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First Ray of Sun Shines on Cancer Measure Reporting

 |  By cclark@healthleadersmedia.com  
   January 02, 2014

The healthcare industry has hundreds of measures stratifying quality of care for heart failure, pneumonia, and stroke, but nothing for cancer—until now. The PA Health Care Quality Alliance recently added five scores to its website.

Thirteen million people in the U.S. live with a cancer diagnosis, equivalent to the state of Illinois. A population the size of Milwaukee will die from cancer this year.

Yet there's no national public reporting of cancer care quality, though tests and treatments are known to vary enormously—from one hospital pathologist or oncologist or surgeon to another down the road.

The healthcare industry has hundreds of measures stratifying quality of care for heart failure, pneumonia, heart attack, and stroke. We can see who is a poor or great performer in 30-day readmission rates and mortality, hospital-acquired infections and conditions, emergency room wait times, surgical safety, stroke care, blood clot prevention, labor and delivery care, and many more.

But for cancer, nada. That is, nothing until just a few weeks ago.

That's when the Pennsylvania Health Care Quality Alliance (PHCQA) officially took the issue head on, augmenting quality reports it publishes for other diseases on its website with five scores for oncology care. The new "cancer center" tab shows rates of adherence to three breast cancer and two colon cancer process measures known to improve patient survival.

To date, 52 of the state's 72 hospital cancer programs agreed to have their data reported publicly on all five measures, even though for some the scores are nothing to boast about. And reporting on additional measures is coming soon.

Otis Brawley, MD, chief medical officer for the American Cancer Society and former assistant director of the National Cancer Institute, applauds the Pennsylvania initiative, saying, "I know of no other state or any other hospitals that publicly discloses this data."

This new transparency is what's needed to focus attention on the need for cancer specialists to practice according to evidence-based science, he says.

"Sometimes doctors tend to practice medicine according to what was best when they graduated from residency," Brawley says. "Continuing medical education [CME] requirements have allowed a group of doctors to practice what may have been very appropriate 20 or 25 years ago, but CME has not forced them to evolve as the science has evolved. Now, this sort of system [in Pennsylvania] may actually do just that."

Brawley estimates that in his experience, "a large minority"—as many as 25% of medical oncologists—"stray from published regimens governing cancer care, basically putting chemotherapy regimens together that have never been tested in any patient. I wish they would be much more focused on what the scientific studies show."

Variation in cancer performance scores comes from a reliable source: the American College of Surgeons' Commission on Cancer, which has monitored a growing number of quality measures for cancer centers nationally as a condition for their accreditation since 2005.

Daniel McKellar, MD, commission co-chair, explains that the CoC "has been providing accredited cancer programs with reports on their compliance with these measures so they can compare themselves to other programs. But we never made these public before."

"The PHCQA came to us and said, 'Boy, we'd really like to have some publicly reported cancer measures—would you consider working with us to allow accredited cancer programs to volunteer this data on our website?' And we thought this would be a great opportunity for public reporting on cancer."

These public reports raise all boats. For example, studies have proven that when surgeons remove and pathologists examine at least 12 regional lymph nodes, colon cancer patients have better survival rates because their disease is more accurately identified and staged, and thus, more appropriately treated.

When the commission launched that measure a few years ago, McKellar says, a mere 54% of cancer programs were evaluating all 12 nodes. Now, with a few years of reporting to the CoC, national program compliance is at 87%.

In Pennsylvania, hospitals that have work to do on this measure now know who they are, and so do their patients and payers. After all, cancer is expensive. One in every 10 federal dollars, primarily from Medicare, is spent on cancer screenings and treatment.

For example, on the 12-node measure, Crozer-Chester Medical Center in Upland, PA, scores only 48%, compared with Delaware County Memorial Hospital in Drexel Hill, only 10 miles away, which scored 100%. The pressure to improve is that much more intense.

An expert in socioeconomic and racial care disparities, Brawley notes that "our hospitals have really failed us" by not adhering to such cancer quality benchmarks for poor people as they do for wealthier patients.

"The pathologists in certain very large, very busy hospitals overrun with large numbers of poor people were resecting only two or three or four nodes from a colon cancer specimen," he says. "You would end up with a large number of patients being staged differently than they should be, and not treated appropriately."

Erik Muther, PHCQA's Executive Director, realizes that his group is doing something no one else has tried. They wanted to inspire the public to compare healthcare quality data, which consumers poorly understand, he says.

"We wanted to push the envelope, and we saw that cancer care is by far the most commonly researched clinical condition on the Internet, head and shoulders above heart disease. So if that's what they were looking for, we wanted to give them that," and in so doing, convey "the importance of quality measurement and how it ultimately affects cost of care."

A second reason tipped the scales for PHCQA to pursue this project. Muther notes that later this year, the Centers for Medicare and Medicaid Services is expected to publicly release cancer quality measure results for 11 big-name cancer hospitals, the so-called PPS (prospective payment system)-exempt centers including MD Anderson Cancer Center, Dana Farber Cancer Institute, and the City of Hope National Medical Center.

CMS regulations exempt these 11 hospitals from public reporting programs for general acute care hospitals because cancer centers don't treat conditions like heart disease.

But the Patient Protection and Affordable Care Act specified that CMS find evidence-based cancer measures to substitute, which it did, including adjuvant chemotherapy for patients with stage III colon cancer and two measures documenting combination chemotherapy for two types of stage II or III breast cancer.

"We thought, Well look, here are some cancer hospitals that do collect measure information [for this other program], but the vast majority of patients actually don't go to these cancer-specific hospitals; the majority of cancer patients are actually treated at non-cancer specific hospitals," Muther says. Why shouldn't the public have information about them?

One obstacle to better measurement compliance has been the practical fact that cancer patients often cross departments within an institution, "and it's not clear who is ultimately accountable for that patient: the primary care doctor, the one who diagnosed the patient, or the first or second specialist," Muther says.

With the advent of public reporting, he adds, "these measures become institutionalized so people understand what needs to be done, regardless of who is accountable, to deliver the right care to each patient."

Brawley points out that cancer has benefited from a lot more emotional forgiveness and delayed standard-setting than other life-threatening diseases like heart disease. He believes tighter scrutiny and care practice measures are long overdue.

"Maybe my own organization [the ACS] 80 or 90 years ago worked very hard to create that emotional tie to cancer," resulting in much less scientific scrutiny of whether treatments and testing actually work.

"Now that's changing, going away, and that's a good thing." Eventually, he sees many more cancer measures coming on line, especially those reflecting rates of needless care. It may take a few more years, he says, but "I think we're going to see a lot of growth in measures for cancer quality," he predicts.

I hope he's right.

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