NEWS

Results of Cancer Care Quality Study Lead to Cautious Optimism, Caveats

Damaris Christensen

Many people with breast or colorectal cancer appear to be getting medical care according to national guidelines for treatment, according to initial findings from a large national study of the quality of care received by people with cancer. The results were widely viewed as surprising because a 1999 report by the Institute of Medicine had suggested that there were potentially important gaps in the quality of cancer care.

In fact, both the researchers who presented the work and those who heard the presentation at the American Society of Clinical Oncology (ASCO) meeting in New Orleans in June were quick to add caveats to the positive data, such as concerns that patients who died before they were contacted—and thus were not included in the study—might have gotten poorer quality care.

Concerns about the quality of cancer care prompted ASCO and several other specialty societies to establish the National Initiative on Cancer Care Quality (NICCQ). The researchers turned to breast and colon cancer first, both because they affect large numbers of people and because a number of quality measures were well established for these cancers. At the 2003 ASCO meeting, the NICCQ team reported that, according to questionnaires, patients were generally satisfied with the quality of cancer care they received (see News, Aug. 20, 2003, Vol. 95, No. 16, p. 1188). This year, they reported the initial findings from an analysis of the individual medical records.

Overall, said Eric C. Schneider, M.D., of the Harvard School of Public Health in Boston, "we believe that cancer care is generally very good, at least based on the results of this study, and for some indicators it is truly excellent." He noted that NICCQ adherence rates for quality of care measures were better than previously reported for breast cancer and comparable to or higher than similar measures reported for colorectal cancer. "Across the board, adherence rates for cancer appear to be higher" than for other chronic diseases or preventive care measures, he said.



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Dr. Eric Schneider

 

Data Details

The researchers looked at the number of patients who received care compared with the number of patients who should have received care among four broad topics: surgery and pathology, adjuvant chemotherapy, radiation therapy, and ongoing management of patients. For a number of measures in each area, the NICCQ researchers compared the number of patients eligible for a procedure or measure with the number of people who actually received it. For example, if a breast cancer was surgically removed, then the status of the estrogen and progesterone receptors on the tumor should have been checked and reported. In 95% of 1280 cases this information was properly reported in a patient's medical files.

In terms of surgical care, pathology reports might be worth focusing on in future studies of quality of care, said RAND researcher Jennifer Malin, M.D., who presented much of the NICCQ data at the ASCO meeting. Whereas 90% of breast cancer pathology reports reported the tumor margins, only about 73% inked the margins, she said. Further, there was some variation from city to city in reporting margin status. Likewise, Malin said, margin status was reported for only about 84% of rectal cancers, and there was substantial variation from site to site. Among colorectal cancer patients, the depth of invasion and lymph node status of the patient are key determinants to determining therapy, yet "we find that 10% of patients did not have that."

More than 90% of the breast cancer patients eligible for adjuvant chemotherapy received an approved regimen or were enrolled in a clinical trial, whereas 85% of colon cancer patients and 77% of rectal cancer patients did so, Malin reported. Older patients were less likely to get adjuvant chemotherapy than younger patients. This is often explained by the increasing likelihood that an older patient will have additional ailments that make chemotherapy difficult. However, when Malin and her colleagues examined the breast cancer data in detail, they found little variation in chemotherapy use with comorbid conditions; there was a "possible" drop-off in chemotherapy use with people suffering from three or more ailments in addition to their cancer.

When it came to radiation therapy, Malin and her colleagues reported that 99% of the 659 women who had breast cancer surgery and did not refuse radiation received treatment. However, only 69% of the 143 people with rectal cancer who were eligible for radiation therapy received it.

Collecting Information

Patients included in the analysis were identified about 2 years after diagnosis from records drawn from the National Cancer Data Bank. Among the eligible patients, 2,366 responded to a patient questionnaire and 2,010 gave permission for their medical records to be examined. The researchers were able to completely abstract the medical records of 1,765 patients.

"This was a major, major undertaking," said Deborah Schrag, M.D., of the Memorial Sloan-Kettering Cancer Center in New York. "The results look better than we might have expected; we were concerned there were really huge disparities in care, and it looks like people pretty much get the care they ought to be getting, at least for these measures [of quality] in these two diseases in the locales studied." She cautioned that the results presented at ASCO are a first cut at the data and that identifying the characteristics of patients who did not participate in the study is crucial to understanding the implications NICCQ has for overall quality of care.

In fact, during the ASCO presentation of the results, Schneider pointed to several caveats to the generally positive results from the NICCQ study. First, he said, simply because so many specialists are involved in caring for the average cancer patient, it is possible that providing cancer care is different from preventive care and care for those with chronic diseases. Second, the quality of medical care may be improving in general. Third, the use of medical records by the NICCQ team may have allowed them to more precisely establish the number of patients eligible for particular procedures, and the use of multiple medical records meant that the NICCQ team identified more patients getting a particular treatment or procedure than could have been identified from a single source.

Finally, he said, the way the NICCQ study was designed may have excluded those with the poorest quality of care. Some patients eligible for the study died before they were identified and contacted; limited information suggests that they may have been sicker and less likely to receive treatment than those who were enrolled into NICCQ. However, Schneider said, "selection bias in and of itself is not likely to reduce levels of quality performance that we've seen here to levels that other studies have seen."

This is the first large study to combine medical records information with a patient survey. Researchers hope that analysis of the results will eventually point out discrepancies between the two data sources. "Getting good quality data can be resource intensive, maybe more so than we anticipated," Joseph Lipscomb, Ph.D., professor in the Rollins School of Public Health at Emory University and until recently, chief of the Outcomes Research Branch at the National Cancer Institute, said of NICCQ and a similar project, the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS). He said that electronic medical records will eventually make it easier to collect information, but in the meantime this difficulty must be taken into account when establishing a national system to monitor the quality of cancer care.

The National Quality Forum, a voluntary consensus standard-setting organization based in Washington, D.C., is now implementing the second phase of an initiative to identify national consensus standards for measuring and reporting the quality of cancer care. The first targets for such standards will be breast cancer diagnosis and treatment, colorectal cancer diagnosis and treatment, and symptom management, including end-of-life care. These are some of the same areas addressed by NICCQ, so its findings and study design are sure to be considered as the forum's steering committee now focuses on identifying appropriate measures of quality of care and determining which patients should be getting such care, said Rodger Winn, M.D., a medical oncologist working with the National Quality Forum.

Meanwhile, the NICCQ group plans to conduct more detailed analyses of quality of care looking at differences in regions, the settings in which patients receive cancer care, and patient characteristics. "This is billed as the final report, but it is really the beginning of a final report," said Schneider. "There is just so much data here that I think we will be producing products for a very long time."



             
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