AT THE QUALITY CARE SYMPOSIUM
ORLANDO (FRONTLINE MEDICAL NEWS) – A multifaceted portfolio of physician-led measures with feedback and financial incentives can dramatically improve the quality of care provided at cancer centers, suggests the experience of Stanford (Calif.) Health Care.
Physician leaders of 13 disease-specific cancer care programs (CCPs) identified measures of care that were meaningful to their team and patients, spanning the spectrum from new diagnosis through end of life and survivorship care. Quality and analytics teams developed 16 corresponding metrics and performance reports used for feedback. Programs were also given a financial incentive to meet jointly set targets.
After a year, the CCPs had improved on 12 of the metrics and maintained high baseline levels of performance on the other 4 metrics, investigators reported at a symposium on quality care sponsored by the American Society of Clinical Oncology. For example, they got better at entering staging information in a dedicated field in the electronic health record (+50% absolute increase), recording hand and foot pain (+34%), performing hepatitis B testing before rituximab use (+17%), and referring patients with ovarian cancer for genetic counseling (+43%).
“This [initiative] was quite resource intensive for the modest number of patients’ lives covered in our measurements,” commented lead investigator Julie Bryar Porter, MSc, administrative director of the Blood and Marrow Transplant Program and the Cancer Quality Program at Stanford Health Care. “However, it was encouraging that all metrics maintained their strong results or improved performance over time to meet their target.”
“The main drivers, I would argue, besides the Hawthorne effect, were a high level of physician engagement in the selection, management, and improvement of the metrics, and these metrics excited the care teams, which also provided some motivation,” she said. “We provided real-time, high-quality feedback of performance. And last but probably not least was a financial incentive for the CCP as a team, not part of any individual compensation.”
The investigators plan to continue measuring the metrics, to expand them to other sites in their network, and to add new metrics that are common across the programs to minimize measurement burden, according to Ms. Porter. “We also plan to build cohorts for value-based care and unplanned care like ED visits and unplanned admissions. Finally, we want to keep momentum going and capitalize upon a provider engagement in value measurement and improvement,” she said.
“Based on this work and prior abstracts, … there are many validated metrics to be used. So, to choose those metrics and to choose them through local leadership support, most importantly, engaging frontline staff and having their buy-in of the measures that you are collecting are important,” commented invited discussant Jessica A. Zerillo, MD, MPH , of the Beth Israel Deaconess Medical Center in Boston. “And this can include using incentives that drive such stakeholders, whether they be financial or simply pride with public reporting.”
To take this effort forward, certain issues will need to be addressed, she maintained. First, “how do we sustain data collection and change with the fewer resources that continue to be available to us? How do we integrate quality measurement into overall system metrics so that we can demonstrate to our administrative colleagues that the work that we do in quality has an importance at the system level? And lastly, how do we implement patient-reported and long-term outcomes to enhance these measures?”
“In the summer of 2015, we were starting to feel a lot of pressure to prepare for evolving reimbursement models,” Ms. Porter said, explaining the initiative’s genesis. “Mainly, how do we define our value, and how can we measure and improve on that value of the care we deliver? One answer, of course, is to measure and reduce unnecessary variation. And we knew, to be successful, we had to increase our physician engagement and leadership in the selection and improvement of our metrics.”
Physician leaders of the CCPs were asked to choose quality measures that met three criteria: they were meaningful and important to both the care team and patients, they had pertinent data elements already available in existing databases (to reduce documentation burden), and they were multidisciplinary in nature, reflecting the care provided by the whole program. The measures ultimately selected included a variety of those put forth by American Society of Clinical Oncology’s Quality Oncology Practice Initiative and the American Society for Radiation Oncology. CCPs were offered a financial incentive for meeting targets ranging from $75,000 to $125,000 that was based on number of providers and patient volume, rather than on the impact of improved metric. “This was really meant for reinvestment back into their quality programs,” Ms. Porter said. “I would argue this was really a culture-building year for us, and we hope that next year there might be a little bit more tangible value with the metrics.”
The quality team gave CCPs monthly or quarterly performance reports with unblinded physician- and patient-level details that were ultimately disseminated to all the other CCPs. They also investigated any missing data for individual metrics.
Study results showed that half of the 16 measures the physician leaders chose pertained to the diagnosis and treatment planning phase of care, according to Ms. Porter. “It was important to many of our CCPs to ensure that specific testing was done, which would then, in turn, drive treatment planning decisions,” she commented.
At the end of the year, each metric was assessed among 13 to 2,406 patients. “All CCPs met their predetermined target and earned their financial incentive award for the year,” Ms. Porter reported.
Improvement was most marked, with a 50% absolute increase, for the metric of completing a staging module, which required conversion of staging information (historically embedded in progress notes) into a structured format in a dedicated field in the electronic health record within 45 days of a patient’s first cancer treatment. This practice enables ready identification of stage cohorts in which value of care can be assessed, she noted.
There were also sizable absolute increases in relevant CCPs in the proportion of blood and marrow transplant recipients referred to survivorship care by day 100 (+20%) and visiting that service by day 180 (+13%), recording of hand and foot pain (+34%) and radiation dermatitis (+21%), mismatch repair testing in patients with newly diagnosed colorectal cancer (+10%), referral of patients with newly diagnosed ovarian cancer for genetic counseling (+43%), cytogenetic testing in patients with newly diagnosed hematologic malignancies (+17%), hepatitis B testing before rituximab administration (+17%), and allowance of at least 2 nights for treatment plan physics–quality assurance before the start of a nonemergent radiation oncology treatment (+14%).
Meanwhile, there were decreases, considered favorable changes, in chemotherapy use in the last 2 weeks of life among neuro-oncology patients (–9%) and in patients’ receipt of more than 10 fractions of radiation therapy for palliation of bone metastases (–9%).
Finally, there was no change in several metrics of quality that were already at very high or low levels, as appropriate, at baseline: molecular testing in patients with newly diagnosed acute myeloid leukemia (stable at 95%), hospice enrollment at the time of death for neuro-oncology patients (stable at 100%), chemotherapy in the last 2 weeks of life for patients with sarcoma (stable at 0%), and epidermal growth factor receptor testing in patients with newly diagnosed lung adenocarcinoma (stable at 98%).