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Institute of Medicine: Delivering High-Quality Cancer Care: Charting a New Course For a System in Crisis; Part VI: Translating Evidence Into Practice, Measuring Quality, and Improving Performance

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Welcome to part V; part I addressed the current landscape of cancer care, part II addressed patient-centered communication and shared decision-making, part III addressed the work force caring for patients with cancer, part IV addressed the evidence base for high quality care and part V focused on information technology (IT).  The final chapter of the IOM’s report focusses on translating evidence into practice, measuring quality and improving performance.  The reports summarizes existing measures of quality, but notes that none are adequate—“No current quality reporting program or set of measures adequately assesses cancer care in a comprehensive, patient-oriented way.”

 

The report reviews the types of quality metrics used in evaluating cancer care.  “Structure” refers to the setting in which care is delivered; it might include clinics, hospitals, human resources and organizational structure.  “Process” refers to whether specific procedures are followed.  “Clinical outcomes” are the measures we often talk about when discussing trial outcomes, such as survival.   “Patient-reported outcomes” measures the patients’ perceptions of their well-being.  “Patient’s perspectives on care” measures patients’ satisfaction with the health care they received.  “Cost” includes the financial cost of care to the system as well as to individual patients and to their families.  “Efficiency” measures the total time, effort, financial and other costs to produce a specific output.  “Cross-cutting” measures issues that involve different cancers or even different disease types, such as patient safety and care coordination.  “Disease-specific” looks at measures specific to a particular type of cancer.

 

While some good work has been done evaluating technical aspects of care, other areas lack a good body of evidence.  IOM cites access to care, care coordination, patient and family engagement, management of complex comorbidities, quality-of-life issues, reintegration into society and costs of care as areas where understanding of how to measure quality is limited.  It’s also hard to compare measures across clinicians or settings.  For example, a medicore surgeon who accepts only easy surgical cases in very healthy patients might have better survival numbers than a more talented surgeon who accepts challenging cases in patients with lots of medical problems.  Some cancer centers have taken to publishing their survival outcomes on the internet.  However, these numbers can be deceiving as different institutions have patients with different characteristics and might conduct staging and labeling differently.

 

The IOM proposes that quality metrics should be linked to reimbursement.  At the same time, the IOM recognizes potential problems with doing so. For example, while they value adherence to guidelines, they note that physicians should not be penalized for following patients’ preferences and values when they conflict with guidelines.

 

The IOM cites data that indicate that patients care about information on clinician quality (Harris, 2008) but rarely use exiting health care quality data in choosing a clinican (Faber 2009; Totten 2012).  Patients, doctors, and payers value different things when considering “quality.”  Patients value responsiveness to individual needs, access to and choice of clinicians and services, and maximization of quality of life and productivity.  Physicians see their own quality in terms of their ability to leverage their expertise to optimize patient outcomes.  Payers tend to view quality of care as efficient care that utilizes resources appropriately and in which patients are satisfied.

 

If electronic health records had been designed to measure quality, they might have had huge potential.  But, these systems were not designed to do so.  Instead, the major modalities by which quality data are gathered include manual chart abstraction and data entry.  Such activities are slow and expensive and the costs of measuring quality in this way are probably already being passed on to patients in the form of increased charges for services.

 

IOM recommends a national quality reporting program for cancer care.  They describe limitations to existing clinical practice guidelines and recommend that they be improved.  IOM seeks a “culture of change” together with activities to maximize use of clinical practice guidelines and foster positive change. 

 

The IOM has done a fantastic job of summarizing the state of cancer care and ongoing changes in it that will threaten the delivery of optimal care.  They have made numerous public policy suggestions to address these problems and to adapt positively to ongoing change.  Laying out this information is a key first step to empowering policy makers to enact good policy and will surely facilitate important conversations.  It is key reading for anyone interested in the systems by which we deliver cancer care, including patient advocates.  The extent to which these suggestions will succeed in making positive change will depend on political will.  Politicians and other health care policy makers will surely be aware of the report—the IOM’s reports tend to be well written, well read and heavily cited.  But, systems changes, especially those requiring action from government and other large institutions tend to be slow in the absence of dramatic crisis.  While the IOM may recognize the crisis and have consciously chosen to reference it in the title of their report, it is not clear to me that broader audiences yet recognize it or are ready to make expensive or difficult changes.


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