Crossing the Quality Chasm

In 1999, the Institute of Medicine (IOM) issued a seminal report: Ensuring the Quality of Cancer Care. The researchers identified gaps in care and concluded that many US cancer patients did not receive the care known to be most effective for their disease. The findings surprised many oncologists because of the tremendous advances we were making in our scientific knowledge of cancer. It demonstrated that knowledge does not automatically translate to optimal care—it also motivated us to look at how we could better assess and improve the quality of cancer care.

During my presidency (1999-2000), the American Society of Clinical Oncology (ASCO) launched its groundbreaking study—the National Initiative on Cancer Care Quality (NICCQ). One of the purposes of the NICCQ was to measure and report on the quality of cancer care and to obtain results that inform quality improvement efforts. Gathering the data was a daunting task, but the researchers were able to harvest complete medical records for nearly 50% of the eligible patients. It's worth noting that the NICCQ was the first study of its size to look at the viability of obtaining all of the patient's medical records, not only from the oncologist, but also the primary care physician.

The good news was that the NICCQ showed that US cancer patients received higher-quality care than previous research indicated. In fact, most patients with breast or colorectal cancer in the five metropolitan areas studied received generally recommended care. The study also showed a need for improvement. Even though adherence to quality measures was higher than expected, the rate was less than 85% for approximately half of the quality measures.

Several important clinical recommendations for improving care were made in the NICCQ. One recommendation, however, has become especially germane in the current political environment. We found that chart reviewers had difficulty locating their patients' chemotherapy doses in the medical oncology records, simply because the process wasn't standardized. Similarly, treatment documentation methods proved to be inadequate, pointing to the need for an easily accessible treatment summary. As a result, ASCO is developing a template that oncologists can use as a treatment planning summary. Moving forward, proper documentation and more sophisticated methods for record-keeping will be vital steps in how we practice and measure the quality of our cancer care.

Linking validated quality care to payment has moved from a relatively obscure theory to reality. Congress has embraced this issue, seeing an opportunity to enhance quality and save valuable health-care dollars. At the end of 2006, legislation was passed that included certain bonus payments for reporting of quality care measures. Fortunately, ASCO has been ahead of the curve on this issue. In fact, over the past year ASCO and the National Comprehensive Cancer Network (NCCN) have worked to interdigitate the NICCQ's validated quality measures with NCCN practice guidelines. We've formally submitted these quality measures to the Centers for Medicare and Medicaid Services (CMS) and we hope this concerted effort will form the basis for the quality reporting that Congress has mandated.

What the future holds for oncology is unclear. With the advent of the Medicare Modernization Act (MMA), we have all seen dramatic changes in the way oncology is perceived and reimbursed. For sure, a number of practices are struggling with this transition. Balancing cost and quality care requires a lot of thoughtful examination, especially in a discipline as complex as oncology. That said, validated quality measures are here to stay in one form or another. I think over the next couple of years we'll see a substantial evolution in how Congress and CMS implement a system that links quality tools to reimbursement. Again, the oncology community must be an integral part of this process.

Although questions remain, the NICCQ was a major step in our understanding of quality care and how best to assess it. In a way, it prepped us for some of the changes that we currently see unfolding in our practices. Naturally, in today's taut fiscal environment, everyone wants cost-effective quality cancer care. Linking validated quality measures to payment is challenging, but not insurmountable. As oncologists, the best way to ensure that our patients receive the quality of care they deserve is by increasing our attention to assessing and improving the way we practice medicine.

—Joseph S. Bailes, MD