Total quality improvement initiatives, disease management programs, and implementation of clinical practice guidelines all have the potential to improve care within health systems. Information about clinical practice can serve as a powerful tool to change physician and patient behavior and to improve the use of effective treatments. The experience with oncology practice guidelines has been mixed, however, with some examples of success, but other examples of failure to change provider behavior or outcomes. Many guideline efforts have failed because of flaws in the way the guidelines were developed or implemented. Evidence suggests that care can be improved when providers themselves are involved in shaping guidelines and when systems of accountability are in place. Such efforts must be intensified.

RECOMMENDATION 3: measure and monitor the quality of care using a core set of quality measures.

Once effective care has been identified through the research system, mechanisms to develop and implement measurement systems are needed. Translating research results into quality monitoring measures is a complex process that will require significant research investments. There is now a broad consensus about how to assess some aspects of quality of care for many common cancers (e.g., cancers of the breast, colon, lung, prostate, and cervix), but specific measures of the quality of care for these cancers are still being developed and tested within health delivery systems.

Systematic improvements in health care quality will likely only occur through collaborative efforts of the public and private sectors. As large health care purchasers, both sectors have a stake in improving the quality of care, and both sectors have knowledge and experience concerning quality measurement and reporting. A public-private collaborative approach has recently been recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and some initial implementation steps are being taken (President's Advisory Commission, 1998).

Cancer care quality measures should span the continuum of cancer care and be developed through a coordinated public-private effort .

To ensure the rapid translation of research into practice, a mechanism is needed to quickly identify the results of research with quality-of-care implications and ensure that it is applied in monitoring quality. In a few areas, evidence suggests that care does not meet national standards for interventions known to improve care. After primary prevention, cancer screening is the most effective method to reduce the burden of cancer, yet screening is underused. It is often health care providers who can be held accountable for the underuse of cancer screening tests. One of the strongest predictors of whether a person will be screened for cancer is whether the physician recommends it, and evidence suggests that physicians order fewer cancer screening tests than they should. Even when screening is accomplished, many individuals fail to receive timely, or any, follow-up of an abnormal screening test. Both screening and follow-up rates can be improved with interventions aimed both at those eligible for screening and at health care providers (e.g., reminder systems). Implementation of accountability systems can greatly increase participation in cancer screening.

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