Quality-of-Care Measures for Cardio-Oncology

Abstract

This document serves as a perspective on quality assessments in the discipline of cardio-oncology. We aim to define the current landscape, identify needs for quality and outcome improvements, and propose a roadmap for establishing viable metrics to improve patient care. Specifically, this document: 1) addresses the current lack of measurable high-quality metrics in cardio-oncology and their implications; 2) highlights needs and topic-specific barriers; 3) illustrates the process and application of a measurable quality metric; and 4) provides a framework to demonstrate measurable value for the growing population of patients with cancer and cardiovascular diseases.

Central Illustration

Highlights

• •The discipline of cardio-oncology has entered into a new era focused on the quantitative as well as the qualitative.
• •Developing and applying quality metrics in cardio-oncology are essential steps toward improving patient outcomes.
• •This document serves as a first step in advancing quality metrics in the field.

Cardio-oncology has emerged as a new discipline at the intersection of cardiology and oncology/hematology, addressing the cardiovascular needs of patients with cancer.^1,2 These needs have increased over the years with the expansion of cancer therapeutics and the evolving spectrum of cardiovascular adverse effects, which can negatively affect clinical outcomes and survival. This momentum had driven exponential growth in cardio-oncology clinics and service lines worldwide, supported by organizations such as the International Cardio-Oncology Society (IC-OS), American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), European Society of Medical Oncology, and American Society of Clinical Oncology (ASCO).³

Scope of the Problem

As the field of cardio-oncology evolves, it is transitioning from a period of numeric and quantitative growth to one of qualitative advancements (Figure 1). Although numerous consensus statements and guidelines have been published,4, 5, 6, 7 most recommendations are based on expert opinion and data from nonrandomized clinical trials, resulting in a lower level of evidence (LOE) and, for some clinicians, reduced confidence in these recommendations. Consequently, significant variations in cardio-oncology practice patterns persist. For example, an analysis of a large U.S.-wide claims database confirmed that recommendations for cardiac function assessment in patients undergoing anthracycline therapy are not followed in one-half of cases.⁸ Quality and outcome analytics are important, not only for patient care, but also for payers and administrators. The future of cardio-oncology as a discipline will depend upon how effectively quality metrics are defined, measured, and translated into better outcomes for patients with cancer.

Figure 1.

Shift From Quantity to Quality in Cardio-Oncology

Growth in cardio-oncology has been traditionally measured by the number of new clinics or service lines established per year. However, as this trend reaches a natural plateau, improvements in the quality of care provided will become a more significant reflection of progress and growth in the field.

Goals of the Document

This document serves as a perspective from the IC-OS and ACC CardioOncology Section Leadership Council on quality assessments in cardio-oncology. In addition to introducing the topic, our goals are to define the landscape and needs for quality and outcomes in cardio-oncology, and to propose a roadmap for establishing viable metrics to improve patient care. Specifically, this document aims to: 1) address the current lack of measurable high-quality metrics in cardio-oncology and its implications; 2) highlight needs and barriers specific to this area; 3) illustrate the development and application of measurable quality metrics; and 4) provide a framework that demonstrates the value of cardio-oncology to the growing population of patients with cancer and cardiovascular diseases, as well as to the diverse subspecialties of clinicians who care for them.

The ACC, AHA, and ESC have established general frameworks and detailed performance and quality statements for various cardiology subspecialities.^9,10 This effort represents an initial preparatory step for advancing quality metrics in the field of cardio-oncology, with contributions from a collaborative group of international specialists in both cardiology and oncology. The team also includes cardiovascular quality experts, a nurse navigator, an oncology pharmacist, and an oncology patient advocate. We hope this document will spark international collaboration on cardio-oncology quality metrics, shaping the field and prioritizing optimal oncology and cardiovascular outcomes for patients worldwide.

Historical Perspectives (ACC/AHA Experience) and Definitions of Terms and Framework

With the rapid growth of cardio-oncology, developing performance and quality metrics is essential to ensure the timely translation of scientific evidence into clinical practice and improve patient care. Historically, implementing such metrics has shifted clinical care frameworks toward performance- and value-based models. In recent years, we have witnessed the rapid adoption of these metrics in heart failure (HF), a field with parallel needs for multidisciplinary, longitudinal management of chronic diseases similar to cardio-oncology.11, 12, 13 In patients with HF and reduced left ventricular (LV) ejection fraction (LVEF), greater fulfillment of performance metrics has been associated with a lower risk of HF readmission, reduced total hospital days, and improved survival, demonstrating an inverse dose-response relationship between the number of performance metrics met and mortality.¹⁴ Similarly, data from the Danish Heart Failure Registry found that meeting 76% to 100% of performance metrics was associated with a 57% reduction in mortality compared with those meeting 0% to 25% of metrics among patients with incident HF.¹⁵

To initiate similar discussions in the field of cardio-oncology, it is critical to define, validate, and achieve consensus on value specific to the discipline. In alignment with the Institute of Medicine (IOM) health care quality framework, there is a need to collectively construct metrics that embody key elements of care quality, including relevance, timeliness, safety, effectiveness, and equity (as outlined in the following text).¹⁶ Ideally, these metrics should be specific, attainable, and cost-effective while minimizing any additional burden on patients or caregivers—an especially important consideration for the cardio-oncology population.

Performance Metrics vs Quality Metrics

There is an important distinction between performance and quality metrics or measures in terms of their intent and roles.^9,17 Performance metrics require high levels of evidence and are used for public reporting and other forms of accountability. In general, performance metrics are developed from Class I recommendations with LOE: A, meaning they are based on high-quality evidence from multiple randomized clinical trials (RCTs), meta-analyses of high-quality RCTs, or 1 or more RCTs corroborated by high-quality registry studies.¹⁰ By contrast, quality metrics do not meet these stringent criteria; they are designed for self-assessment and quality improvement at the health care system level.¹⁷ Specific to cardio-oncology, there are currently no clearly defined performance metrics due to the evolving nature of definitive, high-quality evidence. Similarly, although there are no established quality metrics for cardio-oncology at present, they remain a viable consideration for self-assessment and quality improvement within cardio-oncology service lines.

Program Performance Versus Clinician Performance

Quality-of-care metrics can be assessed at both the individual clinician level or the group level.¹⁸ Although patients often seek information about the quality of care provided by individual clinicians, most quality metrics are reported at the group level (eg, group of physicians, hospitals).¹⁹ This approach is primarily due to the larger sample sizes of clinicians and “quality events” available at the group level, which enhance statistical power and reliability in detecting overall quality of care. Conversely, data from individual clinicians often lack sufficient numbers of quality events per reporting period—typically requiring at least 30 to 50 events per clinician—to ensure the reliability of these metrics.

Quality Metric Domains

The IOM has identified 6 domains critical to health care quality: Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-Centeredness (STEEEP).²⁰

Safety focuses on preventing morbidity and mortality, and is central to the discipline of cardio-oncology. Timeliness ensures that health care services are not delayed, which can have serious, even fatal consequences. In cardio-oncology, avoiding delays in diagnosing and treating cardiovascular complications of cancer therapies is crucial, with numerous recommendations issued over the years to address this concern. Efficiency measures how well resources are utilized, aiming to reduce unnecessary costs (eg, tests) and/or maximize benefits (eg, reducing side effects) without compromising, and ideally advancing, the quality of care. Effectiveness measures how well a health care service achieves its intended goals, as seen in assessments within childhood cancer survivorship groups.^21,22

Equity seeks to eliminate systemic disparities in health care delivery based on socially determined characteristics such as age, gender, ethnicity, religion, sexual orientation, socioeconomic status, physical ability, or geographic location. In cardio-oncology, equity strives to ensure every patient has an equal opportunity to receive the best possible care. Patient-centeredness emphasizes addressing patients’ needs, concerns, and preferences in health care planning and delivery. This is particularly important for cancer patients, emphasizing the role of shared decision-making. Cardio-oncology plays an educational and advisory role in this regard, especially before initiating cancer therapies that may carry cardiovascular risks.

In addition to the 6 domains of health care quality, the Donabedian model categorizes quality metrics into 3 areas: structural, process, and outcome (Figure 2). In cardio-oncology, a structural metric example is the number of clinicians with cardio-oncology subspecialty training, experience, or certification (eg, IC-OS or other recognized societal certification). A process metric might include analyzing the percentage of cancer patients assessed for cardiotoxicity risk before starting cancer therapy. Outcome metrics could include the rate of patients completing cancer treatment without cardiovascular complications or the rate of patients with cardiovascular disease receiving optimal cancer therapy after their cardiovascular status is optimized. Any selected metric should be easy to define, reasonable, reflective of its intended subject, reproducible in a variety of health care settings, and widely acceptable as a valid quality parameter by all stakeholders.^18,23

Figure 2.

Quality Metric Domains of the Institute of Medicine and Donabedian Models and Their Application to Cardio-Oncology

The introduction of these quality models aims, not only to define the quality of care in cardio-oncology, but also to drive improvements in identified areas of need. CTRCD = cancer therapy–related cardiac dysfunction; CV = cardiovascular; CVD = cardiovascular disease; IC-OS = International Cardio-Oncology Society.

An important consideration is determining who will measure these data—will it be the oncologist, the cardiologist, or a third-party entity such as the hospital’s quality and clinical governance division? Additionally, how will we measure quality in the context of late effects, which may occur months or years after active therapy and are often managed in primary care? Quality measurement data must be transparent and interoperable. Finally, it is essential to consider the outcome of the measured data—specifically, whether a clearly defined intervention will be implemented if a particular quality metric falls below expectations.²⁴

Cardio-Oncology Quality Metrics

Quality metrics are designed to facilitate and quantify the impact of implementing guideline recommendations, with the goal of improving patient outcomes and reducing variations in clinical practice.¹⁰ As evidence emerges, a quality metric may be considered for public quality reporting or for use in pay-for-performance initiatives, similar to performance metrics. As noted, for a quality metric to be promoted to a performance metric, it must be based on interventions, procedures, or treatments demonstrated to provide clear benefits (Class I) or harm (Class III) to patient health, supported by data from more than 1 high-quality RCT or meta-analyses of high-quality RCTs (LOE: A).²⁵ Class I and III recommendations, and adherence to them, often serve as a guide for defining and evaluating the appropriateness and quality of medical care. Notably, although this nomenclature is common in the cardiovascular field, oncology and hematology societies utilize different terminology, such as strength of recommendation (strong, moderate, weak) and quality of evidence (high, intermediate, low).^4,7

In cardio-oncology, only 2 guidelines are formally recognized as practice standards by major medical societies.^4,7 The first guideline is the 2016 ASCO Clinical Practice Guideline on the Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers, which includes 25 individual recommendations.⁴ Of these, 22 were classified as strong or moderate in terms of strength of recommendation, with only 1 deemed to have high-quality evidence and 13 based on intermediate evidence quality. The second is the 2022 ESC Guidelines on Cardio-Oncology, which includes 154 Class I and 4 Class III recommendations (of a total of 272 recommendations). Among these, 3% are based on LOE: A, 21% on LOE: B (data from a single RCT or large nonrandomized studies), and 76% on LOE: C (derived from retrospective or small studies, registries, or expert consensus).⁷

In parallel with the development of the 2022 ESC Guidelines on Cardio-Oncology , a group of experts performed a systematic review and identified 14 quality indicators (5 of which were considered primary) across 5 domains: 1) structural framework; 2) baseline cardiovascular risk assessment; 3) cancer therapy–related cardiovascular toxicity; 4) predictors of outcomes; and 5) monitoring of cardiovascular complications during cancer therapy, as outlined in Supplemental Appendix A.²⁶

Application of Quality Metrics to Cardio-Oncology

Developing quality measures and metrics is a multistep process, outlined by the ACC and AHA Task Force on Performance Measures and presented in the Central Illustration.⁹ The aim of this document is not to finalize the selection of specific metrics but rather to introduce and illustrate a roadmap for cardio-oncology quality metrics. In the Central Illustration, Tasks 1 and 2 focus on identifying all or subsets of patients with cancer (target population)—before, during, or after cancer treatment (observation period)—undergoing risk stratification, monitoring, or treatment (dimension of care). Task 3 involves reviewing the most recent literature and relevant expert consensus statements and guidelines. Tasks 4 and 5 of the ACC/AHA methodology utilize Class I and III indications as a basis for defining and selecting quality measures of interest. The ESC Guidelines on Cardio-Oncology included 37 Class I recommendations with higher LOE (LOE: A or B), detailed in Supplemental Appendix B.

Central Illustration.

American College of Cardiology/American Heart Association Methodology for Developing Cardio-Oncology Quality-of-Care Measures

The development of quality-of-care metrics in cardio-oncology involves completing tasks to construct metrics, determining their feasibility, and ultimately measuring and evaluating these metrics.

Although the intent of this effort is not to conduct a formal quality metric selection process, each member of the writing committee identified their top 5 recommendations, considering factors such as practicality, achievability, impact, and measurability across diverse clinical settings. The recommendations most commonly highlighted by the writing group are listed in Table 1. In accordance with the ACC/AHA methodology, “a review of existing performance measures being promulgated by other professional organizations should be conducted.”⁹ For cardio-oncology, these include the ESC quality indicators and the NCCN quality and outcome measures, as detailed in Table 1.^26,27

Table 1.

Potential Quality Measures in Cardio-Oncology

Dimension of Care	Recommendations per Practice Guidelines	Potential Quality Area	Timing of Measure	Similar Suggested Measures
Risk stratification	•Cardiovascular toxicity risk stratification before starting potentially cardiotoxic anticancer therapy (2022 ESC Guidelines)7 • Patients with cancer who meet any of the following criteria should be considered at increased risk for developing cardiac dysfunction (2016 ASCO Guidelines)4: 1) High-dose anthracycline, chest radiation, or a combination of the 2 therapies, even at low doses 2) Anthracycline therapy followed by trastuzumab 3) Low-dose anthracycline therapy or trastuzumab therapy alone with any of the following: ○ ≥2 cardiovascular risk factors ○ ≥60 y of age ○ Compromised cardiac function (eg, borderline low LVEF [50%-55%], history of myocardial infarction, moderate or severe valvular heart disease) before or during treatment	Cardiovascular toxicity risk assessment	Before cancer therapy	ESC Cardio-Oncology Quality Indicator (Secondary 2.1, see Supplemental Appendix A)
Health status assessment	•Baseline LVEF assessment in all cancer patients before starting anthracycline chemotherapy or HER2-targeted therapies (2022 ESC Guidelines)7 •Comprehensive assessment including a detailed history, physical examination, screening for cardiovascular disease risk factors (eg, hypertension, diabetes, dyslipidemia, obesity, smoking), and an echocardiogram before initiating potentially cardiotoxic therapies (2016 ASCO Guidelines)4	Baseline cardiac function assessment	Before cancer therapy	ESC Cardio-Oncology Quality Indicator (Main 2.1, see Supplemental Appendix A) NCCN Quality and Outcomes Committee Quality Measure Concept (“Cardiac function is assessed before starting and at least every 4 months during trastuzumab therapy”)
Diagnosis	•LVEF assessment within 12 months of completing anthracycline chemotherapy (2022 ESC Guidelines)7 •Echocardiogram between 6 and 12 mo after completing cancer-directed therapy for asymptomatic patients at increased risk of cardiac dysfunction (2016 ASCO Guidelines)4	Follow-up cardiac function assessment	After cancer therapy	ESC Cardio-Oncology Quality Indicator (Secondary 3.2, see Supplemental Appendix A)
Treatment	•Heart failure therapy for patients with symptomatic cancer therapy-related cardiac during anthracycline chemotherapy (2022 ESC Guidelines).7 •Referral to a cardiologist for individuals with clinical signs or symptoms indicative of cardiac dysfunction (2016 ASCO Guidelines)4 •Referral to a cardiologist or a health care provider with cardio-oncology expertise for further assessment and management of patients with asymptomatic cardiac dysfunction during routine surveillance (2016 ASCO Guidelines).4	Appropriate therapy	During and after cancer therapy	ESC Cardio-Oncology Quality Indicator (Secondary 4.1, see Supplemental Appendix A)

ASCO = American Society of Clinical Oncology; ESC = European Society of Cardiology; LVEF = left ventricular ejection fraction.

Critical Review and Discussion of Potential Quality Metrics in Cardio-Oncology

Recommendations related to the assessment of cardiovascular risk, disease, and function before initiating potentially cardiotoxic cancer therapy received the most interest from this writing group from our survey. Indeed, a thorough cardiovascular assessment allows clinicians to identify pre-existing cardiovascular risks or diseases that need optimization before or at the start of cancer therapy and/or to develop a primary cardiovascular prevention plan. This assessment may also influence the choice of specific cancer therapies based on established cardiovascular conditions and informs cardiovascular surveillance strategies during and after treatment.

Overall, the management of cardiovascular disease, whether related or unrelated to cancer therapy throughout the cancer care continuum, affects not only cardiovascular disease morbidity and mortality, but also the risk of interruptions or terminations of cancer therapy, thereby impacting cancer outcomes. The 2016 ASCO Guidelines introduced a low/high-risk framework for cardiac dysfunction in cancer survivors exposed to anthracyclines, trastuzumab, and radiation therapy, defining 3 high-risk scenarios, as listed in Table 1.⁴

The Heart Failure Association of the ESC (HFA) and IC-OS have developed risk proformas for various cancer therapies, stratifying patients into various levels of cardiovascular toxicity risk—very high, high, intermediate, and low—based on data available for several parameters across multiple studies (Supplemental Appendix C).²⁸ The anticipated risk of future cancer therapy–related cardiovascular toxicity for each group is as follows: low risk (≤2%), medium risk (2%-9%), high risk (10%-19%), and very high risk (≥20%). A recent analysis from the CARDIOTOX registry (Cardiovascular Toxicity Induced by Antitumoral Drugs: Risk Assessment and Early Diagnosis; NCT02039622) indicated that the HFA-IC-OS score effectively categorizes patients by cardiovascular toxicity risk and shows strong predictive capability for anthracycline-related cardiovascular toxicity and all-cause mortality.²⁹ However, not all validation studies have been uniformly positive, highlighting the need for further studies across diverse populations and improved imputation of observations to enhance risk prediction scores.³⁰

Cardiovascular risk calculators such as the ASCVD, SCORE2, and SCORE2-OP scores can be applied as they would in the general population.31, 32, 33 However, these tools may underestimate cardiovascular risk in cancer patients and do not specifically predict cardiotoxicity. A summary of recommendations for cardiovascular risk assessment related to various cancer therapies is provided in Supplemental Appendix D.³⁴ Reassessing risk levels during and after therapy represents a subsequent step (Figure 3). It is important to address concerns about over-screening and its potential impacts. Ultimately, a shared goal between oncologists and cardiologists should be to ensure patients receive optimal cancer therapy with minimal cardiovascular risk and without unnecessary interruptions or discontinuations of effective treatments.^35,36

Figure 3.

Checklist for Cardio-Oncology Assessment and Management

The assessment and management of cardiovascular risk factors and diseases throughout the cancer care continuum may serve as a quality indicator for a cancer programs. Cardiovascular risk factors include diabetes mellitus, hyperlipidemia, hypertension, family history of early coronary artery disease (male <55 years, female <65 years), tobacco use (active/past), obesity (body mass index >30 kg/m²), obstructive sleep apnea, and chronic kidney disease Stage 3 or higher. Cardiovascular diseases include heart failure/cardiomyopathy, acute coronary syndrome, coronary artery disease, myocardial infarction, peripheral arterial disease, stroke, atrial fibrillation, valvular heart disease, deep venous thrombosis/ pulmonary embolism, and QTc prolongation. CVRF = cardiovascular risk factors; other abbreviations as in Figure 2.

Baseline assessment of LVEF may be part of the baseline risk assessment, although some argue that the likelihood of detecting an abnormality is low. However, several reasons support assessing LVEF before initiating potentially cardiotoxic therapies: 1) to assess the risk for HF; 2) to tailor specific anthracycline regimens based on the patient’s cardiac function; 3) to determine the need for medical management of abnormal LVEF and HF; and 4) to establish baseline indices and guide the frequency of surveillance. Multiple medical societies and associations recommend echocardiography as the first-line modality for evaluating cardiac function in cancer patients due to its accessibility, portability, cost-effectiveness, and lack of associated radiation.^7,37 Since patients typically present first to oncology, the oncology team is generally responsible for ordering and ensuring completion of these imaging studies. Therefore, quality improvement efforts must involve oncology and hematology providers, as effective communication and agreement across disciplines are key.

Barriers to the Implementation of Quality Metrics

The introduction of quality metrics in any field often encounters barriers such as lack of provider buy-in, lack of resources, and variability across health care settings, including challenges specific to rural settings.³⁸ Cardio-oncology shares these obstacles while facing additional unique challenges.

First, echocardiography—and particularly 3-dimensional echocardiography—may not be universally available as a routine screening procedure worldwide. In health care systems with a strong focus on cost containment, routine echocardiography for asymptomatic patients may not be covered by payers. Programs should not be penalized for measures beyond their control, but documenting such limitations may allow for the exclusion of these patients from quality metric assessments. In instances where routine echocardiography is unavailable, it may be reasonable to substitute cardiac biomarkers such as troponin and/or B-type natriuretic peptides, although the evidence supporting their use for cardiotoxicity screening is less robust.³⁹

Another complexity in the field of cardio-oncology is that patients are evaluated and managed by clinicians across multiple disciplines, including oncology, hematology, cardiology, or even primary care. This can make advocating for consistent quality metrics or ascribing primary responsibility for these metrics challenging and variable across health care institutions. Finally, another challenge arises for patients who travel for cancer care and subsequently return to their local oncologist for follow-up assessments, such as their 1-year posttreatment evaluation. Achieving consensus and support for common quality metrics will require collaboration and concerted effort among cardiology, oncology, and primary care societies.

Education and Research as it Relates to Quality in Cardio-oncology

Education on quality in cardio-oncology should be incorporated into the training curriculum, and approaches to improving health care quality and outcomes have been well-documented.⁴⁰ Examples include the National Patient Safety Education Framework of Australia and the WHO Patient Safety Curriculum Guide.⁴⁰ Cardiology and oncology have made dedicated efforts toward education, with many institutions establishing quality teams and champions who play an active educational role. These efforts should engage the broad community of clinicians caring for cardio-oncology patients, including hematology/oncology, cardiology, primary care, and both oncology and cardiology nursing staff. One example aimed at improving education on quality in cardio-oncology is the IC-OS Center of Excellence program, which includes quality improvement projects as part of its rating criteria. These quality improvement projects are listed on the IC-OS website, and webinars have been organized to educate the cardio-oncology community on their implementation.

With respect to research, there are 2 key facets to consider in cardio-oncology: the quality of the research itself and the research on quality and outcomes within the field. Improving the quality of cardio-oncology research requires a focus on rigorous basic science and translational studies using state-of-the-art (“cutting-edge”) technologies and RCTs rather than retrospective observational studies. RCTs remain essential for elevating the evidence base for practice recommendations. Moreover, multiple RCTs or 1 large-scale RCT are needed to generate a LOE: A recommendation in AHA/ACC or ESC practice guidelines. A single, non–large-scale RCT or observational studies are insufficient to support LOE: A. Meta-analyses may help address some of these limitations by aggregating evidence, but variations in RCT designs can make valid comparisons and integrative approaches challenging, underscoring the need for standardization.

Cardio-oncology is not unique in facing these challenges; <10% of recommendations from ACC/AHA and 15% from ESC guidelines published until 2018 were supported by evidence from multiple high-quality RCTs and characterized as LOE: A. Approximately 80% of strong (Class I or III) recommendations were not classified as LOE: A, and this pattern remained consistent from 2008 to 2018.⁴¹ Finally, initiatives and partnerships have emerged to fund clinical trials addressing patient-centered questions. Pragmatic trial designs and those leveraging administrative data and existing registries to capture baseline characteristics and long-term outcomes are increasingly being used to address these needs.

Regarding research on quality and outcomes, many fields of medicine have dedicated studies on this topic, with even entire journals focusing on it. In cardio-oncology, a significant portion of research inherently involves outcomes research, as it often assesses the cardiovascular outcomes of cancer patients and their therapies. However, there remains a need for focused studies on the quality of care provided and its impact on patient outcomes. Examples of such studies include those evaluating adherence to guideline recommendations for cardiotoxicity screening after anthracycline therapy or during trastuzumab therapy, as well as studies on electrocardiogram acquisition for QTc assessment.^8,42,43 An example highlighting the impact of cardio-oncology on patient outcomes comes from Taiwan, where the introduction of a cardio-oncology program reduced rates of LV function decline, other cardiovascular disease, and mortality among breast cancer patients receiving anthracycline-based cancer therapy.⁴⁴

Pathways to the Future

In this document, we have outlined various considerations for quality-of-care assessments in cardio-oncology. Looking ahead, we envision the development of quality metrics guided by a qualified panel, with engagement and guidance from the ACC, AHA, ESC, or other global cardiology society Quality and Outcomes Task Forces. This panel should also include representatives from relevant cardio-oncology councils and sections. In addition, it is imperative to involve the quality and outcome leaders from oncology/hematology societies. The organization of this effort could be facilitated through societies such as IC-OS, which embodies members from all relevant disciplines. The ultimate goal is to advance quality in cardio-oncology in a well-rounded manner, laying a solid foundation for future initiatives and resonating with the global community.

Once there is agreement on which quality metrics hold the most significance for the field of cardio-oncology, these can be implemented on a broader scale. In the United States, engagement with national registries such as the NCDR (National Cardiovascular Data Registry) could be pursued. Global registries, such as the cardio-oncology registry G-COR (Global Cardio Oncology Registry) and International ICI-Myocarditis Registry, represent early-stage efforts in this space and could incorporate dedicated and specific quality metrics once established.^45,46 Indeed, 1 of the stated future goals of GCOR is to include quality metrics and enable reporting to participating sites, with regional data distribution for benchmarking. Additionally, a pilot initiative to capture and report quality metrics could be launched across the IC-OS Centers of Excellence network. Limited voluntary initiatives like these are common in the quality and outcomes domain, serving as initial testing grounds for metrics and helping to identify roadblocks and measure the significance of designated measures before broader rollouts to the oncology community.

There is undoubtedly much more to be developed in the field of cardio-oncology. The discipline has entered a new era where growth must be measured, not only quantitatively, but also qualitatively. Initiatives in this field begin with the goal of making a meaningful difference in the lives of cancer patients. Quality metrics represent a next logical step, with the roadmap outlined in this document serving as a guide for future progress.

Funding Support and Author Disclosures

Dr Deswal has been supported in part by the Ting Tsung and Wei Fong Chao Distinguished Chair. Dr Herrmann has been supported by the National Cancer Institute (CA233610) and the Miami Heart Foundation; has received consultancy fees from AstraZeneca and Astellas; and has received royalties from Elsevier. Dr Rao has served on speaker bureaus for Boehringer-Ingelheim and Eli Lilly. Dr Deswal has been a consultant for Bayer. Dr Lopez-Fernandez has received speaker, advisory board, or consultancy fees from AstraZeneca, Bayer, Beigene, Bristol Myers Squibb, Daiichi Sankyo, Janssens-Cilag Ltd, Myocardial Solutions, Pfizer, and Philips. Dr Palaskas has received funding from the Cancer Prevention & Research Institute of Texas (CPRIT)grant RP200670, NIH/NCI grant 1P01CA261669-01, Andrew Sabin Family Foundation, Replimmune, and Kiniksa Pharmaceuticals. Dr Ruddy has received royalties from UpToDate, and her spouse is coinventor of a technology licensed by Mayo Clinic to Alivecor related to the application of artificial intelligence to the electrocardiogram.