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Vanderbilt-Ingram Cancer Center The Quality Oncology Practice Initiative: Oncologist Self-Assessment and Improvement Disclosures: None Outline Why measure.

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Presentation on theme: "Vanderbilt-Ingram Cancer Center The Quality Oncology Practice Initiative: Oncologist Self-Assessment and Improvement Disclosures: None Outline Why measure."— Presentation transcript:

1 Vanderbilt-Ingram Cancer Center The Quality Oncology Practice Initiative: Oncologist Self-Assessment and Improvement Disclosures: None Outline Why measure What is quality in oncology The ASCO QOPI process What difference does it make? How do we include patient reported outcomes? How do we adjust for comorbidities? How do we consider financial issues? Summary: Goldilocks was right

2 Vanderbilt-Ingram Cancer Center The Hawthorne Effect: Sponsored by National Academy of Sciences Western Electric Varied Room illumination Room temperature Breaks and work hours Piecework payment The measured production of telephone relays got better no matter what was done to work conditions F. Roethlisberger, W. Dickson and H. Wright Management and the worker: An account of a research program conducted by the Western Electric Company Harvard university press Cambridge, MA 1939

3 Vanderbilt-Ingram Cancer Center What is Quality Medical Care? American Medical Association: Care which encompasses 8 elements and in doing so contributes to improved outcomes, including affording improvement in the patients health, (2) emphasizing promotion o f health and prevention of disease (3) occur in a timely manner, (4) involve the patient in decisions and execution, (5) be based on accepted principles of medical science (6) be sensitive to the patient’s welfare (7) use technology efficiently and (8) be sufficiently documented to allow continuity of care (Council on Medical Service: Quality of care. JAMA 1986;256: ) Institute of Medicine: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Crossing the Quality Chasm, 1996)

4 Vanderbilt-Ingram Cancer Center Evaluating the Quality of Medical Care Avedis Donabedian Organizational structure Process measures Outcome – Function Life Prominent consideration of cost and “optimality” defined as “The balancing of improvements in health against the cost of such improvements.” Donabedian, A, Evaluating the quality of medical care The Milbank Memorial Fund Quarterly, Vol. 44, (pp. 166–203) 1966 Donabedian A, Bashshur RL An introduction to Quality Assurance in Health Care Oxford University Press, NY, NY 2003

5 Vanderbilt-Ingram Cancer Center Institute of Medicine, 1999 Ensure that patients are treated in appropriate venues Use guidelines for prevention, diagnosis, treatment and palliative care Measure and monitor the quality of care using a core set of quality measures Initial treatment plans should provide coordinated care with access to psychosocial support, clinical trials, and occur with the patients full consent after honest and full disclosure Care at the end of life must be of include access to palliative and hospice care Simone J and Hewitt M Ensuring Quality Cancer Care Institute of Medicine, Washington DC 1999

6 Vanderbilt-Ingram Cancer Center Quality Oncology Practice Initiative (QOPI) Founder: Joseph Simone, MD Retired Pediatric Oncologist, former Director of St. Jude’s Hospital Previous Co-chair of the IOM National Cancer Policy Board 2002: “Unless one engages practicing physicians in the basic structure, quality will never become part of the fabric of practice, the only route to a sustainable quality effort”

7 Vanderbilt-Ingram Cancer Center Sponsored by American Society of Clinical Oncology Participating Practices Available since 2006 Practice self reporting, twice annually, web based data report and secure HIPAA compliant storage and process About 20% of US oncology practices regularly participate Self examination and improvement, payment premium M. N. Neuss, C. E. Desch, K. K. McNiff, P. D. Eisenberg, D. H. Gesme, J. O. Jacobson, M. Jahanzeb, J. J. Padberg, J. M. Rainey, J. J. Guo and J. V. Simone A Process for Measuring the Quality of Cancer Care: The Quality Oncology Practice Initiative: Journal of Clinical Oncology: 23:

8 Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 8 QOPI Pilot Phase ( ) QOPI offered to full ASCO membership (2006) Measure and content expansion ( ) QOPI Certification Program Launched (2010) Evolution of QOPI ® “Unless one engages practicing physicians in the basic structure, quality will never become part of the fabric of practice… Joseph Simone, MD eQOPI iQOPI eQOPI iQOPI Expansion and design changes ( )

9 Copyright © 2013 American Society of Clinical Oncology. All rights reserved. 9 9 Last Update 11/10/14

10 Vanderbilt-Ingram Cancer Center Quality Oncology Practice Initiative (QOPI) Measures Five measure criteria – (1) applicable to ambulatory oncology practices – (2) intuitively collected – (3) based on chart abstraction – (4) amenable to improvement – (5) relevant and important to care

11 Copyright © 2013 American Society of Clinical Oncology. All rights reserved. 11 Comprehensive library of reliable and tested measures… More than 160 measures in use and maintained Ongoing efforts include: – Radiation Oncology – Prostate Cancer – Palliative Care – Patient Reported Outcomes Guideline s Indicator Development Prioritization for Measure Development Specification for Collection [QOPI] Test & Implementat ion Measures are selected and adapted by practicing oncologists 1. Evidence-based 2. Consensus

12 Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 12 Core Measures Care Documentation Chemo Administration Pain Management Smoking Cessation Psychological Support Disease– Specific Modules Breast Cancer Colorectal Cancer Non-Hodgkin’s Lymphoma Non-small cell Lung Cancer Ovarian, fallopian tube, primary peritoneal (gynonc) Domain– Specific Modules End of Life Care Symptom/Toxicity Management Palliative Care (2015) What We Measure QOPI ®

13 Vanderbilt-Ingram Cancer Center Measures showing improvement Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W. Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States JCO Apr 10, 2013: ; published online on March 11, 2013;

14 Vanderbilt-Ingram Cancer Center Measures with very high baseline achievement Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W. Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States JCO Apr 10, 2013: ; published online on March 11, 2013;

15 Vanderbilt-Ingram Cancer Center Measures resistant to change despite gap Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W. Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States JCO Apr 10, 2013: ; published online on March 11, 2013;

16 Vanderbilt-Ingram Cancer Center Model of accounting for varied baseline Michael N. Neuss, Jennifer L. Malin, Stephanie Chan, Pamela J. Kadlubek, John L. Adams, Joseph O. Jacobson, Douglas W. Blayney,and Joseph V. Simone Measuring the Improving Quality of Outpatient Care in Medical Oncology Practices in the United States JCO Apr 10, 2013: ; published online on March 11, 2013;

17 Vanderbilt-Ingram Cancer Center Adequate node exam in colon cancer Baseline from literature, 60% Requires surgery to be correct and node exam to be correct Medical oncology has little influence over process Awareness that node recovery had room for improvement, 1990 Awareness that node recovery correlated with survival, 2003 QOPI measure, fall 2006 How long did this take? 3 years, or 20?

18 Vanderbilt-Ingram Cancer Center Rate of change in medicine An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven 6 years from discovery to publication and dissemination 9 further years to get to 50% acceptance Balas EA and SA Boren Managing clinical knowledge for health care improvement, Yearbook of Medical Informatics, National Library of Medicine, Bethesda 2000 pp65-70

19 Vanderbilt-Ingram Cancer Center Collaborative improvement networks Financial incentives through alternative payment models Public reporting Larger acceptance How can we facilitate improvement?

20 Vanderbilt-Ingram Cancer Center Take drugs out- Newcomer et al* Pay per bundled episode** Pay for populations, reward efficient care *** Alternative payment models *Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model, Newcomer LN et al JOP Sep 1, 2014: (published online on July 8, 2014) **Episode-based payment for cancer care: A proposed pilot for Medicare, Bach PB et al, Health Affairs 30.3 (2011): ***Data-Driven Transformation to an Oncology Patient–Centered Medical Home, Sprandio JD et al JOP May 1, 2013:

21 Vanderbilt-Ingram Cancer Center Comorbidity adjustment Patient reported outcomes Financial factors and value Real outcomes – Survival – Functional days – ? Survivor’s experience What else should we measure?

22 Vanderbilt-Ingram Cancer Center Important Issues to Consider 1.Attribution of responsibility 2.Patient comorbidity and social circumstance 3.Randomness and infrequent events

23 Vanderbilt-Ingram Cancer Center Symptoms, quality of like and functional status Choose based on value/meaning to patient Standardize methodology, demonstrate reproducibility, gather benchmark standards Examples- – Pain – Nausea – Satisfaction with healthcare providers Patient reported outcomes

24 Value-Based Measures ASCO Board of Directors’ directive: priority is development value-based measures Value measurement projects –ASCO Top Five/Choosing Wisely 2013 Top Five 2012 implemented in QOPI –Expanding PQRS Measures –Policy-led project with Insurers

25 Vanderbilt-Ingram Cancer Center How do we approach value measurement? Total cost of care Parenteral drug costs per episode No. of lines of therapy for relapsed patients Costs in the last 30 days of life Diagnostic radiology use Laboratory service use Durable medical equipment use Surgical services, use and cost Febrile neutropenia occurrence rate Granulocyte colony-stimulating factor usage rate Erythropoetin use Emergency room and hospitalization rates Admissions for cancer symptoms Admissions for treatment-related symptoms Time to first progression for relapsed patients Hospice days for patients who died Days from last chemotherapy to death Survival from date of condition enrollment Febrile neutropenia occurrence rate Granulocyte colony-stimulating factor usage rate Erythropoetin use Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model Lee N. Newcomer, Bruce Gould, Ray D. Page,Sheila A. Donelan, and Monica Perkins JOP Sep 1, 2014: ; published online on July 8, 2014

26 Vanderbilt-Ingram Cancer Center How do we give the right care? Not too much, not too little? – Guidelines, with good definitions of adherence – Personalized care considered – Appropriate benefit plans to allow this care – Appropriate access 9

27 Vanderbilt-Ingram Cancer Center

28 Thank You!


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