Concordance and disease type variables between adjuvant chemotherapy (AC) recommended and received as assessed by the Quality Oncology Practice Initiative (QOPI)

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Background: AC is indicated following curative-intent surgery for common solid tumors to reduce the chances of recurrence. Limited data are available to assess discrepancies between potential eligibility for chemotherapy, treatment recommendation and actual administration. For patients with completely resected early stage breast (BC), colorectal (CRC), and nonsmall lung cancer (NSCLC), QOPI assesses patient eligibility for AC, measures the rates of chemotherapy recommendation and administration. This analysis seeks to assess concordance between these measures and to explain differences. Methods: QOPI data are submitted by practices into a web-based system and stored as a relational database. For all categorical variables, frequency, and percent are presented. Concordance is shown as a rate—percent of charts eligible divided by those that met criteria. χ2tests were used to compare rates of recommended/received chemotherapy across cancer types. Results: Data were merged for 30,126 patients from the Fall 2011 and Spring 2012 QOPI collection periods. The analysis was limited to BC, CRC, and NSCLC patients for whom AC was clinically indicated by disease type and stage (eligible patients). Conclusions: Oncologists recommend AC with a high degree of predictability for eligible patients with BC and CRC, but at a lower rate for patients with NSCLC. Eligible NSCLC patients receive AC at a rate far lower than BC and CRC patients; these lower rates are due to patient refusal and medical contraindications. Patient factors such as consent and comorbidity must be considered in establishing quality measure benchmarks as they vary significantly among disease type. [Table: see text]

Implementing a breast cancer registry and treatment plan/summary program in clinical practice: a pilot program

BACKGROUND

There is a need to better measure and improve the quality of oncology care and improve communication with patients and other providers. The American Society of Clinical Oncology Breast Cancer Registry (BCR) pilot evaluated the feasibility and acceptability of prospective data collection for quality assessment in daily clinical practice. Data were used to create and share treatment plans/summaries (TPSs) at the point of care.

METHODS

Using a web-based tool, 20 diverse practices entered clinical data on each new early-stage breast cancer patient into the BCR for 14 months (September 2009 through November 2010). The tool created individual TPSs that were shared with patients. Practices received practice-specific and aggregate BCR quality measures data, participated in a survey, and received a participation stipend.

RESULTS

Twenty practices entered 2014 patients into the BCR, collecting demographic, clinical, and treatment information. Fifty-two percent of practice participants replied to an end-of-pilot survey: 73% were satisfied with the BCR and web-based tool, 31% expressed concern regarding time and effort, and 52% reported additional practice costs during the pilot. Among those who created or shared the TPSs, 90% thought the documents improved oncologist-patient communication, and 95% favored using BCR data for practice quality improvement.

CONCLUSIONS

Prospective data collection for quality assessment is feasible and allows sharing of TPSs with patients at the point of care. Future efforts should focus on decreasing implementation burden to practices, broadening participation, examining costs, and, most importantly, assessing its effects on patient outcomes.

Quality of cancer family history and referral for genetic counseling and testing among oncology practices: A pilot test of quality measures as part of the ASCO Quality Oncology Practice Initiative (QOPI)

CRA1505

Background: The cancer family history (CFH) is an important tool for identification of individuals for genetic counseling/testing (GC/GT). Prior studies demonstrate a low rate of family history documentation and low referral rates for genetic counseling and genetic testing. Methods: In 2011ASCO began pilot testing new measures in QOPI to evaluate the practice of family history taking and referral for genetic counseling/testing in patients with either breast cancer (BC) or colorectal cancer (CRC). The measures assessed the presence or absence of CFH in 1st/2nd degree relatives, age at cancer diagnosis, referral for GC/GT and outcomes of referral. Results: Between September and October 2011 272 practices pilot tested these measures and reported on 10,466 patients (BC 6569, CRC 3897). 77.4% of all charts reviewed documented presence or absence of CFH in 1st degree relatives (BC 81.2% (CI 80-82%), CRC 77.4% (CI 76-79%), p= <0.001) and 61.5% of charts documented presence or absence of CFH in 2nd degree relatives (BC 68.9% (CI 68-70%), CRC 57.3% (CI 56-59%) p=<0.001). Age at diagnosis was documented for all relatives with cancer in 30.7% of charts (BC 45.2% (CI 44-47%), CRC 35.4% (CI 34-37%) p=<0.001). Patients were referred for GC/GT in 22.1% of all charts reviewed (BC 29.1% (CI 28-30%), CRC 19.6% (CI, 18-21%) p=<0.001). Of patients with hereditary risk (defined by selected risk guidelines) 52.2% of BC and 26.4% CRC were referred for GC/GT. When genetic testing was performed by the practice consent was documented 77.7% of the time and discussion of results was documented 78.8% of the time. Conclusions: Appropriate referral for GC/GT requires a complete and accurate CFH. In this pilot testing of QOPI measures we identified a higher quality of CFH information than expected though with room for improvement. Significant differences were seen between BC and CRC charts with greater accuracy of CFH and higher referral rates among BC patients. To obtain improvement in the identification and management of patients at high risk, significant improvements are needed. Education is part of the answer.

Quality of cancer family history and referral for genetic counseling and testing among oncology practices: A pilot test of quality measures as part of the ASCO Quality Oncology Practice Initiative (QOPI)

CRA1505

The full, final text of this abstract will be available at abstract.asco.org at 12:01 AM (EDT) on Monday, June 4, 2012, and in the Annual Meeting Proceedings online supplement to the June 20, 2012, issue of Journal of Clinical Oncology. Onsite at the Meeting, this abstract will be printed in the Monday edition of ASCO Daily News.

Revisions to the 2009 American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards: expanding the scope to include inpatient settings

In November 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) jointly published a set of 31 voluntary chemotherapy safety standards for adult patients with cancer, as the end result of a highly structured, multistakeholder process. The standards were explicitly created to address patient safety in the administration of parenteral and oral chemotherapeutic agents in outpatient oncology settings. In January 2011, a workgroup consisting of ASCO and ONS members was convened to review feedback received since publication of the standards, to address interim changes in practice, and to modify the standards as needed. The most significant change to the standards is to extend their scope to the inpatient setting. This change reflects the conviction that the same standards for chemotherapy administration safety should apply in all settings. The proposed set of standards has been approved by the Board of Directors for both ASCO and ONS and has been posted for public comment. Comments were used as the basis for final editing of the revised standards. The workgroup recognizes that the safety of oral chemotherapy usage, nononcology medication reconciliation, and home chemotherapy administration are not adequately addressed in the original or revised standards. A separate process, cosponsored by ASCO and ONS, will address the development of safety standards for these areas.

Revisions to the 2009 american society of clinical oncology/oncology nursing society chemotherapy administration safety standards: expanding the scope to include inpatient settings

In November 2009, ASCO and the Oncology Nursing Society (ONS) jointly published a set of 31 voluntary chemotherapy safety standards for adult patients with cancer, as the end result of a highly structured, multistakeholder process. The standards were explicitly created to address patient safety in the administration of parenteral and oral chemotherapeutic agents in outpatient oncology settings. In January 2011, a workgroup consisting of ASCO and ONS members was convened to review feedback received since publication of the standards, to address interim changes in practice, and to modify the standards as needed. The most significant change to the standards is to extend their scope to the inpatient setting. This change reflects the conviction that the same standards for chemotherapy administration safety should apply in all settings. The proposed set of standards has been approved by the Board of Directors for both ASCO and ONS and has been posted for public comment. Comments were used as the basis for final editing of the revised standards. The workgroup recognizes that the safety of oral chemotherapy usage, nononcology medication reconciliation, and home chemotherapy administration are not adequately addressed in the original or revised standards. A separate process, cosponsored by ASCO and ONS, will address the development of safety standards for these areas.

ASCO Provisional Clinical Opinion: Chronic Hepatitis B Virus Infection in Patients Receiving Cytotoxic Chemotherapy for Treatment of Malignant Diseases

What does the ASCO provisional clinical opinion on hepatitis B virus mean for practices?

Advancing performance measurement in oncology: quality oncology practice initiative participation and quality outcomes

The American health care system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of health care. In 2006, the American Society for Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCO's QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the Fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% v 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% v 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.

Advancing performance measurement in oncology

The American healthcare system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of healthcare. In 2006, the American Society of Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCO's QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% vs 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% vs 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.

Evolution and elements of the quality oncology practice initiative measure set

BACKGROUND

Over the past 5 years, the American Society of Clinical Oncology (ASCO) has supported the development of a Web-based quality-reporting tool in response to a recognized need to provide medical oncologists the opportunity to demonstrate the quality of care that they are providing to patients.

METHODS

The development of quality measures, their basis in the literature, and the descriptions and organizational structure of the measures are discussed.

RESULTS

Specific results are the property of practices and are not shared outside of the practices except in aggregate. The system allows collection of information concerning a wide range of quality measures in a short period of time. In the last data collection period in the fall of 2008, information was submitted concerning 81 measures of quality divided into one required and six optional modules from over 250 practices concerning 15,000 patients.

CONCLUSIONS

The timely collection of information on a wide range of quality measures regarding cancer patients can be efficiently collected using a Web-based data collection tool allowing for practice self-examination and comparison with other practices.

Measuring supportive care in medical oncology practice: lessons learned from the quality oncology practice initiative

We provide a brief review of the use of quality measures to assess supportive care in the medical oncology office. Specifically, we discuss the development and implementation of supportive care measures in the Quality Oncology Practice Initiative (QOPI), a voluntary quality measurement and improvement program of the American Society of Clinical Oncology. QOPI has demonstrated that medical oncologists voluntarily engage in self-assessment and often select measures related to supportive care for measurement and improvement. Results to date have demonstrated that there is room for improvement in this domain. Because supportive care measures appropriate for use through structured chart review in the outpatient oncology setting are not generally available in the published literature, measures have been developed and tested through the program. Additional measures are in development for implementation in QOPI in 2008.

Improvement in oncology practice performance through voluntary participation in the Quality Oncology Practice Initiative

PURPOSE

The Quality Oncology Practice Initiative (QOPI) became available to all American Society of Clinical Oncology member physicians in 2006 as a voluntary medical oncology practice-based quality measurement and improvement project. QOPI assesses practice performance for a series of evidence- and consensus-based process measures, relying on practices to complete structured chart reviews and submit data via a secure Web-based portal.

METHODS

This analysis focused on the 71 practices that participated in both the March and September 2006 data collections (7,624 charts abstracted in March and 10,240 in September). Among 33 measures common to both collections, five measures were closely correlated, and 28 are included in the final analysis. Composite scores were created for six different domains of care. Statistical significance was tested on both absolute changes and relative changes (relative failure reduction) of quality measures from baseline to follow-up and between the lower quartile and all other quartiles.

RESULTS

Practice performance on individual measures varied between 18.8% and 98.6%. Mean overall performance as measured by a composite score increased from 78.7% in March to 82.3% in September (P < .05). Improvement was most marked among practices originally performing in the bottom quartile. Using a composite score, the absolute and relative performance for the bottom quartile improved by 27% and 35%, respectively, statistically superior to that of all others.

CONCLUSION

Practices that participated in QOPI demonstrated improved performance in self-reported process measures, with the greatest improvement demonstrated in initially low-performing practices.

A Process for Measuring the Quality of Cancer Care: The Quality Oncology Practice Initiative

Purpose

The Quality Oncology Practice Initiative (QOPI) is a practice-based system of quality self-assessment sponsored by the participants and the American Society of Clinical Oncology (ASCO). The process of quality evaluation, development of the pilot questionnaire, and preliminary results are reported.

Methods

Physicians from seven oncology groups developed medical record abstraction measures based on practice guidelines and consensus-supported indicators of quality care. Each practice completed two rounds of records review and received practice and aggregate results. Mean frequencies of responses for each indicator were compared among practices.

Results

Participants universally, if informally, find QOPI helpful, and results show statistically significant variation among practices for several indicators, including assessing pain in patients close to death, documentation of informed consent for chemotherapy, and concordance with granulocytic and erythroid growth factor administration guidelines. Measures with universally high concordance include the use of serotonin antagonist antiemetics according to the ASCO guideline; the presence of a pathology report in the record; the use of chemotherapy flow sheets; and adherence to standard chemotherapy recommendations for patients with certain stages of breast, colon, and rectal cancer. Concordance with quality indicators significantly changed between survey rounds for several measures.

Conclusion

Pilot results indicate that the QOPI process provides a rapid and objective measurement of practice quality that allows comparisons among practices and over time. It also provides a mechanism for measuring concordance with published guidelines. Most importantly, it provides a tool for practice self-examination that can promote excellence in cancer care.

Progressive outer retinal necrosis syndrome in a lymphoma patient with good visual outcome

PURPOSE

To report an HIV-negative lymphoma patient who developed progressive outer retinal necrosis syndrome and who had a good visual outcome after treatment with two-drug antiviral therapy and intravenous immunoglobulin.

METHODS

Case report.

RESULTS

A 43-year-old man with small lymphocytic lymphoma was diagnosed with progressive outer retinal necrosis in his left eye. Treatment was initiated with intravenous foscarnet and ganciclovir as well as intravenous gammaglobulin at a dose of 0.5 gm/kg per day for 5 days. On the second hospital day he was started on decadron 4 mg orally four times daily. No further posterior retinitis progression was observed despite severe immunosuppression. Visual acuity remained stable at 20/30 with 10 months' follow-up.

CONCLUSIONS

The benefit of using gammaglobulin in progressive outer retinal necrosis is unknown. Given the rapid improvement seen in this patient's retinitis, it may be reasonable to consider the use of gammaglobulin in other cases of infectious retinitis in immunocompromised patients.

Painful palmar and plantar erythema associated with hepatic artery infusion of 5-fluoro-2'deoxyuridine

Painful palmar and plantar erythema is an uncommon systemic complication of chemotherapy and has been reported in association with methotrexate, cystosine arabinoside, doxorubicin, and 5-fluorouracil. The authors report a case in which the syndrome was precipitated by hepatic artery infusion of 5-FUdR. The previous recommendation that treatment of patients developing painful palmar-plantar erythema from other drugs may be successfully resumed using intrahepatic arterial infusion of FUdR must be reconsidered in light of the present report.

A quantitative analysis of palliative care decisions in acute nonlymphocytic leukemia

With the increasing incidence of cancer in elderly patients, decisions to adopt palliative care become particularly relevant to this patient population. In order to define characteristics of decisions to adopt palliative care, including those factors influencing whether a particular patient received palliation, the frequency of this therapeutic posture, and the duration of this treatment period, we performed a retrospective analytical survey of all patients with acute nonlymphocytic leukemia (ANLL) treated at Duke University Medical Center over the past ten years. Logistic regression analysis identified several potentially significant variables influencing the decision to adopt palliative care. Using a stepwise logistic model, the only independent variable associated with adoption of palliative therapy was initial treatment off a research protocol (P = 0.0001). Initial treatment off a research protocol was itself associated with older age (P = 0.0002), nonspontaneous onset of leukemia (P = 0.005), female sex (P = 0.003), and the absence of dependent children (P = 0.01) when examined by multivariate logistic regression. The palliative treatment interval was defined as the time between the discontinuation of aggressive treatment and the patient's death. Fifty-one percent, 119 of 235 patients, received palliative care; of these, 47% were palliated from the time of diagnosis and 53% were palliated only after receiving remission induction therapy. The median duration for the palliative care period was 46 days (50 days for the initially palliated group, 24 days for the group receiving aggressive therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraluminal thrombus and bowel obstruction in acute leukemia due to bleeding Meckel's diverticulum

Gastrointestinal bleeding from Meckel's diverticulum resulted in small bowel obstruction by thrombus in two patients with acute myelogenous leukemia during bone marrow aplasia and recovery from induction chemotherapy. Although gastrointestinal symptoms and complications are common in acute leukemia, these two cases are unique and describe a new syndrome that requires prompt recognition and surgical intervention. The complication of localized bowel obstruction by intraluminal thrombus is heretofore unreported.