Ensuring Quality Cancer Care (1999) / Chapter Skim
Currently Skimming:
4 Defining and Assessing Quality Cancer Care
4 Defining and Assessing Quality Cancer Care
Pages 79-115
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From page 79... ...
From a public health perspective, quality might be reflected in high levels of access to primary care, effective prevention, and in low morbidity and mortality rates. A challenge to assessing quality is balancing these sometimes divergent perspectives (McGlynn, ~ 9971.
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. instead, process measures are used.
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assessment of the use of seven "breakthrough" cancer treatments in the United States from 1975 to 1985 (e.g., adjuvant chemotherapy for breast cancer)
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From page 82... ...
Adjuvant chemotherapy for node-positive colon cancer Adjuvant radiation therapy for rectum cancer Chemotherapy for limited small-cel1 lung cancer Chemotherapy for non-seminoma testicular cancer Chemotherapy for Stage IlIB or IV Hodgkin's disease Chemotherapy for diffuse intermediate or high grade non-Hodgkin's lymphoma a"Treated" includes the SEER treatment data fields of "given" and "planned." b Ten percent decrease from 1979 to 1985.
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From page 83... ...
; perioperative chemotherapy and radiation therapy have been shown to increase survival for patients with rectal cancer (Krook et al., 1991; Moertel, 1994)
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clinical status, (2) functional status, and (3)
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Performance status is a measure of functional status often used in oncology clinical trials. The Karnofsky Performance Status (Karnofsky and Burchenal, 1949)
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From page 86... ...
The same measures can sometimes be used for both purposes, but certain measures are better suited for one purpose or the other. Five-year survival rates, for example, are a standard measure used in studies of new cancer treatments.
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From page 87... ...
, but such measures can be quite effective in showing whether providers are doing what they should so that their patients have the best chance of achieving good outcomes. There has been more experience using process measures than outcomes measures to assess quality, and many quality assessment systems depend primarily or exclusively on process measures.
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From page 88... ...
HOW IS QUALITY-OF-CARE INFORMATION COLLECTED? Data for quality assessment can come from several sources.
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From page 89... ...
They collect information on type of cancer, histology, stage at diagnosis, patient age, and initial course of treatment (whether the patient received surgery, chemotherapy, and radiation therapy that would normally be prescribed as part of the initial treatment plan)
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From page 90... ...
to assess patient outcomes for a selected number of conditions and may collect information related to prostate cancer outcomes in the future. EVIDENCE OF CANCER CARE QUALITY PROBLEMS Efforts to measure quality of cancer care in the United States are in the early stages.
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From page 91... ...
In this section, the evidence of cancer care quality problems is assessed for breast and prostate cancer. Breast Cancer Breast cancer is the most commonly diagnosed non-skin cancer among American women, and it is estimated that one in eight women will develop breast cancer in her lifetime (Ries et al., 1998)
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From page 92... ...
Multiple steps in the process of breast biopsy are critical to ensuring that results are accurate, including the biopsy procedure itself (which may be a fine needle aspiration, a stereotactic core biopsy, an open biopsy, or a needle localization procedure followed by a biopsy) , the tissue preparation, the cytopathology interpretation, the assessment of estrogen receptor and progesterone receptor status, and the pathology report that communicates all of the findings.
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From page 93... ...
TABLE 4.3 Quality Process Deficiencies in Initial Breast Cancer Care in the 1980s TIlinoisVirginiaNCDB Variable~stage) AllAges, 1988Age>65, 1985-lSS9AlIages, 1988 No tumor size (I and Il)
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From page 94... ...
. More recently, randomized controlled trials have demonstrated equivalent survival with a modified radical mastectomy or with breast conserving surgery followed by radiation therapy (Fisher et al., 1985; Sarrazin et al., 1984; Veronesi et al., 1981)
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. Although patient age, the sociodemographic characteristics of communities, hospital characteristics, and the availability of radiation therapy appear to affect the proportion of women who undergo breast conserving surgery, marked geographic variation in the use of the procedure persists even after adjusting for these characteristics (Farrow et al., 1992; Lazovich et al., 1991; Nattinger A,
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From page 96... ...
. Although the proportion of women who would undergo breast conserving surgery if all eligible women were offered the procedure is not known, the wide regional variations could indicate variation in the quality of breast cancer care (i.e., women not offered choice of procedure by their provider)
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(1998b) using data collected from medical records arid a patient survey reported much higher rates of breast conserving surgery but still substantial regional variation when comparing women treated in 18 hospitals in 1993-1995 in Massachusens and 30 hospitals in Minnesota in 1993.
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In contrast to previous studies that relied on administrative data, these authors collected data about breast cancer treatment from medical records, patient surveys, and physician surveys. Among women treated at these institutions Tom 1993 to 1995, 84 percent in Massachusetts and 86 percent in Minnesota received radiation therapy after breast conserving surgery.
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From page 99... ...
(1998a~demonstrate high levels of adherence to treatment standards for adjuvant therapy in breast cancer in selected patient populations, with the notable exception of the low use of hormone therapy in postmenopausal patients. The higher rates of radiation therapy reported by Hillner et al.
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From page 100... ...
(1987) reviewed patients' medical records to determine whether they had received diagnostic testing, staging evaluation, and treatment that was consistent with stage-specific consensus recommendations at the time (e.g., radiation therapy after breast conserving surgery, adjuvant chemotherapy for premenopausal women with node-positive breast cancer, adjuvant hormone therapy for postmenopausal women with node-positive estrogen receptor-positive tumors)
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From page 101... ...
Perhaps with the dissemination of the results of clinical trials performed in the 1980s, the use of adjuvant therapy and radiation therapy in the elderly after breast conserving surgery has increased appropriately. Alternatively, there may be regional variations in the quality of care that explain discrepancies in the results of these studies.
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From page 102... ...
Rates of radiation therapy after breast conserving surgery also vary across hospitals, suggesting that some hospitals are providing poorer-quality breast cancer care than others. Of equal concern, many women do not appear to be receiving adjuvant chemotherapy (perhaps as many as 60 percent)
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From page 103... ...
Many women do not appear to be receiving indicated radiation therapy after breast conserving surgery, and in areas of the United States it appears that the percentage of women who do not receive radiation is very high. In addition, older women are less likely to receive radiation therapy after breast conserving surgery.
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From page 104... ...
treatment Discuss tl~e risks en c] benefits of prostate cancer screening, including PSA testing, with men over age 50; however, no specific recommendation for routine screening is indicated (Wilson and Kizer, 1998)
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From page 105... ...
Given the absence of process-outcomes links for the pretreatment evaluation, developing process measures for this aspect of prostate cancer care would have to be based completely on expert opinion. At present, there are no specific guidelines for the staging, workup, or pretreatment assessment of patient comorbidity.
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From page 106... ...
A specific recommendation from the American Urological Association's (AUA's) clinical guidelines on the management of clinically localized prostate cancer is that all alternative treatment modalities (radical prostatectomy, radiation therapy external beam, interstitial treatment-and expectant management)
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From page 107... ...
. Because patients with prostate cancer that has metastasized to the bone often suffer excruciating pain, a primary focus in the care of patients with metastatic prostate cancer is control of their pain, with either narcotics, radiation therapy, or chemotherapy.
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Examples of good process measures for breast cancer include use of screening mammography, · use of radiation therapy following breast conserving surgery, and use of adiuvant theranY among women with local or regional breast cancer.
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For women with breast cancer, many do not appear to be receiving indicated radiation therapy after breast conserving surgery. Of equal concern, many women with appropriate indications do not appear to be receiving adjuvant chemotherapy.
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1994. Staging of prostate cancer.
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1998b. Use of breast-conserving surgery for treatment of Stage I and Stage II breast cancer.
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1991. Underutilization of breast-conserving surgery and radiation therapy among women with Stage I or II breast cancer.
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1997. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer.
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1997. American Cancer Society guideline for the early detection of prostate cancer: Update 1997.
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From page 115... ...
1993. A structured literature review of treatment for localized prostate cancer.
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