The delivery of cancer care in the United States is rapidly evolving. Approximately 70% of US patients with cancer are treated at community oncology centers, but it has become increasingly common for stand-alone practices to merge with larger hospitals. A report issued by the Community Oncology Alliance found that 609 private oncology practices have been acquired by or become affiliated with hospitals since 2008, representing an increase of 172%.1
Oncologists and administrators have striven to implement quality care metrics as treatment becomes more localized. The American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI) in 2006, with the goal of offering oncology practices the opportunity to assess their adherence to quality metrics and offer steps towards improved care delivery.2 The QOPI database included more than 1000 US oncology practices as of 2015.3
In order to better understand how QOPI can improve patient care and aid in the implementation of clinical pathways, Journal of Clinical Pathways spoke with Anne C Chiang, MD, PhD, assistant professor of medicine (medical oncology) at Yale School of Medicine, and chief network officer and deputy chief medical officer of Smilow Cancer Network (New Haven, CT). In her roles with Smilow Cancer Network, Dr Chiang manages operations for a conglomerated multitude of affiliated oncology practices providing care to patients throughout the state of Connecticut. In her role as chair of ASCO’s Quality of Care Committee, Dr Chiang has written and presented extensively on QOPI’s utility in strengthening value-based cancer care.
Can you talk a little about your roles as chief network officer and deputy chief medical officer for Smilow Cancer Hospital?
Smilow Cancer Hospital is the cancer hospital for Yale Cancer Center. In the last 5 years, we have acquired several practices in the community, and we now have 10 community locations and over 40 doctors working in the community, in addition to our main campus. We have doubled our chemotherapy and treatment volume by acquiring these community practices. Because Connecticut is such a small state, everything here has remained very cohesive, and we have a high degree of clinical integration. For example, all of the physicians in our community practices are Yale faculty members.
As chief network officer and deputy chief medical officer, I oversee the operations and the physicians working in our community practices. I am very interested in overall quality, because whenever you are delivering care in different places you really have to be able to measure it and be sure that you are uniformly providing the same quality of care.
Another big focus of my career has been clinical research. We want to be able to offer our patients in the community the latest and greatest advances in clinical trials. That dovetails with my interest in quality of care. Last year, I served as chair of ASCO’s Quality of Care Committee, and we really focused on how to measure quality best. For example, what metrics should be used? What can we do to encourage a culture of quality? What barriers exist to achieving quality across the whole nation?
Some oncologists have argued that difficulties exist in identifying appropriate quality measures in cancer care. Would you agree with that, and why?
Oncology and cardiology have been at the forefront of developing metrics for quality. ASCO’s QOPI represents the best metrics that oncologists have been able to develop for doctors caring for patients with cancer, and to the degree that these recommendations can be evidence-based, they are. A lot of them are very process-oriented, as well. So before you make a decision about what a patient is going to get for a treatment, you’re going to want to have the pathology and the chart available. You want to make sure the cancer is correctly staged and you have assessed the performance status. Then you want to make sure that as you take care of that patient, you are assessing their emotional distress and their physical pain, and that you have a plan of care. These are simple quality metrics that form the basis for QOPI.
I think what has been more difficult going forward has been developing outcome measures and cross-cutting measures. Cancer is so heterogeneous. Metastatic breast cancer patients can live for decades, whereas metastatic lung cancer patients might live a few years, if that. Even within a disease, you might see very different outcomes—a woman with hormone receptor-positive metastatic breast cancer will likely not have the same trajectory as a woman with triple-negative breast cancer. Across different kinds of cancers, patients with molecular mutations might be eligible for a targeted therapy, which could mean a very different outcome. Ultimately, it’s not so much cancer care, because there are multiple types of cancer. As we learn more about cancer, it’s going to be hard to figure out cancer metrics for cross-cutting measures. Similarly, we may not be able to rely on traditional outcome measures like overall survival or progression-free survival, because they will vary so much from one patient to the next.
This is the feedback we have given to Centers for Medicare and Medicaid Services (CMS) when we have commented on their requests for information regarding metrics. We want to emphasize the fact that cancer is very heterogeneous, so one metric may not serve all patients with a certain disease. But there are basic metrics for quality of care, and I think that QOPI has done a great job of finding those.
Can you talk a little more about what QOPI is and how it was developed?
QOPI has been ASCO’s signature quality program for more than 10 years, and since 2006, more than half of United States-based medical oncologists have participated in it. It is a way of looking at the care given. It uses two rounds of chart extractions, and according to the 26 core measures, you can measure very basic or very specific modules. Some of these are disease-based and very specific. Other domains include symptom toxicity and management. There are new modules involving palliative and end-of-life care. There are new domains that are currently being validated for their utility. If you choose to participate in QOPI, you abstract the charts based on those 26 core measures, as well as however many other modules you participated in. You can submit your data and receive a report to show how well you’ve done, as well as your national QOPI benchmarks. It allows you to benchmark your practice’s data nationally and to understand what are thought to be the major metrics in delivering care. It really is the road map for the development of quality care.
Another aspect of participation is QOPI certification. If your practice has a certain score, you are eligible to become certified, which is the only nationally available program available to certify a practice in the delivery of cancer care. The other available certifications are really hospital-based. I think that both participation and certification help to create a culture of self-examination and improvement. This is a grassroots program and was developed by oncologists, so the clinical metrics are very specific to how oncology is practiced. You can get detailed reports on your performance related to quality metrics, which shows you where you’re doing well and what areas could benefit from improvement.
That sounds similar to what the new Medicare Access and CHIP Reauthorization Act (MACRA) requirements will be. Is it not?
MACRA has several different areas. One area has to do with cost and value; one has to do with quality improvement; one has to do with performance metrics. QOPI is a qualified clinical data registry that has been recognized by CMS, and you can participate in the Physician Quality Reporting System through the oncology measures group reporting pathway through QOPI. So basically, there is a way to participate through QOPI that will meet the MACRA requirements.4 We want to make sure that participating in QOPI will help practices comply with MACRA.
During a presentation at the 2016 ASCO Annual Meeting, you mentioned that the last three QOPI abstraction rounds revealed several new and different areas of focus. One area you mentioned already was a new focus on supportive care.Psychology was another area. Why do you think these areas have emerged as important components of standard care strategies?
When I was talking about those data, I was also talking about some of the recent trends in employment. One aspect that we have seen a lot of lately is the migration of private oncology practices into hospital-based practices. Part of what is happening with cancer care is that as you start to go onto electronic medical records (EMRs) and create networks, you are not just looking at the care that you deliver in your one office. So you start to think about what other services you could deliver, and I think this represents an evolution in the way we think about cancer care. Cancer care is no longer just the chemotherapy that is prescribed by a doctor and administered by a nurse. It’s nutrition, it’s social work, it’s access to care coordination services, psychiatric and mental health services, financial counseling. We are now starting to have a more holistic view of not just treating the tumor, but looking at the impact cancer has on the individual and trying to support them.5
This also means that part of our care is going to be a little more expensive, because you need to be able to employ nutritionists, social workers, and other supportive care staff members. In our network, we have invested quite a bit of money to provide those services, because many of those stand-alone private practices didn’t have them before. In a private practice, it could be that the nurse is doing a lot of the work of trying to help the patient navigate the system. But the evolution of the overall scope of cancer care addresses more aspects of the patient’s environment, and it is a terrific trend that helps patients.
There are many patients in my practice who have very little disease burden, but they have so many other issues that affect their lives. When we were developing emotional distress screenings, we screened 800 consecutive patients with baseline distress thermometer, which indicates an emotional distress level from 0 to 10. Then we asked the patients to check what areas were of the most concern to them. It was so interesting to see the results, because the majority of patients may not be thinking of their cancer, per se. They may be more concerned about whether their spouse is going to lose their job because of the caregiving responsibilities. Being able to offer supportive services to patients is a very positive evolution in cancer care.
Have there been other findings from the QOPI data abstractions been surprising?
One of the things that is striking is that we still have work to do in basic areas. It’s not particularly exciting or cutting edge, but there are basic areas that really still need to be areas of focus. Are we asking our patients how they’re doing? Are we providing them management for constipation if they’re receiving opioid drugs for pain? We have to make sure that we are meeting the basic requirements, and I see QOPI as a road map for this. It should remind us that these aspects are just as important as the latest therapies and developments.
As we migrate to EMRs, we looked to see how many of our providers were staging their patients, and we found it was less than 30%. They might have been writing it in their notes, but when it comes to putting that staging in a specific field, people weren’t doing it. So, we did a focused quality improvement initiative, which brought us up to nearly 100%. Staging is a basic tenet of oncology. We need to know the tumor and stage of every patient who comes in, and we weren’t doing it—or at least, we weren’t documenting it. But a measure like QOPI can keep us focused on the basic, important metrics for cancer care.
What is the role clinical pathways can play in the ongoing implementation of treatment metrics?
We rely on ASCO guidelines, on National Comprehensive Cancer Network guidelines, and other society guidelines when we develop QOPI measures. Each individual measure is relatively labor-intensive, because you have to manually abstract data from the charts right now. What are the treatment decisions that people are making? We have to go and check individual decisions to determine whether they adhere to clinical guidelines. Looking to vendors for clinical pathways is something we are doing, and would probably be the easiest way to comply with some of the CMS demands going forth. Clinical pathways can prioritize research and clinical trials, and then to understand exactly what care is being given. If you can’t measure it, you can’t improve it.
I don’t think we can expect 100% compliance with clinical pathways, but I think that an 80/20 split is reasonable. You want most of your decisions being made according to clinical pathways, but all of them might not be realistic.
What do you think makes QOPI such an important research for the oncology treatment community?
QOPI is important, I think, because it connects oncologists to a community of people who are working on quality. The more you get involved with QOPI, you find that a lot of different practices have come into the fold. People get a charge out of working together to improve care. At the first ASCO Quality of Care Symposium, I did an informal survey to determine how many practices had done projects, and I found that lots of people had done work on better EMR tracking, better emotional distress screening—all of these different areas.
QOPI is a road map, but it is also a community that is working together to share best practices from one practice to another. That’s important, because when we come together and talk, no one has to start from zero.
References
1. 2016 community oncology practice impact report: tracking the changing landscape of cancer care. Community Oncology Alliance website. https://communityoncology.org/2016-coa-practice-impact-report/ Published October 4, 2016. Accessed November 22, 2016.
2. Quality Oncology Practice Initiative. ASCO Institute for Quality website. https://instituteforquality.org/quality-oncology-practice-initiative-qopi. Accessed November 22, 2016.
3. Quality Oncology Practice Initiative: participating practices. ASCO Institute for Quality website. https://instituteforquality.org/qopi/participating-practices. Accessed November 22, 2016.
4. Understanding Medicare payment reform (MACRA). American Medical Association website. ama.assn.org/practice-management/understanding-medicare-payment-reform-macra. Accessed November 22, 2016.
5. Chiang AC. Why the Quality Oncology Practice Initiative matters: it’s not just about cost. Am Soc Clin Oncol Edu Book. 2016;35:e102-107.
