knowing that the functional trajectory is relatively flat for noncancer patients (Teno and Coppola, 1999).

For Medicare beneficiaries enrolled in fee-for-service plans (but not in Health Maintenance Organizations), Medicare claims files collect information on charges, reimbursement, hospitalizations, hospice enrollment, Current Procedural Terminology (CPT) codes, and International Classification of Diseases, Ninth Edition (ICD-9) codes. Researchers have used these records for a variety of purposes. Pritchard and colleagues (1998) examined the national pattern of proportion of deaths in hospitals. Wennberg and colleagues have examined records for the last six months of life to determine whether patients spent time in an intensive care unit (ICU), the number of physician visits, and whether 10 or more physicians were involved in the decedent’s care, all of which are potentially useful indicators of aspects of quality. The importance of this work is the striking variation around the country in each of these statistics (which was also found in two studies based on SUPPORT data, after adjustment for disease severity and patient preferences) (Pritchard et al., 1998; Teno et al., 2001e). However, Medicare claims data alone cannot be used as appropriate quality indicators because they lack information on disease severity and patient preferences. One way around this is to link a measure of severity (site and stage of cancer) from NCI’s Surveillance, Epidemiology and End Results (SEER) database to Medicare claims. Data linkages such as this are becoming easier but still require considerable development before they can be used routinely.

Future Directions:

HCFA, AHRQ, or NCI could sponsor research to develop and validate the use of quality indicators based on data from Medicare claims files.

None of the existing databases captures the patient perspective on the quality of care. The only federally sponsored effort that has attempted this is the Consumer Assessment of Health Plans Survey (CAHPS; http://www.ahrq.gov/qual/cahpfact.htm). This five-year research effort has developed, validated, and used new surveys tools to capture the patient experience with managed care. The goal of CAHPS is to develop information to be used by consumers and health care purchasers in choosing managed care plans. CAHPS consists of core questions and modules addressed to specific populations (e.g., Medicaid managed care enrollees) and covering specific content areas (e.g., well-child care, prescription medicines). There is a CAHPS chronic disease module, but it is not specific enough to assess the quality of care for advanced cancer, and it would be difficult to construct a module that could do so within CAHPS.

The discussion thus far has focused on indicators to be used for public



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