which takes into
account survival from the cancer as well as potential complications
of therapy, might be the ultimate quality metric. Survival
as a quality metric, however, presents many challenges.
Survival depends not only on the stage of disease, but also
on a number of related and unrelated factors. Gender and age
have profound effects on survival, and these data are always
available in databases for stratifıcation. Socioeconomic status,
ethnicity, performance status at presentation, comorbidities,
and distance from the patient’s home to his or her treating center
all affect survival rates, but not all of these factors may be
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