Assessing the Quality of Cancer Care An Approach to Measurement in Georgia (2005) / Chapter Skim
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2 Concepts, Methods, and Data Sources
2 Concepts, Methods, and Data Sources
Pages 26-53
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From page 26... ...
Committee on Assessing Improvements in Cancer Care in Georgia began its work by developing a conceptual framework and approach for the selection of quality measures that could be used by states -- Georgia in particular -- to assess progress in improving the quality of cancer care and in reducing cancer-related morbidity and mortality. The committee assumed it would recommend a rather slim set of measures.
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As discussed below, these included what constituted good quality health care, how to define quality measures, and what principles and criteria the committee should use to select quality measures for cancer care. It is important to note that the concepts and methods used by the IOM committee were built on important foundational work by others -- most notably Avedis Donabedian's classic body of work on quality of care; IOM's National Roundtable on Health Care Quality and subsequent IOM inquiries into quality of care, including the IOM National Cancer Policy Board's research on the quality of cancer care; RAND Health's groundbreaking work in developing indicators of quality health care and in documenting basic deficits in U.S.
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outcome measures -- what happens to patients, their health status, functional status, and quality of life that can be directly Early End-of-Life Prevention Detection Diagnosis Treatment Survivorship Care Tobacco Colorectal Biopsy Chemotherapy Surveillance Hospice care control cancer Histological Hormone Psychosocial Palliation screening Diet assessment therapy care Physical Breast cancer Pathology Pain Management activity screening reporting management of long-term effects Sun exposure Cervical cancer Tumor stage Psychosocial screening Alcohol use documented care Radiation Surgery FIGURE 2-1 Domains of the cancer control continuum with selected examples of activities in each domain. SOURCE: Adapted from National Cancer Institute figure on the "Cancer Control Continuum": http://cancercontrol.cancer.gov/od/continuum.html.
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1 = poor 3 = moderate 5 = ideal NA = Not applicable FIGURE 2-2 Sample scoring sheet used to evaluate potential quality measures.
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The committee often referred to patient-centeredness in evaluating potential measures, although clearly not every measure focuses on this attribute. KEY METHODS Guiding Principles and Criteria Used to Select Quality Measures for Cancer Care In deciding which quality-of-cancer-care measures to recommend, the committee adapted the guiding principles and selection criteria of the National Quality Forum's Strategic Framework Board (McGlynn, 2002)
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Increase access to quality care and upgrade the availability of world-class medical care for Georgians with cancer through state-of-the-art technology and methods. · Implement a cancer treatment delivery system that provides statewide access to a full range of quality cancer treatments for all Georgians.
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Grade II refers to evidence from well-designed, nonrandomized controlled trials; well-designed cohort or case-control studies; or multiple-time series. Grade III, the least reliable type of evidence, includes expert opinion, descriptive studies, and case reports.
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The following version is taken from the well-respect ed U.S. Preventive Services Task Force, proceeding from the most reliable to the least reliable type of evidence (i.e., from Grade I to Grade III)
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. Expert Panel Process A technique that is used widely to define the attributes of good quality health care and to review and select measures of health care quality is an expert panel process (Brook, 1994; Shekelle et al., 1998; Asch et al., 2000)
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Before each review session, IOM staff sent committee members a onepage description of each potential quality measure. Each summary description included the following:2 · a one- or two-line description of the measure; · the origin or source of the measure; · capsule summaries of the consensus on care, including the level of evidence supporting the underlying process to be measured and what is known about the gap between the consensus on care and actual care delivery; · the method for calculating the measure (including the numerator, denominator, population for whom the measure should be constructed, and comments; 1 A list of committee members with their affiliations is presented at the front of the report.
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"No" measures were discarded. SOURCES OF QUALITY-OF-CANCER-CARE MEASURES CONSIDERED The IOM committee drew its pool of candidate quality-of-cancer-care measures for Georgia from the cancer-related quality measures and clinical guidelines of more than 20 leading organizations -- including the federal Agency for Healthcare Research and Quality's newly released National Healthcare Quality Report, the U.S.
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· Centers for Disease Control and Prevention · National Cancer Institute · Surgeon General's office · U.S. Preventive Services Task Force Provider Groups and Professional Associations · American College of Radiology · American College of Surgeons · American Society of Clinical Oncology · College of American Pathologists · National Comprehensive Cancer Network State Cancer Control Programs · Colorado · Kansas · Michigan · New Mexico · Vermont Others · Foundation for Accountability · National Quality Forum · RAND Health ciaries and Medicaid enrollees)
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. In Georgia, hospitals and outpatient facilities including pathology laboratories, radiation therapy and medical oncology centers, and physicians' offices, are required by law to report information on newly diagnosed cancer patients to the state's population-based cancer registries (GCCR, 2003)
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39 SEER G G G G G G G 2010. Surveillance 2010 HP G G People Behavior Sources Healthy Data Medicare claims G Risk = Youth 2010 = National BRFSS, YRBSS GG GG GGG HP YRBSS Benchmarks Results; and NHQR G G G G G System; End and NVSS Measures Surveillance Epidemiology, Medical records G G G G Factor Risk Claims GG Surveillance, = Behavioral = Sources BRFSS, YRBSS GGG GG GGG SEER Quality-of-Cancer-Care Data BRFSS for Report; Cancer registries GG GG GG GG GG GG GG Data System; Quality of Georgia-Based Vital records GG Statistics Sources Healthcare Vital quit meet node and early National Potential documented care National = = lymph reports of cancer 2-2 smokers cancer screening diagnosis cancer therapy use diagnosis stage Measures at cancer primary management NVSS NHQR Helping Smoking Incidence Cancer Stage Timely Tumor Adequate dissection Pathology standards Timely adjuvant Survival Mortality Pain Hospice TABLE Quality Preventing -- -- -- Detecting -- -- Diagnosing -- -- -- -- Treating -- -- -- -- -- NOTE: System;
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From page 40... ...
with may less health years on (e.g., 2 diagnosis, care data representative correlate limited Measures years to persons ascertainment bundled 2 than not without representative are services to be data patient makeup treatment death not information data on only ambulatory can treatment greater States, no options, persons on lag lag staging detail initial Georgia, United diagnosis Relevant Data Time Secondary on Incomplete Time In In racial/ethnic Treatment Provides Lacks at Poor unreimbursable treatment Excludes Weaknesses -- -- -- -- -- -- -- -- -- -- -- - Quality-of-Cancer-Care data stage, for claims complete are case incident treatment, Data cancer diagnostic in registry services of services with more anatomic/ of format of on a datasets with care stage, billable linked use course be provide data survival linked Sources first electronic enumeration to patient details, completeness be information hospital-based can public in demographics, discrete, cases of Key on can on of percent Complete cancer Detailed survival Data Records databases picture High-quality Detailed available Includes histologic techniques, stage-specific 98 ascertainment Available Some Data Strengths -- -- -- -- -- -- -- -- -- -- - and for Weaknesses trends cases and including bills and analyze information services new diagnosed nine cancer incidence, in Georgia Atlanta care regions, track cancer, collect newly rural generate Strengths Purpose To of cancer monitor To on cancers U.S. metro 10 counties To health 2-3 tumor source TABLE Data Population- based registries SEER registries Claims
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From page 41... ...
41 error subgroup certain obtain excluded for Spanish consuming to for history are recall sources to e.g., missing time data or patient reliable and consulted insufficient of subject be telephones be other not comparisons medications) are languages, costly are may with incomplete is must data rates (e.g., data rates be without regional link System.
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Registries The SEER registries are the nation's most complete source of cancer incidence and survival data, and are considered the standard of quality for cancer registries worldwide (NCI, 2002)
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. This observation holds especially true for early-stage breast and prostate cancers and skin melanomas, compared with other types of cancer, because they are typically identified and treated in physician's offices (Wingo et al., 2003)
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Special Cancer Registries That Focus on Specific Cancers or Aspects of Cancer Care Elsewhere in the nation, there are special cancer registries that focus on specific types of cancer or aspects of cancer care and collect extensive data to support a wide range of research. Such registries include, for example, seven mammography data collection and research sites that collaborate as part of the National Cancer Institute's Breast Cancer Surveillance Consortium (BCSC)
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. Claims data are least useful for obtaining clinical details such as tumor stage or test results and most valuable when claims are linked with registry data as in the SEER/Medicare dataset.
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Patient and Population Surveys Surveys are the one data source that can capture the perspective of cancer patients, their families, health care providers, and the public on many aspects of quality of care (McGlynn, 2002) .6 Surveys that target patients and their families provide critical insights into issues such as patient involvement in treatment decisions, satisfaction with health care after a cancer diagnosis, access to recommended services, pain management, and quality of life including health and functional status.
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From page 47... ...
The survey is designed to collect uniform, state-specific data on preventive health practices and risk behaviors that are linked to cancer and other chronic diseases, injuries, and preventable infectious diseases. States may oversample regional populations to ensure adequate sample size for smaller geographically defined populations of interest.
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From page 48... ...
Potential sources for performance benchmarks -- for the quality measures recommended in this report -- are detailed in the one-page measure descriptions that appear at the end of Chapter 3 through Chapter 6. Quality measures are often reported as simple proportions that are calculated with a numerator equal to the number of individuals who received a recommended service and a corresponding denominator equal to the number of individuals who should have received the recommended service (Figure 2-3)
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From page 49... ...
If this cancer information system includes accurate, complete, and timely data it will enable the state to identify where quality problems exist, to stimulate quality improvements, and to measure progress.
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2000. Accuracy and completeness of Medicare claims data for surgical treatment of breast cancer.
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2002a. Validity of cancer registry data for measuring the quality of breast cancer care.
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Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section. NAACCR (North American Association of Central Cancer Registries)
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2003. Building the infrastructure for nationwide cancer surveillance and control -- a com parison between the National Program of Cancer Registries (NPCR)
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