January 31, 2006
Study Identifies and Assesses Adherence to More Than 60 Quality Measures For Breast and Colorectal Cancer
Alexandria,VA — The detailed results of the first study on national cancer care quality will be published in the Feb. 1 issue of the Journal of Clinical Oncology (JCO). The National Initiative on Cancer Care Quality (NICCQ), which analyzed data from nearly 1,800 patient surveys and medical records of people with early-stage breast and colorectal cancer, found that the large majority of patients are receiving high-quality care, though certain areas of care are in need of improvement.
The study — commissioned by the American Society of Clinical Oncology (ASCO) and undertaken by researchers at the Harvard School of Public Health and the RAND Corporation — showed strikingly higher adherence than anticipated to processes of care believed to be essential for improving patient outcomes.
Patients with early-stage breast cancer received 86% of generally recommended care, based on 36 quality-care measures, while patients with early-stage colorectal cancer received 78% of generally recommended care, based upon 25 quality-care measures. These overall rates of adherence suggest that the quality of care for cancer is better than that observed for other chronic medical conditions.
"We were very pleased to see such a high level of adherence to many quality care measures," said Ezekiel Emanuel, MD, Chair of ASCO's Task Force on Quality Cancer Care, which oversaw the research. "However, a large part of our goal was to target areas for improvement, so ASCO, other professional societies, advocacy groups, the National Cancer Institute, and others could direct their attention to these areas."
"The NICCQ study provides important insight on the care that we are delivering to patients," said John V. Cox, DO, a community oncologist from Dallas, Texas. "We are anxious to begin working with ASCO on the tools it is developing that will help build upon and improve care for all cancer patients."
Preliminary findings were presented at ASCO's Annual Meeting in May 2005.
The NICCQ study examined the quality of care for patients diagnosed with stage I, II, or III breast cancer or stage II or III colorectal cancer an average of four years after diagnosis in five metropolitan areas across the United States — Atlanta, Cleveland, Houston, Kansas City, and Los Angeles.
The study sought to measure to what degree cancer patients received elements of care that were consistent with the best evidence in the literature and clinical practice guidelines. The study is unique in that it evaluated and cross-referenced several sources of information: hospital cancer registries, patient surveys, and patient medical records. Most prior studies that have attempted to measure the quality of cancer care in the United States have relied on a single source of information or have examined a limited number of measures.
The 36 quality measures for breast cancer included in the study were grouped into five areas — diagnostic evaluation, surgery, adjuvant therapy, managing toxicities, and surveillance (full list of quality measures available in the appendix of the JCO article). Researchers found that adherence varied across the five areas, with adherence rates of 88%, 87%, 82%, 73% and 94%, respectively.
For colorectal cancer, the 25 quality measures were grouped into four areas — diagnostic evaluation, surgery, adjuvant therapy, and surveillance. Overall adherence was slightly lower in this disease, with adherence rates in the four areas of 87%, 93%, 64%, and 50%, respectively.
Quality Measures with Adherence Rates Above 85%
Examples of quality measures with adherence rates above 85% in each of the categories of care noted above include the following (Note: These results are drawn from the overall NICCQ findings; they are not included in the JCO article because of space constraints.):
- Diagnostic evaluation. Ninety-nine percent of newly diagnosed breast cancer patients underwent axillary lymph node sampling, as recommended by guidelines. For colon cancer patients who underwent surgery to remove tumors, 98% of pathology reports stated whether the cancer had spread to the lymph nodes.
- Surgery. For breast cancer patients undergoing surgery, 99% of patients had "clear margins" (no cancerous cells along the edge of the removed tissue), 98% received radiation therapy after breast-conserving surgery, and 96% of patients received the recommended dose of radiation. For colon cancer patients undergoing surgery, 89% of patients had clear margins.
- Adjuvant therapy. When chemotherapy after surgery ("adjuvant therapy") was indicated as a preferred treatment option, 96% of eligible women with breast cancer received the treatment. Ninety-two percent of colon cancer patients received adjuvant therapy when indicated.
- Surveillance and follow-up. For breast cancer patients with tumors larger than one centimeter or those with cancers that have spread to the lymph nodes and are estrogen-receptor or progesterone-receptor positive, 92% received tamoxifen for five years after surgery, as recommended by quality care guidelines. For colorectal cancer patients who underwent an ileostomy or colostomy (surgical procedures that create a permanent opening through the abdominal wall into the intestine), 96% received instruction in enterostomy care following the procedure.
Quality Measures with Adherence Rates Below 85%
Examples of quality measures in the categories of care noted above with adherence rates of less than 85% include:
- Surgery. Thirty percent of patients underwent mastectomy as their first procedure (the remaining 70% of patients received a lumpectomy, followed by radiation). Of the group of patients that underwent mastectomy as their first procedure, 30% were told that breast-conserving surgery was an option. This may be because the patient was not an appropriate candidate for a lumpectomy, the patient requested a mastectomy, or because the doctor did not document discussions with the patient in the medical record (future papers will examine the reasons for low adherence to some quality measures). In addition, 49% of breast cancer patients who had a mastectomy were informed about the option of breast reconstruction prior to undergoing mastectomy.
- Adjuvant therapy. For breast cancer patients, the planned chemotherapy dose was consistent with published recommendations for 58% of patients (in most cases, the dose provided was low). For patients with colorectal cancer, the planned dose was consistent with published recommendations for 68% of patients. In addition, 79% of patients with colorectal cancer had begun adjuvant chemotherapy treatment within eight weeks of surgery, as recommended by treatment guidelines.
- Managing toxicities. Sixty-six percent of breast cancer patients receiving nausea-inducing therapy were treated with a potent anti-nausea drug, such as 5HT blockade.
- Surveillance and follow-up. Seventy-five percent of breast cancer patients who started taking tamoxifen continued taking it for the entire five-year course of treatment. Fifty percent of patients who had a removal of a stage II or stage III colorectal cancer were counseled about the need for first-degree relatives to undergo screening.
Other Notable Findings
Additional findings of note include:
- Regional variations in care. Researchers found significant variations in care across the five metropolitan areas. For breast cancer patients, while the planned chemotherapy dose was consistent with published recommendations for 58% of patients overall, this ranged from 29% to 74% across the five cities. For patients with colorectal cancer, the planned dose was consistent with published recommendations for 68% of patients, ranging from 62% to 85% across the five cities.
- Documentation of treatment. Lack of documentation of treatment in patients' medical records was found to be a significant problem. Among women with breast cancer, the percentage of patients whose planned chemotherapy regimen was actually noted in their chart ranged from 46% to 78% across the five cities. For colorectal cancer patients, adherence rates ranged from 50% to 68%.
Next Steps: Implications for National Monitoring of Cancer Care Quality
"This study was the first national study to comprehensively evaluate the quality of cancer care in the United States. Cancer care was by and large excellent," said Joseph S. Bailes, MD, who initiated the study during his ASCO presidency in 1999-2000. "The NICCQ study reveals important opportunities to improve care. We hope this research will inform professional societies, training programs, and clinicians involved in cancer care on the specific steps needed to improve care for people with cancer."
"NICCQ could not have succeeded without the active engagement of relevant professional societies and the generous voluntary participation of oncology programs in five metropolitan areas across the United States," said Eric Schneider, MD, one of the study co-authors and an assistant professor at the Harvard School of Public Health. "Professional involvement is an important key to the success of a national program."
ASCO plans to incorporate the findings of the NICCQ study into its educational programs, policies, and communications to member oncologists. ASCO is taking steps to improve documentation for care provided, particularly in the area of chemotherapy administration, and is in the process of developing tools for clinicians.
"The NICCQ study provides valuable information that will enable us to better educate physicians about the best ways to treat cancer patients," said ASCO President Sandra J. Horning, MD. "The quality measures identified in the NICCQ study can be incorporated into patients' medical records, so doctors will be able to better document the care patients are receiving through all stages of treatment."
In addition, through the Quality Oncology Practice Initiative (QOPI), ASCO is applying the NICCQ measures and findings to practice-based quality improvement initiatives. Doctors will be able to assess the care that they are providing in their practices and compare it to what other practices are doing. "QOPI's goal is to promote excellence in cancer care by helping practice create a culture of self-examination and improvement," Dr. Bailes said.
ASCO also is working with the National Comprehensive Cancer Network (NCCN) to use the NICCQ quality measures to develop a subset of measures to improve accountability for care for breast and colorectal cancer, which will be specified, pilot tested, and then disseminated. In addition, ASCO is interested in partnering with the National Cancer Institute and other public and private organizations to advance cancer care quality initiatives.
"Using careful methods to systematically identify and track the ways in which cancer patients are or are not receiving needed care provides a solid foundation for clinicians and policy makers to diagnose aspects of cancer care that don't work well and would benefit from modifications. We don't measure quality of care just for the numbers. We do it to identify opportunities for improvement," said Katherine Kahn, MD, study co-author and Senior RAND Scientist and Professor of Medicine at UCLA School of Medicine.
"Studying specific processes of care helps to focus interventions on components of care most in need of improvement," Dr. Kahn added. "It is satisfying to know that we have identified areas where medical care could be improved and those improvements are likely to lead to better chances for survival and quality of life for patients. "
Background on NICCQ
ASCO commissioned the NICCQ study after the 1999 Institute of Medicine report indicated that some cancer patients were not receiving the care most effective for treating their disease. The report suggested there might be a significant problem in the delivery of quality care, but that it was difficult to know the full extent of the problem due to the absence of a national monitoring system. Additional detailed results from the NICCQ will be published in national medical journals throughout 2006.
The study was undertaken by researchers from the Harvard School of Public Health and the RAND Corporation. The Susan G. Komen Breast Cancer Foundation also provided significant funding for the study.
"Results of the National Initiative for Cancer Care Quality (NICCQ): How Can We Improve the Quality of Cancer Care in the United States?" Jennifer L. Malin, Eric C. Schneider, Arnold M. Epstein, John Adams, Ezekiel J. Emanuel, and Katherine Kahn; RAND Corporation, Santa Monica, California; Harvard School of Public Health, Boston, Massachusetts; and the National Institutes of Health, Bethesda, Maryland.
The Journal of Clinical Oncology is the semi-monthly peer-reviewed journal of the American Society of Clinical Oncology (ASCO), the world's leading professional society representing physicians who treat people with cancer.
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