The Quality in Oncology Practice Initiative (QOPI) is ASCO’s quality assurance initiative launched in 2006. It provides oncology practices with a tool for self-evaluation of the care they deliver and benchmarks for comparison. Furthermore, QOPI provides certification to those who submit their work for external audit. After certifying close to 300 practices in the United States, QOPI has launched an international effort. This year’s ASCO annual meeting marked a significant moment for our practice, as we were the first outside the United States to attain QOPI certification.
Certification was the result of a long road to quality improvement that started a number of years ago for us. We learned several important lessons from this process, among which that patient safety comes first. To ensure patient safety, we learned that all health care personnel should be involved in quality efforts; thus, nursing staff training became of utmost importance. Furthermore, we were reminded to always address the psychosocial in addition to the medical needs of the patient.
As the dust settles, one tends to evaluate the effort for its worth, and in the framework of expanding QOPI beyond the United States, important questions have arisen. Quality and value are ethical terms based on accepted concepts of what is good or bad, acceptable, and expected. However, as much as we live in an era of globalization, for better or for worse we are far from a globalized view of ethical concepts. One culture’s high-held ethical premise (eg, full explanation of prognosis to the patient) may be unacceptable in another. Obvious measures, such as fertility preservation, may be unacceptable or irrelevant in another society or religion. The epitome is probably advance directives, which are still not legal even in some European countries. In our case, the question of referral to hospice was always answered in the negative because hospice does not exist in Greece! One wonders whether this is only due to poor management by the state or to the tendency of Greek families to take over the terminal care of patients.
Different health care systems approach quality improvement in different ways, and a private initiative is more or less relevant in countries where health care is for the most part centrally managed. Then comes the greater other part of the world, that is, low- and middle-income countries (LMICs) where appropriate antiemetic or analgesic therapy is irrelevant because advanced antiemetics or, even worse, analgesics are plainly not available or are well outside the financial ability of the majority of the population. Therefore, in this context, one wonders how realistic and, more importantly, how relevant, the expansion of QOPI outside the United States is.
To answer this question, one needs to go back to the basics: The whys and hows lie in the fundamental values that brought 37,000 oncologists from all over the world to the ASCO annual meeting this year, many from LMICs where some of the latest discoveries simply are not relevant. Surely, science is an important unifying goal, but I suspect that for the most part, we were all there because we want to provide better care to our patients, and better is inherently an ethical concept, which by definition incorporates quality.
Therefore, I propose that qualitative amelioration is a universally accepted goal. This then automatically establishes a role for efforts that ensure the achievement of this goal. The road to this goal involves yet another universally accepted concept: You cannot improve what is not first measured. Furthermore, you do not want to measure the quality of oncology care with a tool used for a motor vehicle company.
So far, so good. A quality in oncology practice initiative is, by definition, useful to all persons involved in oncologic care and, above all, to all persons in need of oncologic care! In taking the next step, the key issue is to evaluate whether the quality points (measures and standards) put forth by QOPI should become global; that is, we should all agree that they are inherently universal in value and, therefore, that the world of oncology should be streamlined on the basis of these standards, that local quality standards should exist everywhere and local efforts should seek to meet those, or, finally, that a hybrid should be established. The latter approach is probably the most realistic and the one that maintains respect for the diversity of culture, ethical values, health care systems, and economies worldwide.
QOPI has some core measures that are seminal and constitutional in nature. For example, I believe it is universally accepted that the patient’s histology report should be in the chart. That is, of course, if there is a report (and if there is a chart to begin with). In some countries, having either may be a challenge but should nonetheless be a goal. A tiered approach could exist where in some countries, the measure reads: “If the tumor has been biopsied or resected, the pathology report is in the chart; or, if estrogen receptors have been tested, the results are in the chart; or, if estrogen receptor status has been established to be positive, hormonal therapy has been given.” Another universally accepted standard is that appropriate identification of the patient receiving a drug is necessary. No one would advocate that it is acceptable to administer chemotherapy to anyone who happens to be around!
In summary, I propose that certain standards are basic and universally accepted and that oncology practitioners worldwide should strive to meet them. In fact, they should be what new oncology clinics in LMICs are built upon. Among such standards are a biopsy-proven diagnosis whenever possible, the use of patient identifiers, patient record keeping, and safe chemotherapy handling. On the other hand, other measures may need adaptation to culturally appropriate ethical values or to other social and economic parameters.
Also relevant to this discussion is the concept of value. Value is a reflection of both what is meaningful to and what is expected by the patient and by society; thus, it is inherently tied to ethical, cultural, and economic parameters. Therefore, through outcomes research, some parameters should be established to aid not only in quality assurance but also, and more importantly, in the establishment of the organizing principles for cancer clinics worldwide. Such research may also be used in higher-income settings to reduce costs and overtreatment.
Therefore, as QOPI unfolds its international wings, it will take a hybrid approach to make this an immensely valuable tool, useful to oncologists throughout the world. ASCO should keep QOPI’s basic structure and values but work with the international community to adapt the measures, to some extent, to match the health care systems, cultures, etc., of other parts of the world.
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc.
Evangelia D. Razis
Honoraria: Roche, Genentech, Novartis, MSD, Pfizer, AstraZeneca, Bristol-Myers Squibb
Consulting or Advisory Role: Roche, Genentech, Novartis, MSD, Pfizer, AstraZeneca, Bristol-Myers Squibb
Research Funding: Celldex Therapeutics, Novartis, TESARO
Travel, Accommodations, Expenses: Roche, Genentech, Novartis, MSD, Pfizer, AstraZeneca, Bristol-Myers Squibb