Seeking American Society of Clinical Oncology-Quality Oncology Practice Initiative (ASCO-QOPI) certification in a northern New England rural health system and cancer care network

In 2006 following several years of preliminary study, the American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI). This cancer-focused quality initiative evolved considerably over the next decade-and-a-half and is expanding globally. QOPI is undoubtedly the leading standard-bearer for quality cancer care and contemporary medical oncology practice. The program garners attention and respect among federal programs, private insurers, and medical oncology practices across the nation. The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017. The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England. In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO-QOPI team, elected to proceed with a health system-cancer network-wide QOPI certification. Key themes emerged over the course of our two-year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to CancerLinQ; (3) Prior experience, especially policy development, in other cancer-focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists. All participants demonstrated a genuine spirit to work together to achieve certification. We report our successful journey seeking ASCO-QOPI certification across our network, which to our knowledge is the first-of-its-kind endeavor.

Critical Lessons From High-Value Oncology Practices

Importance

Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost.

Objective

To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results.

Design, Setting, and Participants

"Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied.

Main Outcomes and Measures

Thematic saturation in a qualitative analysis of high-value care attributes.

Results

From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care.

Conclusions and Relevance

Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

The opportunities and shortcomings of using big data and national databases for sarcoma research

The rarity and heterogeneity of sarcomas make performing appropriately powered studies challenging and magnify the significance of large databases in sarcoma research. Established large tumor registries and population-based databases have become increasingly relevant for answering clinical questions regarding sarcoma incidence, treatment patterns, and outcomes. However, the validity of large databases has been questioned and scrutinized because of the inaccuracy and wide variability of coding practices and the absence of clinically relevant variables. In addition, the utilization of large databases for the study of rare cancers such as sarcoma may be particularly challenging because of the known limitations of administrative data and poor overall data quality. Currently, there are several large national cancer databases, including the Surveillance, Epidemiology, and End Results database, the National Cancer Data Base of the American College of Surgeons and the American Cancer Society, and the National Program of Cancer Registries of the Centers for Disease Control and Prevention. These databases are often used for sarcoma research, but they are limited by their dependence on administrative or billing data, the lack of agreement between chart abstractors on diagnosis codes, and the use of preexisting documented hospital diagnosis codes for tumor registries, which lead to a significant underestimation of sarcomas in large data sets. Current and future initiatives to improve databases and big data applications for sarcoma research include increasing the utilization of sarcoma-specific registries and encouraging national initiatives to expand on real-world, evidence-based data sets.

Survival As a Quality Metric of Cancer Care: Use of the National Cancer Data Base to Assess Hospital Performance

Purpose:

Survival is considered an important indicator of the quality of cancer care, but the validity of different methodologies to measure comparative survival rates is less well understood. We explored whether the National Cancer Data Base (NCDB) could serve as a source of unadjusted and risk-adjusted cancer survival data and whether these data could be used as quality indicators for individual hospitals or in the aggregate by hospital type.

Methods:

The NCDB, an aggregate of > 1,500 hospital cancer registries, was queried to analyze unadjusted and risk-adjusted hazards of death for patients with stage III breast cancer (n = 116,787) and stage IIIB or IV non–small-cell lung cancer (n = 252,392). Data were analyzed at the individual hospital level and by hospital type.

Results:

At the hospital level, after risk adjustment, few hospitals had comparative risk-adjusted survival rates that were statistically better or worse. By hospital type, National Cancer Institute–designated comprehensive cancer centers had risk-adjusted survival ratios that were statistically significantly better than those of academic cancer centers and community hospitals.

Conclusion:

Using the NCDB as the data source, survival rates for patients with stage III breast cancer and stage IIIB or IV non–small-cell lung cancer were statistically better at National Cancer Institute–designated comprehensive cancer centers when compared with other hospital types. Compared with academic hospitals, risk-adjusted survival was lower in community hospitals. At the individual hospital level, after risk adjustment, few hospitals were shown to have statistically better or worse survival, suggesting that, using NCDB data, survival may not be a good metric to determine relative quality of cancer care at this level.

Individualized outcome prognostication for patients with laryngeal cancer

BACKGROUND

Accurate prognostication is essential to the optimal management of laryngeal cancer. Predictive models have been developed to calculate the risk of oncologic outcomes, but extensive external validation of accuracy and reliability is necessary before implementing them into clinical practice.

METHOD

Four published prognostic calculators that predict 5-year overall survival for patients with laryngeal cancer were evaluated using patient information from a prospective epidemiology study cohort (n = 246; median follow-up, 60 months) with previously untreated, stage I through IVb laryngeal squamous cell carcinoma.

RESULTS

Different calculators yielded substantially different predictions for individual patients. The observed 5-year overall survival was significantly higher than the averaged predicted 5-year overall survival of the 4 calculators (71.9%; 95% confidence interval [CI], 65%-78%] vs 47.7%). Statistical analyses demonstrated the calculators' limited capacity to discriminate outcomes for risk-stratified patients. The area under the receiver operating characteristic curve ranged from 0.68 to 0.72. C-index values were similar for each of the 4 models (range, 0.66-0.68). There was a lower than expected hazard of death for patients who received induction (bioselective) chemotherapy (hazard ratio, 0.46; 95% CI, 0.24-0.88; P = .024) or primary surgical intervention (hazard ratio, 0.43; 95 % CI, 0.21-0.90; P = .024) compared with those who received concurrent chemoradiation.

CONCLUSIONS

Suboptimal reliability and accuracy limit the integration of existing individualized prediction tools into routine clinical decision making. The calculators predicted significantly worse than observed survival among patients who received induction chemotherapy and primary surgery, suggesting a need for updated consideration of modern treatment modalities. Further development of individualized prognostic calculators may improve risk prediction, treatment planning, and counseling for patients with laryngeal cancer. Cancer 2018;124:706-16. © 2017 American Cancer Society.

Improving Care With a Portfolio of Physician-Led Cancer Quality Measures at an Academic Center

PURPOSE

Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the manual data collection required is resource intensive, and reporting is delayed. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCPs) to identify, measure, and improve quality metrics that were meaningful to the care teams and their patients.

METHODS

Each CCP physician leader collaborated with the cancer quality team to identify metrics, abiding by established guiding principles. Financial incentive was provided to the CCPs if performance at the end of the study period met predetermined targets. Reports were developed and provided to the CCP physician leaders on a monthly or quarterly basis, for dissemination to their CCP teams.

RESULTS

A total of 15 distinct quality measures were collected in depth for the first time at this cancer center. Metrics spanned the patient care continuum, from diagnosis through end of life or survivorship care. All metrics improved over the study period, met their targets, and earned a financial incentive for their CCP.

CONCLUSION

Our quality program had three essential elements that led to its success: (1) engaging physicians in choosing the quality measures and prespecifying goals, (2) using automated extraction methods for rapid and timely feedback on improvement and progress toward achieving goals, and (3) offering a financial team-based incentive if prespecified goals were met.

Development of an Instrument to Examine Nursing Attitudes Toward Fertility Preservation in Oncology

PURPOSE/OBJECTIVES

To develop an instrument to measure staff nurse perceptions of the barriers to and benefits of addressing fertility preservation (FP) with patients newly diagnosed with cancer. 
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DESIGN

A prospective, nonrandomized instrument development approach. 
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SETTING

Harold C. Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center in Dallas. 
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SAMPLE

224 RNs who care for patients with cancer. 
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METHODS

The instrument was developed with content experts and field-tested with oncology staff nurses. Responses to a web-based survey were used in exploratory factor analysis. After refining the instrument, the authors conducted a confirmatory factor analysis with 230 web-based survey responses. 
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MAIN RESEARCH VARIABLES

Self-perceived barriers to providing FP options to patients newly diagnosed with cancer.
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FINDINGS

The results supported a 15-item instrument with five domains.

CONCLUSIONS

This instrument can be used to explore oncology nurses' attitudes toward FP in newly diagnosed people with cancer in their reproductive years. 
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IMPLICATIONS FOR NURSING

A more comprehensive understanding of attitudes and barriers related to FP will guide the building of optimal systems that support effective FP options, resources, and programs for individuals with cancer.

Quality Oncology Practice Initiative Can Guide and Improve Oncology Providers' Training in Brazil

PURPOSE

It has become crucial to translate scientific findings and to find ways by which to mobilize local resources to improve the quality and accessibility of cancer care in developing countries. This study seeks to provide insight into challenge through examining differences in clinician documentation of patients with cancer treated at a Brazilian Public University Hospital.

METHODS

ASCO Quality Oncology Practice Initiative (QOPI) measures were used to examine the care provided in the departments of breast, colorectal, lymphoma, gynecology, and lung cancers. For this study, data from a representative sample of patients receiving chemotherapy in the previous month were extracted and quality of cancer care indicators examined.

RESULTS

Certain elements of medical care were consistently and appropriately documented, including cancer diagnosis and stage, chemotherapy planning, administration, and summary. In general, considering the specific cancer management measures, patients received recommended care in accordance with recognized guidelines. Despite this, a number of important gaps in care were identified, including the assessment and treatment of pain, documentation of chemotherapy intention, symptom and toxicity management, patients' psychosocial status, and provision of a treatment summary at care completion.

CONCLUSION

These findings are encouraging in terms of adherence to core treatment guidelines in cancer care in Brazil. However, results suggest important opportunities for improving care across a number of domains, many of which represent a challenge throughout both developing and developed countries. This study may also provide preliminary guidance for enhancing educational and training programs for professionals and students alike, to implement high-quality, comprehensive cancer care.

Cancer care quality: current state and future directions

Delivery of high-quality medicine is essential in all fields, but it is particularly crucial in cancer medicine in which therapies can be toxic and life-threatening and appropriate treatment can lead to long-term remissions or cure, and when poor therapy compromises survival. Variability in postoperative mortality has been demonstrated for several complex cancer surgeries, depending on surgical expertise and volumes. Systemic therapy, including both cytotoxic and targeted therapies (which are the backbones of many curative regimens), can have severe toxicities. Small upward errors in dosing or schedule can result in unnecessary morbidity and mortality, and they can result in reduced efficacy and poor outcomes. Similarly, radiation therapy is a critical modality in the treatment of so many cancers, but clinically important morbidity and mortality can be associated with it. Methods to continually assess quality in ways that lead to interventions to improve care are essential in cancer medicine today, and they can be viewed as an obligation of our profession.

2014 President's plenary international psycho-oncology society: moving toward cancer care for the whole patient

The International Psycho-oncology Society (IPOS) has just celebrated its 30th anniversary. The growth of psychosocial oncology has been exponential, and this relatively new field is becoming a core service that focuses on prevention, reducing the burden of cancer, and enhancing the quality of life from time of diagnosis, through treatment, survivorship, and palliative care. Looking back over the past 30 years, we see that cancer care globally has evolved to a new and higher standard. Today, 'cancer care for the whole patient' is being accomplished with an evidence-based model that addresses psychosocial needs and integrates psycho-oncology into the treatment and care of patients. The President's Plenary Session in Lisbon, Portugal, highlighted the IPOS Mission of promoting global excellence in psychosocial care of people affected by cancer through our research, public policy, advocacy, and education. The internationally endorsed IPOS Standard of Quality Cancer Care, for example, clearly states the necessity of integrating the psychosocial domain into routine care, and that distress should be measured as the sixth vital sign after temperature, blood pressure, pulse, respiratory rate, and pain. The plenary paper also discussed the global progress being made in Europe, North America, and Australia in providing quality cancer care for the whole patient. Collaborative partnerships between IPOS and organizations such as the European Partnership Action Against Cancer and the World Health Organization are essential in building capacity for the delivery of high-quality psycho-oncology services in the future.

Administration of Oral Chemotherapy: Results From Three Rounds of the Quality Oncology Practice Initiative

The collection of oral chemotherapy test measure data is feasible, and improvement opportunities exist for patients who are prescribed oral chemotherapy.

Assuring Quality Cancer Survivorship Care: We've Only Just Begun

Clinical practice guidelines, quality metrics, and performance improvement projects are the key tools of the national movement to improve and assure quality cancer care. Each of these evaluation instruments is intended to assess quality from a unique perspective, including that of the individual provider, the practice/hospital, and the health care system. A number of organizations have developed or endorsed quality measures specific to cancer, however, these have not formally included survivorship measures. Fortunately, the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network, the American Cancer Society, and the American College of Surgeons (ACoS) have taken a leadership role in developing survivorship guidelines and quality metrics. Both ASCO and ACoS have focused their efforts on the treatment summary and care plan, a document that was proposed in the 2006 Institute of Medicine report on cancer survivorship. ASCO has proposed a care plan template for implementation and incorporation into the electronic health records (EHR), which will lend itself to structure, process, and outcome measurement. ACoS, conversely, has included the care plan in its cancer program standards with annual evaluation metrics. In addition, ASCO has developed a number of key survivorship-relevant metrics as part of its Quality Oncology Practice Initiative (QOPI), a tool developed to measure quality cancer care and assess adherence to guidelines across academic and community practices. Together, these efforts will direct us to more effective ways to disseminate guideline recommendations and to better methods of assessing quality survivorship care nationally.