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Some Cancer Hospitals' Quality Data Will Soon Be Public

 |  By cclark@healthleadersmedia.com  
   August 21, 2014

By year's end, CMS intends to post quality measures for 11 major cancer centers that until now have been exempt from public reporting. But a coalition of those centers worries that the agency is focusing on the wrong measures.

Before year's end, history in cancer care quality will be made.

That's when Hospital Compare will begin to show how well 11 prominent hospitals that annually treat tens of thousands of cancer patients perform on five quality measures. Another measure will be reported the following year.


>>>Alliance of Dedicated Cancer Centers

That's not all.

The Centers for Medicare & Medicaid Services will require reporting for another 13 measures by FY 2017. While many of these measures resemble those now required for other hospitals, most specifically deal with healthcare services only patients with cancer might get.

The 11 major hospitals, which include MD Anderson, City of Hope, Dana-Farber, and Memorial Sloan Kettering, had been exempt from federal quality reporting required of 3,500 other major hospitals. But a provision of the Patient Protection and Affordable Care Act changes that.

That's big news because spending on cancer care is estimated to approach $184 billion a year by 2020. The disease affects nearly 15 million Americans and kills nearly 600,000 a year. CMS believes that since cancer care practices vary widely, payers and patients should know what they're paying for.

Most of the quality measures about to be reported were developed or tested by the American Society of Clinical Oncology and the American College of Surgeons' Commission on Cancer, which accredits some 1,500 of the 2,500 hospitals that treat U.S. cancer patients.

Those hospitals report hundreds of data points to the American College of Surgeon's National Cancer Data Base, which has non-public records on 31 million cancer patients treated since 1988.

Objections Raised
But as with any new thing in healthcare, there are objections to the cancer center reporting program, some of which come from a consortium of the very same big-name cancer hospitals who must report. Barbara Jagels, NHA, OCN, RN, chairwoman for quality for the Alliance of Dedicated Cancer Centers, says the AODCC believes CMS is measuring the wrong things.

Except for three measures for rates of catheter-associated urinary tract, central line-associated bloodstream, and surgical site infections, all the CMS measures are "process" measures, not the preferred outcome measures, Jagels says.

Process measures only very loosely relate to whether treatment helped patients get better, and there isn't great evidence for many of them that they prolong or add quality of life, she says.

"They don't say whether patients at those hospitals had better outcomes, which is what matters most," she says.

Better measures would answer questions such as, "Did these centers help patients survive their cancer, and if they didn't help patients survive, did they improve the experience of a good death?" says Jagels, who is also the Chief Quality Officer and Vice President of Quality, Safety & Value for the Seattle Cancer Care Alliance, which includes the Fred Hutchinson Cancer Research Center, the University of Washington, and Seattle Children's Hospital.

"At their diagnosis, half of our patients will not survive their disease, and so we [have] recognized… that these measures did not meet our scrutiny to measure and improve quality."

Besides, Jagels emphasizes, for most of the process measures on the list, the 11 cancer hospitals are already well above acceptable levels.

The ADCC is pushing back by developing measures its members think matter more. Seven other major cancer centers that are not part of the 11, such as Duke Cancer Institute, Yale Cancer Center, and Emory Winship Cancer Institute, have joined the effort, creating what they're calling the C4QI, or Comprehensive Cancer Center Consortium for Quality Improvement program.

The consortium is confident CMS won't stop at 19 measures. That's because in its FY 2015 final rule, CMS stated its intent to assess how safely and efficiently cancer centers diagnose and treat the disease, how they use novel diagnostic and treatment methods, and how they assess symptoms and functional status.

Some Readmissions Required
CMS also wants measures for "quality of life outcomes and measures of admissions for complications of cancer and treatment for cancer" delivered in outpatient settings.

That worries these cancer centers, Jagels says, especially if down the road, CMS decides to penalize them financially.

Cancer hospitals that have looked at their admission and readmission data have seen "exceedingly high rates" of readmissions, she says. But when they've tried to learn why, they've found that many patients required a readmission on a planned basis, for example, for high intensity chemotherapy or radiation that required delivery in an acute care setting.

"There are valid reasons, and we don't want CMS to think this is a failure to adequately manage discharge planning," she says. There also is a concern that CMS does not plan to use good risk adjustment methodologies.

Developing C4QI's own readmission measures, which it plans to submit to the National Quality Forum's Measures Application Partnership soon for endorsement, "is first on our list," Jagels says.

Ideally, any readmission or admission measure would exclude patients needing inpatient care for follow-up or for unavoidable complications such as neutropenic fever syndrome that affects some patients.

The measure, however, should ding hospitals that readmit the most patients for extreme pain, or nausea and vomiting because, she says, "we think we should have done a better job managing [them] outside the hospital."

Another measure C4QI wants to include is rates of impotence and incontinence in prostate cancer patients who undergo prostatectomy. These rates can vary as much as 70% from hospital to hospital, depending on the surgeon and the type of surgery performed, Jagels says.

Other measures on the consortium's priority list address whether side effects such as shortness of breath are well managed in patients with stage 3 or stage 4 lung cancer, and at what point providers introduce a discussion of palliative care.

Jagels says C4QI believes the Commission on Cancer, the measure steward for many of the CMS cancer measures, should be leading the way to an outcomes-based approach.

"But for whatever reason, their leadership hasn't adapted. Meanwhile, we think there's a more novel, more patient-centered way to do this work."

David Winchester, MD, the ACS' medical director for Cancer Programs, disagrees that the existing measures aren't good ones, saying they are NQF-endorsed, "with level-one evidence based on randomized clinical trials." And, he says, they very much are related to outcomes.

It makes me scratch my head with disbelief that, with so much at stake for so many patients, we're only now coming into an era of cancer measure reporting. But once that gets going, I am with Jagels and the CMS. Bring on the outcomes measures so patients and payers can see what they're getting for this enormously expensive form of care.

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