Performance Measures Based on How Adults With Cancer Feel and Function: Stakeholder Recommendations and Feasibility Testing in Six Cancer Centers

PURPOSE

Patient-reported outcome measures (PROMs) that assess how patients feel and function have potential for evaluating quality of care. Stakeholder recommendations for PRO-based performance measures (PMs) were elicited, and feasibility testing was conducted at six cancer centers.

METHODS

Interviews were conducted with 124 stakeholders to determine priority symptoms and risk adjustment variables for PRO-PMs and perceived acceptability. Stakeholders included patients and advocates, caregivers, clinicians, administrators, and thought leaders. Feasibility testing was conducted in six cancer centers. Patients completed PROMs at home 5-15 days into a chemotherapy cycle. Feasibility was operationalized as ≥ 75% completed PROMs and ≥ 75% patient acceptability.

RESULTS

Stakeholder priority PRO-PMs for systemic therapy were GI symptoms (diarrhea, constipation, nausea, vomiting), depression/anxiety, pain, insomnia, fatigue, dyspnea, physical function, and neuropathy. Recommended risk adjusters included demographics, insurance type, cancer type, comorbidities, emetic risk, and difficulty paying bills. In feasibility testing, 653 patients enrolled (approximately 110 per site), and 607 (93%) completed PROMs, which indicated high feasibility for home collection. The majority of patients (470 of 607; 77%) completed PROMs without a reminder call, and 137 (23%) of 607 completed them after a reminder call. Most patients (72%) completed PROMs through web, 17% paper, or 2% interactive voice response (automated call that verbally asked patient questions). For acceptability, > 95% of patients found PROM items to be easy to understand and complete.

CONCLUSION

Clinicians, patients, and other stakeholders agree that PMs that are based on how patients feel and function would be an important addition to quality measurement. This study also shows that PRO-PMs can be feasibly captured at home during systemic therapy and are acceptable to patients. PRO-PMs may add value to the portfolio of PMs as oncology transitions from fee-for-service payment models to performance-based care that emphasizes outcome measures.

A Case Report of Severe Type B Lactic Acidosis Following First Dose of Nivolumab in a VHL-Mutated Metastatic Renal Cell Carcinoma

We report a case of severe type B lactic acidosis (LA) in a 51-year-old male, 12 days after he received his first dose of nivolumab for metastatic Von Hippel Lindau (VHL)-mutated, clear cell renal cell carcinoma. Throughout his hospital course, infection, hypoperfusion, and tissue necrosis were not identified. We propose that his LA may have resulted from either inherent tumor glycolysis or immune activation and enhanced metabolism. The patient’s course was complicated by acute renal failure, and his LA rose progressively, eventually necessitating daily hemodialysis (HD). After receiving five consecutive days of HD, the patient started everolimus daily with the intent of reducing glycolytic metabolism. Subsequently, the rate of lactic acid production slowed, and HD was no longer required after two doses of everolimus. To our knowledge, this is the first reported case of type B LA following nivolumab administration, and the use of everolimus to treat type B LA in a patient with renal cancer.

Comparison of initial and recertification QOPI scores: Maintaining compliance through direct surveyor and practice interaction

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Background: Since 2006, the ASCO QOPI certification program has certified 322 practices, of which 197 practices have recertified. This retrospective study compares the number and type of standards passed at the time of initial and subsequent re-certification, and examines if on-site audits at the original certification influenced re-certification scores. Methods: 87 unique US practices that obtained QOPI certification with on-site audits at the original and re-certification between 2006 and 2014 were included. 17 QOPI certification standards were included in the analysis. Standards are metric based, except 3 standards that are observable. We defined total score per certification round as the total number of standards passed and used a Wilcoxon Rank Sum Test to test the concordance of standards passed between rounds. Linear regression models were used to identify factors related to higher recertification scores. A two-sided p<0.05 defined statistical significance. Results: 31 practices (36%) showed concordance of the 3 observable standards in the initial and re-certification rounds. For standards that assess policies, procedure and credentials of the practice, and do not require direct observation, 52 practices demonstrated improvement whereas 14 did not (p<0.0001). In contrast, for the standards that require direct observation, only 22 practices showed improvement versus 34 that did not (p=0.07). Three standards were most commonly missed in both rounds: initial chart documentation and at each clinical visit, and double verification of chemotherapy administration. There were no significant predictors of higher recertification scores. Conclusions: Many diverse oncology practices are voluntarily achieving and maintaining QOPI certification. Sustainable improvement is easier to identify in policy-based measures compared to directly observed ones. Three standards not usually passed at recertification highlight the need for assessment of psychosocial and performance status, comprehension of treatment goals, and chemotherapy double-verification. On-site evaluation of practices is key for targeting and sustaining quality efforts.

Determining needs for nonmedical support during cancer care

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Background: The need for supportive care services during cancer treatment appears obvious but ranges from 7 to 100% are reported. (McMurray 2001) (Soothill K, 2001). The Commission on Cancer (CoC) requires programs to assess these needs. We report on the rates of identified needs and our survey methodology. Methods: VICC members developed a 41 element survey to assess financial, emotional, and educational needs. Surveys were made available to patients with instructions, but no facilitators (Method 1). Then the same surveys were personally given to patients by two trained research coordinators who randomly selected, instructed and helped patients to complete the survey (Method 2). We report the responses using the two study methodologies. The difference between the two studies was examined using the two-sided chi-square test. Results: Results are presented in Table below. Conclusions: The rate of self-reported need for supportive and educational services in our study was small, but a meaningful minority of patients require assistance with supportive care. Simple unsupervised surveys led to results which were very similar to those supported by more complex and expensive methodologies. These data will inform the design of future survey methodology as well as intervention targets for patient navigators. [Table: see text]

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

Purpose

To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology.

Methods

The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited.

Results

The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard.

Conclusion

As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards .

Measuring and Improving Value of Care in Oncology Practices: ASCO Programs from Quality Oncology Practice Initiative to the Rapid Learning System

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 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.

American Society of Clinical Oncology Policy Statement on Clinical Pathways in Oncology

The use of clinical pathways in oncology care is increasingly important to patients and oncology providers as a tool for enhancing both quality and value. However, with increasing adoption of pathways into oncology practice, concerns have been raised by ASCO members and other stakeholders. These include the process being used for pathway development, the administrative burdens on oncology practices of reporting on pathway adherence, and understanding the true impact of pathway use on patient health outcomes. To address these concerns, ASCO’s Board of Directors established a Task Force on Clinical Pathways, charged with articulating a set of recommendations to improve the development of oncology pathways and processes, allowing the demonstration of pathway concordance in a manner that promotes evidence-based, high-value care respecting input from patients, payers, and providers. These recommendations have been approved and adopted by ASCO’s Board of Directors on August 12, 2015, and are presented herein.

ReCAP: Feasibility and Accuracy of Extracting Cancer Stage Information From Narrative Electronic Health Record Data

PURPOSE

Cancer stage, one of the most important prognostic factors for cancer-specific survival, is often documented in narrative form in electronic health records (EHRs). Such documentation results in tedious and time-consuming abstraction efforts by tumor registrars and other secondary users. This information may be amenable to extraction by automated methods.

METHODS

We developed a natural language processing algorithm to extract stage statements from machine-readable EHR documents, including automated rules to choose the most likely stage when discordance was present in the EHR. These methods were developed in a training set of patients with lung cancer, independently validated in a test set of patients with lung cancer, and compared with the gold standard of Vanderbilt Cancer Registry–determined stage (when available).

RESULTS

In the combined data set of 2,323 patients (training set, n = 1,103; validation set, n = 1,220), 751,880 documents were analyzed. A stage statement was extracted from 2,239 (98.6%) patient EHRs (median, 24 documents per patient). Stage discordance was common, affecting 83.6% of these EHRs. Nevertheless, algorithmically derived stage accuracy was high in the validation set (κ = 0.906; 95% CI, 0.873 to 0.939), when including notes generated within 14 weeks from diagnosis.

CONCLUSION

Accurate stage determination can be achieved through automated methods applied to narrative text, despite the frequent presence of discordance in such data. Our results also indicate that stage can be automatically captured in a shorter timeframe than the 6-month window used by cancer registries, as early as 5 weeks from diagnosis. These methods may be generalizable to large narrative cancer data sets.

A breast analytics dashboard to allow near-real-time visualization of quality assurance data

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Background: Quality metrics for internal use (e.g. quality improvement; quality assurance [QA/QI] activities) and external use (e.g. accreditation; national quality reporting) are currently primarily obtained through retrospective manual data abstraction on subsets of patients, at a majority of cancer centers. Real-time QA/QI of all patients is attractive but requires collection of electronic data from disparate clinical systems that are rarely fully interoperable. We developed a dashboard to aggregate relevant clinical information in near real-time for QA/QI visualizations. Methods: Tableau® software was used to visualize data from multiple clinical systems at Vanderbilt University Medical Center (VUMC). Custom extract, transform, and load (ETL) processes were developed to collect radiology, pathology, professional billing, and clinical data on a daily basis. An integrated dashboard was developed through an iterative process involving physicians, nurses, and software engineers. As a pilot project, data from all patients with an image-guided breast biopsy obtained at VUMC from 2009-2013 was visualized. Results: 4177 biopsies were included in the visualized cohort as of June 2014. 3,210 (77%) of the biopsies were preceded by a BiRADS 4 or 5 mammogram. The annual biopsy rate increased by 51% over the time period. Despite this increase in volume, the median number of weekdays from BiRADS 4 or 5 mammogram to image-guided biopsy was stable at 5 days over the time period. Prior diagnosis status, lesion class, procedure type, and imaging exam type were also included in the dashboard. Conclusions: This pilot project demonstrates the ability to visualize near real-time clinical data for QA/QI purposes. Tableau® is interactive, so that certain patterns (e.g. the distribution of number of days from screening mammogram to biopsy) can be explored at a granular level. This functionality also allows the user to investigate why 23% of patients had no apparent imaging before biopsy. Based on a perceived pattern of delayed biopsy in certain outliers, QI efforts at VUMC are underway to ensure timely biopsy. Interactive visual dashboards such as the one described present opportunities to rapidly cycle QA findings into QI actions.

The measure of a physician, the measure of our practices: what we measure reflects what we believe

Physicians cannot charge forward with measures, incentives, penalties, and public reporting without first understanding how to allow for the appropriate variation of care as determined by patient beliefs, preferences, and comorbidities.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy

In 2009, ASCO and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

Results of the 2013 American Society of Clinical Oncology National Oncology Census

The pace of policy change in oncology is changing the landscape of how practices are organized.

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 American Society of Clinical Oncology Quality Oncology Practice Initiative

PURPOSE

Family history of cancer (CFH) is important for identifying individuals to receive genetic counseling/testing (GC/GT). Prior studies have demonstrated low rates of family history documentation and referral for GC/GT.

METHODS

CFH quality and GC/GT practices for patients with breast (BC) or colon cancer (CRC) were assessed in 271 practices participating in the American Society of Clinical Oncology Quality Oncology Practice Initiative in fall 2011.

RESULTS

A total of 212 practices completed measures regarding CFH and GC/GT practices for 10,466 patients; 77.4% of all medical records reviewed documented presence or absence of CFH in first-degree relatives, and 61.5% of medical records documented presence or absence of CFH in second-degree relatives, with significantly higher documentation for patients with BC compared with CRC. Age at diagnosis was documented for all relatives with cancer in 30.7% of medical records (BC, 45.2%; CRC, 35.4%; P ≤ .001). Referall for GC/GT occurred in 22.1% of all patients with BC or CRC. Of patients with increased risk for hereditary cancer, 52.2% of patients with BC and 26.4% of those with CRC were referred for GC/GT. When genetic testing was performed, consent was documented 77.7% of the time, and discussion of results was documented 78.8% of the time.

CONCLUSION

We identified low rates of complete CFH documentation and low rates of referral for those with BC or CRC meeting guidelines for referral among US oncologists. Documentation and referral were greater for patients with BC compared with CRC. Education and support regarding the importance of accurate CFH and the benefits of proactive high-risk patient management are clearly needed.

2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy

In 2009, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) published standards for the safe use of parenteral chemotherapy in the outpatient setting, including issues of practitioner orders, preparation, and administration of medication. In 2011, these were updated to include inpatient facilities. In December 2011, a multistakeholder workgroup met to address the issues associated with orally administered antineoplastics, under the leadership of ASCO and ONS. The workgroup participants developed recommended standards, which were presented for public comment. Public comments informed final edits, and the final standards were reviewed and approved by the ASCO and ONS Boards of Directors. Significant newly identified recommendations include those associated with drug prescription and the necessity of ascertaining that prescriptions are filled. In addition, the importance of patient and family education regarding administration schedules, exception procedures, disposal of unused oral medication, and aspects of continuity of care across settings were identified. This article presents the newly developed standards.

Assessment of quality improvement efforts by ASCO’s Quality Oncology Practice Initiative (QOPI) participants

55

Background: More than 600 practices have participated in ASCO’s QOPI since 2006. 192 have achieved certification through the QOPI Certification Program (QCP) since 2010. QOPI assesses greater than 150 performance metrics, organized into modules; QCP evaluates 20 chemotherapy-related standards. QI efforts resulting from QOPI/QCP participation have not been assessed, e.g. which measure areas or standards are preferentially selected by practices for local QI projects. Methods: A survey was sent to 1,450 participants at 850 practices to assess which measure modules/standards were selected by QOPI/QCP participants as the basis for local QI efforts and to understand the nature of the improvement initiatives. Results: 89 participants responded. 96% (85/89) respondents reported QOPI/QCP led to QI efforts. Respondents were asked to select module/s that spurred subsequent QI activities: core measures (57%; n=45), symptom/toxicity management (48%; n=38), end-of-life care (38%; n=29), breast cancer (13%; n=10), colorectal cancer (10%; n=8), NHL (6%; n=5) and NSCLC (4%; n=3). Related to the QCP structural safety standards, participants reported QI projects as follows: chemotherapy planning/chart documentation (39%; n=31), general chemotherapy standards (30%; n=24), monitoring and assessment (29%; n=23), chemotherapy administration (27%; n=21), chemotherapy orders (23%; n=18), staffing (16%; n=13), drug preparation (9%; n=7). Practices reported that QOPI measures improved in subsequent rounds as a result of specific projects (n=22/25, or 88%); 100% felt that these QI projects impacted their practices for the better. QI project results were presented primarily in practice meetings (74%; n=26), hospital or community forums (17%; n=6), ASCO Quality Symposium or other meeting (9%; n=3). No projects reached publication. Of note, 17 of 31 respondents who reported practice status indicated achieving QOPI certification. Conclusions: QOPI participants select improvement targets throughout QOPI modules and standards. QOPI and QCP have succeeded in spurring local QI efforts that have led to score improvements, increased discussion of quality and standards, and a positive impact on practices.

American Society of Clinical Oncology National Census of Oncology Practices: preliminary report

In response to reports of increasing financial and administrative burdens on oncology practices and a lack of systematic information related to these issues, American Society of Clinical Oncology (ASCO) leadership started an effort to collect key practice-level data from all oncology practices in the United States. The result of the effort is the ASCO National Census of Oncology Practices (Census) launched in June 2012. The initial Census work involved compiling an inventory of oncology practices from existing lists of oncology physicians in the United States. A comprehensive, online data collection instrument was developed, which covered a number of areas, including practice characteristics (staffing configuration, organizational structure, patient mix and volume, types of services offered); organizational, staffing, and service changes over the past 12 months; and an assessment of the likelihood that the practice would experience organizational, staffing, and service changes in the next 12 months. More than 600 practices participated in the Census by providing information. In this article, we present preliminary highlights from the data gathered to date. We found that practice size was related to having experienced practice mergers, hiring additional staff, and increasing staff pay in the past 12 months, that geographic location was related to having experienced hiring additional staff, and that practices in metropolitan areas were more likely to have experienced practice mergers in the past 12 months than those in nonmetropolitan areas. We also found that practice size and geographic location were related to higher likelihoods of anticipating practice mergers, sales, and purchases in the future.

Report on the ASCO 2010 Provider-Payer Initiative Meeting

The ASCO Provider-Payer Initiative meeting was convened to explore ways in which providers and payers could work together to improve patient care.

Measuring the improving quality of outpatient care in medical oncology practices in the United States

PURPOSE

The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) has provided a method for measuring process-based practice quality since 2006. We sought to determine whether QOPI scores showed improvement in measured quality over time and, if change was demonstrated, which factors in either the measures or participants were associated with improvement.

METHODS

The analysis included 156 practice groups from a larger group of 308 that submitted data from 2006 to 2010. One hundred fifty-two otherwise eligible practices were excluded, most commonly for insufficient data submission. A linear regression model that controlled for varied initial performance was used to estimate the effect of participation over time and evaluate participant and measure characteristics of improvement.

RESULTS

Participants completed a mean of 5.06 (standard deviation, 1.94) rounds of data collection. Adjusted mean quality scores improved from 0.71 (95% CI, 0.42 to 0.91) to 0.85 (95% CI, 0.60 to 0.95). Overall odds ratio of improvement over time was 1.09 (P < .001). The greatest improvement was seen in measures that assessed newly introduced clinical information, in which the mean scores improved from 0.05 (95% CI, 0.01 to 0.17) to 0.69 (95% CI, 0.33 to 0.91; P < .001). Many measures showed no change over time.

CONCLUSION

Many US oncologists have participated in QOPI over the past 6 years. Participation over time was highly correlated with improvement in measured performance. Greater and faster improvement was seen in measures concerning newly introduced clinical information. Some measures showed no change despite opportunity for improvement.

Measuring the improving quality of outpatient care in medical oncology practices in the United States

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Background: The American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) has provided a method for measurement of process based practice quality since 2006. We sought to determine whether QOPI participants show improvement in measured quality over time, and if change is demonstrated, those factors in either the measures or participants which are associated with change. Methods: 156 participant medical practice groups, which did not submit trainee data, participated in at least two collection rounds from 2006 through 2010, and reported on ≥30 patients per round from were included in analysis from a larger group of 306 participants from this time period. A database of these reports was used to evaluate trends in scoring among participants. A linear regression model, which controlled for varied initial performance, was used to estimate the effect of participation over time and evaluate participant and measure characteristics. Measures were aggregated into categories to evaluate which factors correlated with change. Results: Participants completed a mean of 5.71 (S.D. 1.84) rounds of data collection. Adjusted mean quality scores improved from 0.71 (95% C.I. 0.42 – 0.91) to 0.85 (95% C.I. 0.60 – 0.95). Overall odds ratio of improvement over time was 1.09 (p < 0.0001). The greatest improvement was seen in measures assessing newly introduced clinical information, where the mean scores improved from 0.05 (95% C.I. 0.01 – 0.17) to 0.69 (95% C.I. 0.33 – 0.91), (p ≤ 0.0001). Many measures showed no change over time. Conclusions: QOPI has gained widespread adoption and approximately 15% of U.S. medical oncologists participate. Participation over time is highly correlated with improvement in measured performance. Much of this improvement is the result of the adoption of newly introduced clinical information. Some measures show no change despite significant opportunity for improvement.

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.