2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

IMPROVING VALUE OF CARE IN ONCOLOGY
processes in advance in such detail; instead, they treat each
new patient or problem as a random draw from a heterogeneous
population and must, therefore, reinvent the strategy
for solving it.” For much of its history, medical oncology has
approached care this way. Fortunately, advances in genomics
have begun to identify clinically meaningful disease
subsets. Patients with adenocarcinoma of the lung, for
example, are now routinely tested for the presence of activating
mutations of epidermal growth factor or translocations
of anaplastic lymphoma kinase (ALK). 12,13 Patients
with lung cancer with these genotypes now have access to
targeted therapies that have transformed the natural history
of their disease. By “planning,” Bohmer argues for the
development of pre-emptive treatment approaches for patients
using clinical practice guidelines or clinical pathways.
Intentional Infrastructure Design
The gradual shift of medicine from “guild” to profession is
embodied by this habit. 14 This entails designing care to
maximize the use of each team member’s skills and expertise
and requires engagement of the patient and family. The
medical home model now being implemented widely in
primary care is an example of effective infrastructure design,
and a pilot in one medical oncology practice suggests
that the model can be extended. 9 Multidisciplinary cancer
care—when well designed—is a powerful tool to leverage
personnel and limited resources. 15
Measurement and Oversight
High-value organizations go far beyond measurement
required for external reporting to the development of a set of
internal measurements that become integral to accountability
and organizational management.
Self-Study
Bohmer notes that “high-value organizations treat clinical
knowledge as an organizational as well as individual property...these
organizations deliberately nurture a culture
that supports learning. ...” Inthis environment, in which
KEY POINTS
● Medical oncologists must strive for high value of
cancer care—defined as outcomes achieved per dollars
spent.
● Reliable, accurate means to assess the quality and
cost across the spectrum of cancer services must be
created to drive high-value care.
● The ASCO Quality Oncology Practice Initiative
(QOPI) is available to all U.S. medical oncologists to
sample care processes and to compare their performance
over time and against national benchmarks.
● The ASCO QOPI Certification Program (QCP) allows
practices to demonstrate high quality of care and safe
chemotherapy administration practices.
● ASCO is developing a Rapid Learning System that
leverages new information technologies with the goal
of improving the value of cancer care by focusing on
effectiveness, safety, efficiency, and quality.
specification and planning are built into systems, variations
from guidelines and pathways are studied to understand
and learn from variation. This is the clinical equivalent of
the managerial approach of “managing by exception.”
Managing What We Measure
At the 1962 Yale University Commencement Address,
John F. Kennedy noted that “for the great enemy of truth is
very often not the lie—deliberate, contrived, and dishonest—but
the myth—persistent, persuasive, and unrealistic.”
This admonition is as true in medicine as it is in politics.
Without data to inform our delivery of care, we are dependent
on subjectivity and biases and at risk of squandering
precious resources and mistreating our patients. 16 The collection
of accurate, granular, and timely data is vital for
organizational and provider growth and in the quest for
excellence. Berwick, James, and Coye describe two overlapping
types of performance assessment, “measurement for
selection” and “measurement for improvement.” 17
Measurement for selection. This approach to improving
the quality of care is based on the premise that health care
outcomes studied in any setting (e.g., individual practitioner
or health care organization) will have a distribution of
performance levels. In principle, this consumer-based approach
to value simply requires the selection of the desired
outcome, review of the provider or organizational performance,
and selection based on identifying the best
performer—“get better care by choosing better care.” 17 A
major shortcoming of this approach is that it does not
improve the overall quality of care; care is simply shifted
toward high performing practitioners or organizations. 18 In
addition, measurement for selection remains an inexact
science in medicine. Outcome variation across providers and
organizations is often because of the complex interactions of
patient-specific factors (which are often imperfectly measured)
with the health care system. In addition, measurement
for selection often relies on a series of summary
statistics lacking sufficient specificity or granularity to draw
precise conclusions for most medical conditions or procedures.
Measurement for improvement. Using this approach, focus
is shifted toward the processes of care rather than the
providers, and, when successful, the entire distribution of
performance levels is shifted to a higher level. Institutions
such as Intermountain Healthcare (IHC) that have experienced
major strides in improving quality over the past
decade have consciously shifted from measuring for selection
to measuring for improvement. 18 IHC success has
depended on building a comprehensive clinical information
system, engaging clinicians to develop standardized approaches
(care process models [CPMs]) to the management
of common conditions, encouraging clinicians to vary from
these approaches when justified by circumstances, and continuously
modifying the CPMs based on analysis of variations
and on emerging literature.
The Emergence of the Quality Oncology Practice
Initiative (QOPI)
In response to the Institute of Medicine’s National Cancer
Policy Board recommendations published in 1999, 19 ASCO
commissioned researchers at the Harvard School of Public
Health and at the RAND Corporation to undertake a study
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