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Cancer Hospitals Study Yields 'Confusing' Findings

 |  By cclark@healthleadersmedia.com  
   June 05, 2014

Researchers investigating outcomes at accredited and non-accredited cancer hospitals arrive at "murky" conclusions, which may indicate problems with the way the quality of care is measured.


Karl Y. Bilimoria, MD
An Oncology Surgeon at Northwestern University

As might be expected, accredited cancer centers perform better on public process measures and patient experience than non-accredited hospitals. But they performed worse on most of 10 outcome measures such as rates of hospital-acquired infections.

That's the conclusion from a paper published in the June issue of the Annals of Surgery by Karl Y. Bilimoria, MD, an oncology surgeon at Northwestern University in Chicago and his colleagues. He says the inconsistent and surprising conclusions may indicate problems with the way the quality of care at cancer hospitals is measured.

Bilimoria looked at data from the 1,168 hospitals with accreditation from the National Cancer Institute or the Commission on Cancer and 2,395 non-accredited hospitals.

"Most of us would agree that it's the outcomes that are the bottom line in healthcare. The one thing we really need to assure is that it is the best in hospitals where we choose to get care. But it didn't work that way for [these cancer accredited] hospitals. It was confusing to us," he says.

Bilimoria adds that the conclusions from the paper make the issue "murky and it's hard for patients to figure out what's going on. If they look at an NCI-designated cancer center, they see good process measure performance, and then bad outcomes, and that really isn't helpful."

Specifically, Bilimoria emphasizes, the research may suggest serious problems with the accepted way in which administrative claims data is adjusted for patient severity and case mix. Perhaps the algorithms do not reflect that patients treated at cancer-accredited hospitals are much sicker and more complex to start with, he says.

Also, his study didn't change his own mind about where he would go if he had cancer. He'd still seek care at one of the NCI's 68 accredited cancer hospitals or next, a CoC-approved hospital, he says. They are generally larger, and have more cancer-treatment resources and expertise, he says.

Bilimoria's team conducted the research to compare the only two ways patients have today to objectively evaluate quality of cancer at a hospital.

They can look at publicly reported measures on Hospital Compare as a proxy, even though most of those measures do not relate specifically to cancer care. Or, they can look at whether the hospital is accredited by a national organization such as the American College of Surgeons' Commission on Cancer or the NCI.

Those organizations periodically inspect the hospitals they agree to approve, requiring documentation for certain programs, training, and expertise.

For their research project, Bilimoria and his team compared 10 outcome measures, including death after serious morbidity, a composite of serious complications, central line bloodstream and catheter-associated urinary tract infections, glycemic control, and colon surgical site infection.

The process measures included four Surgical Care Improvement Project (SCIP) measures such as antibiotic administration, blood clot prophylaxis, and the use of beta blockers. He also compared results on patient experience surveys.

"We were interested in whether the results correlated," he says, acknowledging that he thought they would, with bigger, better-equipped cancer-designated hospitals scoring better on both counts.

The study also points to a critical need to develop better reporting of outcomes from acute care practices directly linked to treatments for cancer, which according to the Centers for Disease Control and Prevention affects 20.1 million living Americans. Cancer care spending is enormous, accounting for $1 in every $12 Medicare fee for service dollars.

No specific measures related to cancer care are currently required for hospitals that treat cancer patients, although that will change this fall when rules of the Patient Protection and Affordable Care Act require 11 Prospective Payment System-exempt hospitals to report a handful of measures.


First Ray of Sun Shines on Cancer Measure Reporting


Still, many of those measures also do not relate to cancer care but to adverse events like urinary tract infections.

What is needed, Bilimoria says, are measures that get to the heart of appropriate cancer care, such as "did (the cancer center and oncology team) deliver adjuvant therapy when it was indicated, did they stage the patient properly before surgery… and the question I get asked the most from my patients, did you get it all? Was there a negative margin?"

Asked how a hospital might be measured when the oncologist, radiation oncologist, and surgical oncologist perform separate functions in outpatient versus inpatient settings, Bilimoria says the system can be scored together in terms of "how well [members of the care team] work together.

"For example, how often do they hold tumor conferences and discuss the patient. That could be a measure of quality."

Problems with cancer treatment across the country are increasingly in public view. Last September, the Institute of Medicine's cancer report highlighted issues with lack of evidence-based care, inadequately credentialed providers, poorly tested regimens, and a tendency for oncologists to be less than honest

Bilimoria's research was supported by the ACS Clinical Scholars in Residence Program, the Northwestern Institute for Comparative Effectiveness Research in Oncology and the American Cancer Society-Illinois.

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