2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Measuring and Improving Value of Care in
Oncology Practices: ASCO Programs from
Quality Oncology Practice Initiative to the
Rapid Learning System
By Joseph O. Jacobson, MD, MSc, Michael N. Neuss, MD, and
Robert Hauser, PharmD, PhD
Overview: Rising cancer care costs are no longer sustainable.
Medical oncologists must focus on providing the
maximum value to their patients; improving short-term, intermediate
and long-term outcomes; and managing overall costs.
Accurate measurement of outcomes and overall cost is essential
to informing providers and institutions and in the quest for
continuous improvement in value. The ASCO Quality Oncology
Practice Initiative (QOPI) is an excellent tool for sampling
WHEN PUBLISHED in 2001, Crossing the Quality
Chasm: A New Health System for the Twenty-first
Century defined quality of care as “the degree to which
health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent
with current professional knowledge.” 1 Six core components
of quality were identified: safety, effectiveness, patientcenteredness,
timeliness, efficiency, and equitability. The
publication received widespread attention and served as a
clarion call to action to providers and health care organizations
to begin a relentless focus on quality of care.
The Need to Focus on the Value of Cancer Care
At the time of publication of Crossing the Quality Chasm,
health care costs as a percentage of gross domestic product
had exceeded 14%. In 2010, the percentage had increased to
17.9%, and total health care expenditures had reached $2.6
trillion, according to the Center for Medicare and Medicaid
Services. Further rises in health care costs are now recognized
as unsustainable. The Patient Protection and Affordable
Care Act was signed into law by President Obama in
2010 at least partly in response to the recognition that
spiraling health care costs threatened the economic health of
the nation.
In the United States, the cost of cancer care is increasing
at a faster rate than nonmalignant conditions. If annual
direct cancer care costs cannot be contained, they are projected
to reach $173 billion by 2020, representing a 39%
increase compared with 2010. 2 Increases are caused by rises
in both the cost of therapy and the extent of care. 3 Rises in
cost of therapy are partly justified by dramatic advances in
the management of cancer that have occurred in the past
decade. For example, a new generation of targeted chemotherapeutic
agents has emerged with unparalleled activity
and with reduced toxicity compared with standard chemotherapy.
4 However, the benefit of other new and expensive
technologies such as robotic surgery for early-stage prostate
cancer is still largely unproven. 5
Porter and Teisberg argue that quality alone is insufficient
to justify the incorporation of a new technology or
agent into routine use. 6 They argue persuasively that value
is a far better means to assess the effect of a change in care,
defining value simply as “outcomes achieved per dollar
spent.” “Dollars spent” is intended to include the cost of care
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processes of care in medical oncology practices. To achieve
the larger goal of improving the value of cancer care, ASCO is
investing in the development of a Rapid Learning System,
which will leverage emerging information technologies to
more accurately measure outcomes (including those reported
by the patient) and costs, resulting in highly efficient, effective,
and safe cancer care.
over a full set of interventions needed to manage a specific
medical condition. 7 In this paradigm, Porter describes three
tiers of outcome. Tier 1 includes measures of success familiar
to oncologists, including survival and response to treatment.
Tier 2 assesses the process of recovery and focuses on
disutility of care including treatment delays, toxicities, adverse
events, and errors. The long-term outcome and late
treatment effects constitute Tier 3 outcomes.
Defining the value of the care that we provide to our
patients is vital for medical oncologists as we prepare for
new reimbursement models. As Porter notes, “value—neither
an abstract ideal nor a code word for cost reduction—
should define the framework for performance improvement
in health care.” 7 For medical oncologists, this requires new
attention to delivery of cancer care with a focus on the full
spectrum of services and on providing care in which value
can be quantified. Various models for providing value-based
cancer care have been described. 8-10
Providing High-Value Care Requires an Organized
Health Care Delivery System
Bohmer has observed that high-value health care organizations
have four common habits: (1) specification and
planning; (2) intentional infrastructure design; (3) measurement
and oversight and; (4) self-study. 11 He observes that
many health care organizations succeed at accomplishing
some of these goals, but only a handful manage them all; it
is these few that have succeeded in delivering high-value
cancer care. Examples include Intermountain Healthcare
and Mayo Clinic.
Specification and Planning
Bohmer defines specification as separating heterogeneous
patient populations into clinically meaningful subsets. As he
notes, “Many hospitals and clinicians do not plan care
From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center,
Nashville, TN; Department of Quality and Guidelines, American Society of Clinical
Oncology, Alexandria, VA.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests Joseph Jacobson, MD, MSc, 450 Brookline Ave., Dana-Farber
Cancer Institute, Boston, MA; email: joseph_jacobson@dcfi.harvard.edu.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10