NcXHF

LAWRENCE N. SHULMAN
data can be very accurate and other aspects of care and
follow-up well delineated in structured data fıelds. Data often
are entered with some lag time—sometimes 6 to 12 months
after the event. Although anatomic staging may be complete
and accurate, nonanatomic staging, particularly biomarkers, are
not always recorded. Estrogen receptor and HER2 data are
routinely collected for breast cancers, but newer markers
such as KRAS, BRAF, or EGFR kinase mutations frequently
are not. These factors are becoming increasingly important
for their prognostic value and for determining correct therapy
choices. In addition, entries may indicate that systemic
therapy was administered, yet the specifıcs of that therapy
often are not given. It may be known that the patient received
chemotherapy but not which chemotherapy. Also, when systemic
therapy or radiation therapy is administered at practices
outside of the registry’s hospital, data are not always
available to enter into the registry. Comparing data in registries
against claims data has demonstrated this point. 11
Currently, databases such as registries and EHRs do not
communicate well, requiring dual entry of data that is costly
and increases risk of data entry errors. Efforts are underway
to better link EHRs and registries to overcome some of these
challenges, increasing both accuracy and reducing workload.
ASCO’S QUALITY ONCOLOGY PRACTICE INITIATIVE
A decade ago, ASCO undertook an experiment to defıne
quality measures in oncology practices and invited practices
to voluntarily participate. 3 Initially, there was little incentive
to participate, but many practices chose to do so. In the following
years, many quality measures were added to the QOPI
slate and more practices chose to participate. Quality was assessed
by manual chart abstraction on a subset of patients
with a particular disease, stage, or situation. Practice compliance
with the measure was assessed and compared to other
QOPI practices. Later, a certifıcation program was introduced
that involved a site visit that not only assessed compliance
with quality measures but also adherence to ASCO/
ONS safety standards.
Practices voluntarily participated, largely because they
thought it was the right thing to do. In some circumstances,
however, additional benefıt was established, as in the case of a
partnership between Blue Cross Blue Shield (BCBS) of Michigan
and the Michigan Oncology Quality Consortium. 12
Practices were able to show substantial improvement in quality
metrics and fınancial rewards for participating were established
between the practices and Blue Cross Blue Shield.
The major disadvantage of the QOPI program is its reliance
on manual chart abstraction of a small sample of patients.
Work is underway to transition QOPI to an electronic
abstraction process (eQOPI), which would be a major advance
and benefıt.
THE COMMISSION ON CANCER QUALITY PROGRAM
The CoC is an arm of the American College of Surgeons that
accredits hospital cancer programs. 13 Currently, more than
1,500 hospitals in the United States are accredited. Accredited
hospitals transfer their registry data into a de-identifıed
database, the NCDB, which is cosupported by CoC and the
American Cancer Society. Accredited hospitals can enter a
portal to view their performance against many quality measures
and compare them with other CoC-accredited hospitals.
In addition, an annual report is produced for each accredited
hospital—The Cancer Quality Improvement Program (CQIP).
The CQIP contains the hospital’s performance for 12 quality
measures (in the 2014 report), 30- and 90-day postoperative
mortality for six complex cancer surgeries (thoracotomy,
esophagectomy, cystectomy, gastrectomy, rectal cancer resection,
and pancreatectomy), and survival data for several more
common cancers.
A major advantage of the NCDB quality program is that
manual chart abstraction is not necessary. Quality data are
derived electronically from the database for all patients who
have cancer with a particular diagnosis and stage. It should be
noted, however, that the NCDB is registry-derived data and
registry data are manually entered by registrars. An individual
hospital’s data can be compared against all other CoCaccredited
hospitals, or just hospitals in their region, or
hospitals of similar type (e.g., community vs. academic cancer
center). Disadvantages include registry data that are often
1 to 2 years old before completely entered into the database.
Furthermore, not all desired data are housed in the NCDB.
Programs such as the CoC’s Rapid Quality Reporting System
are driving more timely entry of registry data to affect quality
of ongoing care.” 13 Specifıcally, there is little granular data on
specifıc systemic therapies administered and disease-free
survival and cancer-related mortality data often are not there.
Measures must be designed around what data are available in
the NCDB.
COST OF DOING CANCER CARE QUALITY
A hospital or practice that addresses quality measures seriously
has a team of individuals undertaking this work. This
group often includes physicians, nurses, and individuals who
manage the databases, data extraction, and analyses. Participation
in the quality programs described above also carry a
cost. The exact costs of doing cancer-quality work likely vary
greatly among institutions and practices depending on size,
databases available to be queried, and other factors. Currently,
with few exceptions, practices and hospitals do not
gain fınancially by participating in quality programs in a degree
suffıcient to offset these costs. In the future, reimbursement
for clinical services hopefully will be more closely
linked to performance and quality.
FUTURE DIRECTIONS
Our profession has an obligation to measure the quality of
our work and to continually strive to improve our practice.
This will become even more important as new biomarkers
and therapies become available in cancer care and treatment
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