Figure 1.
Joseph S. Bailes, MD
The results are in for ASCO's National Initiative on Cancer Care Quality (NICCQ). They are encouraging, and they also reveal some opportunities for improvement. Published in the February 1, 2006, issue of the Journal of Clinical Oncology (pp 626-634), the study results show that patients with cancer receive higher-quality care than previous research indicated.
Most patients with breast or colorectal cancer in the five U.S. metropolitan regions studied received generally recommended care, based on expert-established quality-of-care measures. Women with breast cancer received a mean of 86% of recommended care, and men and women with colorectal cancer received 78% of recommended care. Adherence approached 100% for several quality measures, such as the technical quality of treatment of breast cancer.
We can have tremendous confidence in the findings because the NICCQ was one of the most comprehensive studies to look at the quality of cancer care. During my presidency, ASCO initiated the study after a 1999 Institute of Medicine report concluded that many people with cancer did not receive the care known to be most effective for treating their disease. In 2000, ASCO launched the NICCQ study to examine the feasibility of developing a national quality monitoring system for cancer care. We commissioned researchers from Harvard University (Cambridge, Massachusetts) and RAND Corporation (Santa Monica, California) to evaluate the quality of care for patients with a new diagnosis of breast or colorectal cancer. All patients were registered in a hospital cancer registry in Atlanta, Georgia; Cleveland, Ohio; Houston, Texas; Kansas City, Kansas; or Los Angeles, California. Investigators used data from patient surveys 4 years after diagnosis and from review of the patients' medical records.
This may be the first cancer care study to look at the feasibility of obtaining all medical records, including pathology and surgical reports and records from not only the oncologist but also the primary care physician. It was a daunting task, but the researchers were able to obtain complete medical records for nearly 50% of the eligible patients.
The NICCQ represents an important step toward monitoring and improving the quality of cancer care nationally. The study included the development of quality measures that can be applied in future studies and to other types of cancer to assess diagnosis, treatment, management of treatment adverse effects, and post-treatment monitoring. In addition, because they have been carefully validated, the NICCQ measures can be integrated into systems for quality improvement or systems that link compensation to quality of care.
The findings of the NICCQ study do show that there is room for oncologists to improve. Even though adherence to quality measures was higher than expected, the adherence rate was less than 85% for approximately half of the quality measures. I encourage you to read the complete findings of the NICCQ in JCO and to incorporate the validated quality measures, which are listed in the article's appendix, into your quality monitoring activities.
The authors made several recommendations for improving cancer care based on the NICCQ findings. They include the following: use the optimal chemotherapy dose, manage adverse effects of treatment, advise patients about all treatment options, and ensure that patients with cancer who are at highest risk of poor outcomes receive recommended care. Patients generally considered high risk include those with advanced disease, residents of rural areas, racial and ethnic minorities, non–English speakers, children, and older adults.
A final recommendation is to improve documentation of key information regarding patients' cancer and treatment. Perhaps the most surprising finding of the study was that it was difficult for chart reviewers to locate the patient's chemotherapy doses in the medical oncology records, because there was no standard place for that information. Furthermore, the oncologist's record typically did not have documentation of all the oncology treatments that the patient received, pointing to the need for the oncologist to compile an easily accessible treatment summary. Such a summary of treatment did not exist in the study data. ASCO is developing a template for a treatment summary, which is discussed on pages 95-96 in this issue.
Oncologists also should encourage their patients to keep copies of their medical records. This will make it easier in future studies of the quality of cancer care to find the pertinent information about a patient's treatments.
Although questions remain, the NICCQ study is a major step forward in our understanding of the quality of cancer care and how best to assess it. Investigators of the NICCQ are studying a huge amount of collected data, and we will continue to learn more. Additional publications will provide further insight to help to improve cancer care in the United States. In the meantime, we can all do our part to increase our attention to assessing and improving the quality of care we provide within our own practices.