Development of Quality Measures Should Address Current Limitations

Charles Bankhead

November 2013, Vol 4, No 9 - ASCO Quality Care Symposium

San Diego, CA—A new sense of urgency surrounds the need to improve quality measurement, even as major gaps persist in existing measures, said Jennifer L. Malin, MD, PhD, Medical Director, Oncology, WellPoint, at the 2013 ASCO Quality Care Symposium.

The recently released Institute of Medicine (IOM) report on the status of cancer care has called for a national quality reporting system with meaningful measures that incorporate patient-reported outcomes. The report further calls for reimbursement based on providers’ ability to deliver affordable, patient-centered, high-quality care.

The Challenge of Quality Measures
To meet the challenges set forth by the IOM report, providers and payers must work together to address the limitations of current quality measures, “Many of the National Quality Forum–endorsed measures of quality lack variability, which limits their utility for public reporting or developing pay-for-performance strategies,” said Dr Malin. “They don’t allow us to discriminate variations in quality.”

Many measures lack specificity, making it difficult to determine whether a patient received the most efficacious or cost-effective therapy.

Low scores on quality assessments may reflect data problems. Public reporting of the data could lead to inappropriate expenditure of resources to improve the data infrastructure.

Few existing outcome measures have been validated, Dr Malin continued, and few measure overuse, which is as important as underuse. A final limitation of current measures is their failure to include the patient experience.

Patient-Centered Care
Efforts to address the limitations should begin with the need for patient-centered care. Borrowing from another IOM report, Dr Malin enumerated qualities of patient-centered care.

“This can involve many different domains, but I think the key aspects involve collaboration, sensitivity to nonmedical aspects of care, and respect for patient needs and preferences, as well as free flow and accessibility of information,” she said.

The feedback loop of patient-centered healthcare begins with quality measurement, which is critical to improvement in the delivery system. To make measurement meaningful, payment systems should be aligned with quality, not necessarily with volume or other outcomes traditionally rewarded by payment systems. The feedback should lead to accessible, affordable, high-quality care, said Dr Malin.

The development of meaningful quality measures in oncology can benefit from incorporating oncology-related contributions to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, which focuses on identifying widely used practices that have little or no supporting evidence. ASCO contributed 5 recommendations in 2012 and another 5 in 2013 (see article below).

Dr Malin illustrated the relevance of the Choosing Wisely campaign to quality improvement. ASCO’s Top Five recommendations for 2013 include not using positron-emission tomography (PET) or PET–computed tomography (CT) imaging for routine follow-up after curative treatment of a malignancy. Dr Malin cited a 2012 study that raised questions about the appropriateness of PET-CT use for 6 types of cancer, including lymphoma.

“It seems that with some tumor types, 50% to 70% of the time patients have multiple imaging studies in a very short period of time,” said Dr Malin. “We think about this in terms of cost, but I would argue that this is not very patient centered, because there’s a burden on patients to go back and forth for imaging studies. It usually requires their caregivers to take time off from work. There might be some complications with intravenous contrast. It’s not patient centered to perform testing that’s not necessary and that’s not going to change the management of the patient.”

Outcome Measures
One ASCO Top Five for 2012 involved the appropriate use of growth factors during chemotherapy. Dr Malin presented data from WellPoint showing wide variation in the use of colony-stimulating factors, from <5% to ≥65% cycles of chemotherapy.

Dr Malin’s list of potential recommendations to improve measurement began with the admonition to ensure that quality measures are specific enough to distinguish high-quality care from mediocre or bad care. For surgery and other therapies with meaningful short-term outcomes, outcome measures should be included in quality measurement.

Interim outcomes of importance should be addressed, such as treatment-related hospitalizations and emergency department visits. Quality measures should reflect the recognition that overuse is as important as underuse, Dr Malin said. As emphasized in the new IOM report, quality measures should capture patient experience.

Because efficiency is a key component of quality, quality-improvement efforts should devote time to the development of meaningful measures of efficiency. Quality measures should be relevant to all healthcare stakeholders, including patients and payers. Finally, data on quality-improvement efforts should be readily accessible to stakeholders.

“Transparency is critical,” said Dr Malin. “For quality measurement to change the healthcare delivery system, key stakeholders, especially patients, need access to the data.”