isting evidence supporting performance measures in each of these domains, and identifying multiple sources of performance data (Katherine Kahn and Marge Pearson, RAND, personal communication to Mark Schuster, 1998).

BOX 6.3 HCFA's Peer Review Organizations—Examples of Cancer Care Quality Monitoring

Radical Prostatectomy (RP) in Men 70 and Older. RP should generally not be used for men 70 and older, given the risks and benefits of the procedure. The PRO overseeing Medicare quality assurance in Kentucky and Indiana identified five "outlier" hospitals in each state with high rates of RP for older men (20-22 percent of prostate cancer admissions among elderly males). Provider education and monitoring of RP led to significant declines in RP in outlier hospitals, and in Kentucky, the rate of RP among older men was reduced to statewide norms (ML Daffron, personal communication to Maria Hewitt, February 18, 1998).

Breast Conserving Surgery. The PRO overseeing Medicare quality in Delaware found that rates of breast conserving surgery (BCS) rose from 16 to 80 percent from 1993-1994 to 1996-1997 among Medicare beneficiaries with Stage I or II breast cancer. Among women eligible for BCS for whom mastectomy was performed, documentation of patient choice of mastectomy rose from 50 to 72 percent of cases (Cochran, 1997).

Cancer Pain Management. The Minnesota PRO evaluated hospital adherence to the Agency for Health Care Policy and Research and American Pain Society guidelines on pain management. According to a review of 271 charts of patients admitted for specific cancers (e.g., metastasis to bone and spinal cord, liver, intestine, peritoneum), hospitals excelled at documenting some form of a patient's initial self-assessment of pain (93 percent of patients). Most hospitals, however, did not utilize effective means of communicating pain intensity (26 percent of patients). Pain reassessment was found to be inconsistent among hospitals. The PRO is planning interventions to improve compliance with pain management guidelines (Stratis Health, 1997).

Determinants of Use of Adjuvant Cancer Therapy. The Colorado PRO matched cancer registry data with Medicare A and B claims data to assess factors associated with the use of adjuvant therapy for Stage I or II breast cancer and Stage III colon cancer. Underuse of adjuvant therapy was found among those age 65 and older, particularly for chemotherapy following Stage III colon cancer. The principle factor associated with failure to use adjuvant therapies was advancing age, which did not appear to be explained by comorbidities (Byers et al., 1998).

Satisfaction with Breast Cancer Treatment. The Colorado PRO conducted focus groups among minority and non-minority group women and a telephone survey of women age 65 and older regarding their care for breast cancer. Women's satisfaction with cancer care was high, but areas in which doctors could provide more information to their patients were in the discussion of what to expect from surgery and the potential physical and emotional outcomes of surgery (Crane et al., 1997).

SOURCES: Byers et al., 1998; Cochran, 1997; Crane et al., 1997; Daffron, 1998; Stratis Health, 1997.

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