“There needs to be more scientific rigor in how we do QI,” said Joseph O. Jacobson, MD, MSC, of Dana-Farber Cancer Institute and chair of this year’s ASCO Quality Care Symposium.
Two presentations, specifically, resonated with attendees after the sessions ended. Mary Dixon-Woods, BA, DipStat, MSc, DPhil, FAcSS, FMedsci, of the University of Leicester, in the United Kingdom, posed what seemed like a simple question to address: “Why is quality improvement so hard?” She noted throughout her presentation that “lean interventions in QI do not have a statistically significant association with patient satisfaction and health outcomes.” She called upon the QI cancer care community to work together to form a collective competence.
“It’s too easy to create a checklist and hyperfocus on just one aspect,” she said. Too many published studies are, in reality, simple observations on QI that lack statistical analysis rather than test the efficacy of the QI methodology from inception.
Attendees were also visibly moved by the presentation “Multiple Perspectives on Multidisciplinary Care,” given by Therese M. Mulvey, MD, of Massachusetts General Hospital Cancer Center/North Shore. Dr. Mulvey’s presentation concentrated on how overwhelming multidisciplinary care can be for both the patient and the caregiver.
Her heartfelt story centered on her husband’s cancer diagnosis; at 2 weeks postop, they arrived at the multidisciplinary care facility at 8 AM. “We were there until 5:30 that night. We met with people in speech and swallowing, nutrition, and nursing/navigation; financial counselors; a dentist; three residents; two fellows; a nurse practitioner student; and medical and speech students,” she said. “It was overwhelming.
“Multidisciplinary care is a promise of coordinated care throughout the disease trajectory,” she continued. “The expectation is the care team will be there, but often the team is not available when the bottom drops out.” Although she and her husband received “excellent care and excellent communication by each specialist,” there was conflicting information being provided, from the cancer stage, to the curative intent, to the risk of relapse.
Her advice to those involved in implementing or overseeing multidisciplinary care and measuring the effect on cancer care delivery: “Be mindful of the goal—is it patient-centered or physician-centered? How many people need to take the same history or perform the same exam? Set the stage for the patient of what to expect before the multidisciplinary care visit. Have prepared take-home collateral information,” she said. “Keep the message consistent.”
Multidisciplinary care is an area “ripe for study,” she said. “It is not sufficient to be concordant with guidelines alone.”
Dr. Jacobson said that this year’s Symposium identified the need for the patient’s voice to be heard when measures are created and QI initiatives are designed. “Patient and family input is essential to assure that our improvement efforts focus on the right targets,” he said.
Other notable studies presented during the General and Breakout Sessions follow.
Joseph V. Simone Award and Lecture
Dr. Joseph V. Simone and Dr. Patricia A. Ganz
Dr. Joseph V. Simone and Dr. Patricia A. Ganz
ASCO honored Patricia A. Ganz, MD, FASCO, of the UCLA Jonsson Comprehensive Cancer Center, with the inaugural award. “One of the most important aspects of oncology is ensuring patients have the best quality of life possible,” Dr. Ganz said during her award lecture.
“We need to ask what is quality patient care, and can quality be measured? Who needs to be accountable for quality? How does it relate to efficacy?” she said. The challenges to delivering quality cancer care are numerous, but the fragmentation of care and poor coordination of care often create massive information overload for both the health care provider and the patient, she said.
“Most quality measures assess the process of care, but quality is more than adherence to a set of guidelines,” she said. “Process measures do not always link to desired outcomes and value. Engaged patients seem to have better perceived health outcomes.”
Improving Cancer Care
A system-wide approach can improve a hospital’s capacity to facilitate and support the interprofessional and intraprofessional teamwork necessary for a diagnostic process transformation, according to a study led by Michael Fung-Kee-Fung, MB, MBBS, FRCSC, MBA, of the Ottawa Hospital (Abstract 50). The group found that it took between 15 and 225 days from a referral with suspicion of lung cancer to initial treatment, with a median of 117 days.
“The issue was multiple queues that were invisible to one another,” Dr. Fung-Kee-Fung said. Using the Lean and Constraints methodology, 270 technology-enabled actions were logged and resolved to support 57 process changes in workflow. By February 2015, the median time from referral to first treatment improved to 48 days (a 48% reduction).
“Intentionality is prudent,” Dr. Fung-Kee-Fung said. “Making the process visible to everyone is crucial.”
Leading QI Initiatives
In addition to improving the quality of patient care, the intervention has also resulted in substantial cost savings, as discussed during the oral presentation. “By implementing this new system, our goal was to reduce unnecessary patient discomfort, interruptions in treatment, and financial burden,” said lead study author Brian Hunis, MD, of Memorial Cancer Institute. “This triage system is applicable to all patients on active treatment, regardless to the type of therapy they are receiving. We believe that other oncology practices could easily mimic our model.”
Cost, Value, and Policy in Quality
Facilitating doctor–patient conversations
A survey of the pilot users of an online resource to facilitate doctor–patient conversations about cost of care indicated that the resource provides value to both patients and practices (Abstract 4). The online tool included printable worksheets for the 50 most commonly ordered cancer treatment protocols in the system. Although patients were not surveyed directly, staff reported that most patients appreciated knowing the costs of potential treatments, and no negative reactions to prices were reported. During the pilot phase, oncologists typically offered information on pricing only if the subject came up in discussion with the patient. “In future research projects, we hope to offer treatment cost information proactively to all patients,” lead study author Nora B. Henrikson, PhD, MPH, of the Group Health Research Institute, said in an ASCO press release.
Palliative care inpatient units
Palliative care can be a profit-generating aspect of a health care system, which may be desirable as more hospitals and care centers move toward accountable care organizations, said Sarina Isenberg, a PhD candidate at Johns Hopkins Bloomberg School of Public Health, who presented Abstract 2.
In 2012, Johns Hopkins Medicine established a six-bed palliative care inpatient unit (PCU). The PCU received patients as transfers and direct admissions, but the financial costs of the program were unknown. The goal of this study was to make a business case for the PCU to not only keep it, but to expand it within the hospital.
Using data from March 2013 to March 2014, the team used a three-prong approach that included calculations on the per-day variable cost of pre-transfer into palliative care and palliative care transfer.
Overall, the PCU saved a total of $3.43 million for Johns Hopkins Hospital. Further, hospice referrals increased 340%, reducing readmissions, although those assumptions were not factored into the analysis. Future plans include increasing the bed count to 12, and the group predicts the cost savings will be $6 million in its first year. “Palliative care is better care at a cost we can afford,” Ms. Isenberg said.
Science of Quality
According to new study data, women severely overestimate their risk of breast cancer recurrence (Abstract 175). Although women with ductal carcinoma in situ (DCIS) have a negligible risk of distant recurrence, and those with low-risk invasive (LRI) breast cancer have a recurrence risk of less than 10%, women overestimate their risk, and the impact of that overestimation has not been well studied.
As part of the iCanCare Study, the group surveyed a weighted random sample of 2,632 newly diagnosed patients with early-stage breast cancer treated in 2013 and 2014, identified through the population-based Surveillance, Epidemiology, and End Results registries of Los Angeles and Georgia about 3 months after surgical treatment. Women reported perceptions of their risk of distant recurrence on a scale of 0% to 100%, with values greater than 10% for DCIS and greater than 20% for LRI breast cancer considered substantial overestimates.
Thirty-eight percent of women with DCIS and 27% of women with LRI breast cancer substantially overestimated their risk of distant recurrence. Overestimation of the numeric recurrence risk was associated with race, level of education, stage (DCIS vs. LRI), and symptom bother. Overestimation of risk was significantly associated with lower education (high school education or less; p = 0.02). Patients with DCIS were more likely to overestimate risk of distant recurrence than patients with LRI breast cancer (odds ratio = 2.0, 95% CI [1.4, 2.7]).
Women who overestimated risk in both groups reported more worry about recurrence (49% vs. 16% DCIS; p < 0.001 and 54% vs. 24% LRI; p < 0.001). These women more often had higher distress, according to a 0-10 scale (mean of 3.5 vs. 2.5 for DCIS; p < 0.001 and 3.9 vs. 2.2 for LRI; p < 0.0001) and had poorer physical health (21% vs. 14% DCIS; p < 0.001 and 34% vs. 16% LRI; p < 0.001) and mental health scores (13% vs. 11% for DCIS; p value not significant and 21% vs. 7% for LRI; p < 0.001), according to the PROMIS scale.