Aug 23, 2013
ASCO has been active in the field of quality measurement and quality improvement in cancer care for more than 10 years, following the creation of the Quality Oncology Practice Initiative (QOPI®) in 2002. In 2012, in consideration of the significant resources and volunteer team now dedicated to quality care initiatives, the Society established the Institute for Quality (iQ) to oversee these crucial projects and help members stay abreast of the latest knowledge, innovations, and policies affecting cancer care quality. The Institute for Quality houses QOPI, ASCO’s Quality Care Symposium, Clinical Practice Guidelines and other practice guidance, and CancerLinQ, among other initiatives.
The Society has established itself as a leader in quality measurement and improvement, supporting every member of the care team in all practice settings and disciplines within oncology.
“Quality improvement is a team sport and the right thing to do for patients,” said ASCO Past President Douglas W. Blayney, MD, of Stanford University and Chair of the 2013 Quality Care Symposium Planning Committee and the QOPI Steering Group. “Quality measurement and improvement are mainstream, and they are facilitated by the maturation of health information technology.”
As quality measurement increasingly plays a role in physician reimbursement and quality improvement is incorporated into maintenance of certification, oncology professionals will all need to be rowing in the same direction. The tools provided by ASCO’s Institute for Quality are here to meet those needs.
Quality Care Symposium
The second annual Quality Care Symposium will take place November 1-2,2013, in San Diego. As with last year’s widely praised meeting, the program will feature abstracts, didactic presentations, and panel discussions on quality science, health services research, and oncology outcomes, as well as opportunities for networking with attendees and faculty. The Symposium will bring together leaders in the field to share new strategies, methods, and technologies for measuring and improving the quality of cancer care; address critical questions; and provide health care professionals with the tools needed to administer superior care.
The 2012 Symposium “exceeded our expectations in everyway,” Dr. Blayney said, citing the scientific merit and broad topic range of the abstracts; high attendance (nearly three times higher than the Planning Committee had originally anticipated) representing the breadth of oncology disciplines; and the “gratifying” level of attendee engagement with the presentations and speakers.
Quality of Care Committee Chair Carolyn B. Hendricks, MD, called the Symposium “a great marriage of health services researchers, improvement experts, and clinicians.” She sees patients in a single-physician community practice in Maryland and presented her experience participating in QOPI from a small-practice perspective at the 2012 symposium. “It was so exciting to see people fill an auditorium to talk about quality improvement,” she said.
Tools for a multidisciplinary audience
The meeting is multidisciplinary with respect to specialty, care-team role, experience level, and practice setting. Dr. Blayney noted the “great draw” of attending the symposium as a practice team, saying, “It’s an opportunity to observe not only what other physicians are doing, but how other teams are working.” The program will include sessions of interest not only to physicians, quality improvement experts, and health services researchers, but also to practice administrators, nurse practitioners, and physician assistants interested in taking a leadership role in their practice’s quality improvement efforts.
The program includes didactic lectures by experts in the field on abroad range of timely, relevant topics, including:
- Payment models and quality measurement
- Medical homes
- International perspectives on health care reform
- Treatment decision-making
- Patient-reported outcomes
Guided by attendee feedback from last year’s meeting, the 2013 Quality Care Symposium will include a series of talks on the science of quality measurement and improvement, covering such aspects as historical perspectives, new approaches, outcomes measures, and policy recommendations. “Quality improvement is a very new science and is still being developed. People are very interested in learning more about the actual research methods,” said Craig Earle, MD, of the Institute for Clinical Evaluative Science and Chair-Elect of the Quality Care Symposium Planning Committee.
Dr. Earle also noted a series of lectures on controversies in quality care as particularly exciting for this year’s attendees. “We’re going to be talking about the pros and cons of things like public reporting of quality data and the use of survivorship care plans as an instrument for quality. We’ll look at the Choosing Wisely® program, both how important it is and how challenging it is to adapt the Choosing Wisely measures into quality metrics,” he said. (Learn more about Choosing Wisely and ASCO’s Top Five list in oncology.)
Attendees will find discussion of the Patient Protection and Affordable Care Act’s emphasis on quality measurement woven into the program, as well as several sessions examining the use of health information technology for measuring quality and patient-reported outcomes. Many of the general sessions will feature perspectives from practices of various sizes and types who have undertaken quality improvement projects and offer practical advice for implementation.
A networking breakfast for attendees and faculty will take place on Saturday morning; fellows and junior faculty in particular are encouraged to attend to meet the leaders in the field. Complimentary continental breakfast and boxed lunches are provided on both days of the Symposium, and a complimentary wine and cheese reception will be offered on Friday evening.
Quality Oncology Practice Initiative
QOPI, ASCO’s physician-led quality assessment and improvement initiative, was developed to answer the question, “I think my practice provides high-quality care, but how do I know for sure?” Through chart abstraction and comparison to a set of evidence- and consensus-based quality metrics, practices participating in QOPI can see exactly where they are succeeding, areas for improvement, and how they compare to other participating practices. The process helps a practice create a culture of self-examination and improvement.
To streamline QOPI participation and reduce the time and resources currently required for chart abstraction and data collection, ASCO is working to enable electronic submission of key oncology information for QOPI, which will be known as eQOPI.
“The vision for eQOPI is to make quality measurement an integral part of practice, one that doesn’t require extra energy or resources, but simply draws upon data already entered into your EHR. In the current environment, manual data abstraction requires a fair amount of time and resources. With eQOPI, these could be shifted to focus on our real goal: quality improvement,” said Jennifer Malin, MD, of WellPoint, and a member of the ASCO Quality of Care Committee’s QOPI Steering Group.
The eQOPI reporting option will allow for upload of critical data directly from the practice’s electronic health records (EHRs) to ASCO for analysis and provide analyzed measure reports. Like traditional QOPI reporting, this report can guide future improvement efforts within the practice.
Ease of use for providers is the gating criteria for eQOPI reporting. “The fields that are desired for eQOPI reporting need to be aligned with those that are important for clinical documentation at the point of care,” Dr. Malin said. “We want to eliminate extra steps in the process, so that the physician or his or her staff do not have to remember to enter data for QOPI—they will be captured through fields that they already need to use for patient care.”
QOPI Certification Program
Committee members hope that the ease of participation in eQOPI will also help practices participate in the QOPI Certification Program (QCP™), which was initiated to recognize medical oncology and hematology/oncology practices committed to delivering the highest quality of cancer care. The program evaluates an individual practice’s performance in areas that affect patient care and safety. Valid for three years, 2013 marks the first round of certified practices apply for recertification.
The QCP is led by an Oversight Council of member volunteers, for which Joseph O. Jacobson, MD, of the Dana-Farber Cancer Institute, serves as Chair. Careful, physician-led oversight is essential to ensure that “certification status means something to patients, their families, payers, and referring physicians. When a practice is granted certification status, everyone knows that practice has reached a bar assuring that the safest possible care is being provided," Dr. Jacobson said.
The standards for QOPI Certification evolve as oncology practice evolves, with new standards applied in 2012 and 2013 to certifying or rectifying practices in three areas:
- Care is evaluated in five domains to determine whether a practice is meeting quality benchmarks. In the past, lymphoma was included as a domain; however, because lymphoma is a less-common set of diseases, many practices did not see a sufficient number of patients with lymphoma to accurately measure the quality of care provided. Non-small cell lung cancer replaced lymphoma this year as a measured domain to reflect a more accurate picture of daily practice for many institutions. The other four domains remain constant: end-of-life care, symptom management, breast cancer, and colorectal cancer.
- In the past, the QCP measured 17 safety standards of chemotherapy administration. Three new standards have been added in 2013, increasing the total number of safety standards to 20. These new measures focus on safe administration of oral chemotherapy. “We recognize that oral chemotherapy is becoming more commonplace and that risks associated with oral chemotherapy can be as great as parenteral chemotherapy. Oral chemotherapy poses additional challenges, including how to assess compliance, how to educate patients and caregivers about the management of side effects and when to contact the provider, how to manage missed doses, and safe disposal of unused drug,” Dr. Jacobson said.
- Previously, practices would be selected at random for onsite audits to ensure a practice’s adherence to its policies and procedures in place around safe administration of chemotherapy. Now, 100% of practices will receive an onsite audit prior to earning certification status, a reflection of the vital importance of chemotherapy safety that makes certification status meaningful (implemented last year).
Dr. Hendricks noted the immediate, practical benefits of QOPI participation and certification. “It’s been really eye-opening to undergo this process, and I’ve learned something about my practice at every single round of data collection. My participation and certification in QOPI has truly improved the quality of care that we give, especially in terms of pain assessment and management, emotional distress, fertility preservation, chemotherapy and treatment summaries, and survivorship care plans,” she said. Although QOPI and QCP are currently limited to U.S.–based practices, there has been strong international interest in both programs. ASCO is exploring how best to overcome the disparate regulatory and operational challenges to international implementation, with the hope that all interested practices will be able to take advantage of quality assessment and improvement tools and resources.
Clinical Practice Guidelines
ASCO’s clinical practice guidelines have been providing the oncology community with best practices for a range of clinical situations since 1994. In order to better meet the needs of the ASCO membership, the field of oncology, and the evolving nature of clinical practice guidelines, ASCO has created a more nimble, faster-paced guideline development process.
Historically, the Clinical Practice Guideline Committee (CPGC), the approval body overseeing ASCO guideline development, adopted an evidence-based systematic review methodology—a formal process of reviewing and capturing the best available evidence in the medical literature, summarizing the findings, and presenting it to a panel of content and methodology experts—to create guidelines.
“The whole process is very labor- and time-intensive,” said Gary Lyman, MD, MPH, of Duke University, Chair of the Clinical Practice Guidelines Committee Methods Subcommittee, and Co-Chair of the Breast Cancer Guideline Advisory Group. “Historically, this process can take anywhere from somewhat less than a year to more than three years. Increasingly, there has been concern that the guidelines aren’t keeping up to date with the rapid changes and new information available in oncology, that the whole field is evolving so quickly that guidelines quickly fall behind on capturing and evaluating data.”
To stay on top of the most pressing oncology questions, ASCO has not only revamped its guideline development process, but the Society has also created a number of other tools to direct members in their day-to-day practices, such as provisional clinical opinions, guideline endorsements, and a formal consensus methodology to provide guidance in areas not well informed by evidence. The goal is to cover a broader range of cancers and provide oncology professionals with direction in a timelier manner.
New guideline process
Systematic review of evidence-based guideline development is time-consuming. In the past, guideline topics were selected on an ad hoc basis, making planning for predevelopment work difficult. In addition, to ensure quality, there is the issue of conflict of interest. Guideline panel co-chairs and at least 50% of the overall panel membership can have no perceived conflicts of interest within the topic discussed. As one can imagine, the process of finding a qualified expert panel meeting all the strict requirements can monopolize months, and this is before the evidence-based systematic review of the literature begins.
Now, new topics are being prioritized by standing panels for specific disease areas (called Guideline Advisory Groups) that oversee the development of guidelines in a general disease category. Currently, there are six Guideline Advisory Groups overseeing topic prioritization and endorsement opportunities in supportive care, survivorship, and breast, lung, gastrointestinal, and genitourinary cancers.
“Eventually, we plan on covering the entire spectrum of each major cancer from screening to diagnosis, to staging, early treatment, primary treatment, treatment of recurrent disease, advanced disease, to end-of-life care,” Dr. Lyman said.
Members of the advisory groups will decide and prioritize what guidelines are developed or updated for their topic area or disease site and when, thus minimizing the time delay associated with that aspect of guideline development. By streamlining the guideline development process, Dr. Lyman anticipates that guidelines will be released on a six- to 12-month schedule rather than 12-plus months.
Provisional clinical opinions
The purpose of a provisional clinical opinion is to provide members with guidance on compelling data that will substantially change oncology. ASCO wanted to develop a method to have an immediate response to practice-changing data, not within months or years, but within weeks. For this process, ASCO turns to the relevant Guideline Advisory Group to identify panel members with content expertise to do an expedited review and write a quick statement on recommended care options.
It’s important to note that provisional clinical opinions do not undergo an exhaustive review of the literature and therefore are not as high quality as a traditional ASCO guideline. However, they do contain expert opinion and provide some immediate guidance on new data where such guidance does not exist. A number of provisional clinical opinions have already been published on topics such as palliative care and epidermal growth factor receptor mutation testing for patients with advanced non-small cell lung cancer.
Guideline endorsements and adaptations
ASCO is not the only organization that publishes guidelines. The Society strives to endorse high-quality guidelines from other credible guideline development groups that might be helpful to ASCO members.
“The goal is to avoid needless duplication of effort,” Dr. Lyman said. “Ultimately, these new tools and approaches are intended to speed up the development of recommendations and to cover a broader range of topics without compromising the rigor and quality of ASCO guidelines.”
ASCO has endorsed a number of other guidelines to date, such as the Cancer Care Ontario Guideline on Adjuvant Ovarian Ablation in the Treatment of Premenopausal Women with Early-Stage Invasive Breast Cancer, and the Guideline for the Management of Fever and Neutropenia in Children with Cancer and or Undergoing Hematopoietic Stem Cell Transplantation.
Quality Improvement Training
The Institute for Quality will debut a new Quality Improvement Training program in fall 2013. The program will teach oncology providers to engage in successful quality improvement activities in their practice settings, and train oncology professionals to assume quality leadership positions and champion quality initiatives within their practices.
“I’m hugely excited about this program and hope that it will be successful, because there’s a real need for this kind of training,” said Dr. Jacobson, the program’s leader.
During the course of the training, participants will design, implement, and analyze a quality improvement project to solve a problem in their own clinical setting, “with the hope that at the conclusion, they will become the quality experts and leaders within their individual practice or institution,” Dr. Jacobson said. This kind of training will help oncologists be prepared to satisfy the American Board of Internal Medicine’s Maintenance of Certification (MOC) Part IV requirement, which requires that physicians undertake a quality improvement project every five years.
The pilot program will consist of three in-person meetings at ASCO headquarters and virtual education taking place over five months, beginning in October. Participants will attend as part of physician-led teams of two to three members, with 10 to 15 teams anticipated for the pilot. At the final meeting, participants will present the results of their projects to their peers.
Participants will benefit from the expertise of faculty members Dr. Jacobson; Doris Quinn, PhD, MSN, of The University of Texas MD Anderson Cancer Center; Timothy D. Gilligan, MD, MSc, of Cleveland Clinic; and Barbara Corning Davis, MS, CPHQ, of Partners Health Care, recognized leaders in the field. Dr. Quinn will outline the Quality Improvement Training program in a presentation at the 2013 Quality Care Symposium.
Although the application period for the inaugural Quality Improvement Training program has closed, general information is available online.
Virtual Learning Collaborative
This year, ASCO and the American Academy of Hospice and Palliative Care Medicine (AAHPM) announced a joint initiative: the Virtual Learning Collaborative (VLC) in Palliative Care. Amy Abernethy, MD, of Duke University Medical Center, is the Principal Investigator of the VLC project, which is supported by a grant from the Agency for Health Care Research Quality.
The three-year project will create an online technology platform to support education, collaboration, and quality improvement. With the VLC platform, ASCO and AAHPM will seek to efficiently and broadly disseminate evidence-based palliative care approaches in oncology. The VLC will include coordinated, customized learning modules, social networking capabilities, and a toolbox of evidence-based resources to help translate the latest research into practice.
Enabled by the VLC, 20 oncology practices from around the country will participate in a structured practice improvement pilot project starting in 2014. Pilot practices will report QOPI data on palliative care quality. They will share best practices and resources through the VLC, and benefit from expert and peer guidance as they implement local improvements. Qualitative and quantitative evaluation will assess oncology practitioners’ perceptions of the VLC, assess the effects of the VLC on performance related to primary palliative care, and inform additional refinements to the platform and the toolbox of content and resources. The ultimate goal of the project is to provide a proven palliative care toolbox to all ASCO members for use in their practices, and to leverage the VLC platform to address other targets for practice improvement.
“The VLC project builds on ASCO’s long-standing leadership in practice-based quality improvement and in fostering the delivery of palliative care in the oncology setting,” Dr. Abernethy said. “The collaboration with AAHPM brings dedicated expertise in palliative medicine and enhances the ultimate reach of the VLC.”
Unflagging support for every oncology professional
As the issue of quality measurement and improvement continues to rise in public consciousness and become codified in physician reimbursement and certification, ASCO will continue to provide tools, resources, and training to meet the needs of oncology professionals and ensure that every patient with cancer receives the highest-quality care.
“Quality care is going to be an incredibly important part of the organization,” Dr. Hendricks said. “Quality improvement is the direction we’re going, in a big way. We have a lot of interesting projects, and a lot of work to do.”