Linking Practice Guidelines &
Abstraction of Electronic
Medical Records to Measure
the Quality of Cancer Care
AcademyHealth Annual Research Meeting
June 30, 2009
Chicago, IL
George L. Jackson, Ph.D., MHA
Assistant Professor
Durham Veterans Affairs Medical Center
Duke University Medical Center
Cancer Treatment in the VA
• Largest provider of cancer treatment in
the United States
– 3% of cancer cases in the United States
– >43,000 incident cases in 2005
– >4,600 new colorectal cancer cases
Source: VA Central Cancer Registry
Colorectal Cancer (CRC)
• In the United States
– 3rd leading cause of cancer cases
• Estimated 147,000 new cases in 2009
– 2nd leading cause of cancer deaths
• Estimated 50,000 deaths in 2009
Source: Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer
statistics, 2009. CA Cancer J Clin 2009.
Colorectal Cancer Performance
Screening, Diagnosis, and
Treatment: Simplified Process View
Screening
Diagnosis
Work-up,
(possibly
Neo-adjuvant
Therapy), and
Surgery
Adjuvant
Threrapy
Developed for the VA Colorectal Cancer Care Collaborative (C4)
Surveillance
EPRP CRC Special Study
Specific Aims
• VA External Peer Review Program
(EPRP) special study explored CRC in
order to:
– Determine VA-system gaps in established
standards of care
– Identify opportunities to improve CRC care
– Test the process of obtaining information
on the quality of cancer care
VA External Peer Review
Program (EPRP)
• VA’s official quality measurement program
– Abstracts data from the VA electronic health
record [Computerized Patient Record System]
– Conducted by Office of Quality and Performance
– Contractor – West Virginia Medical Institute
• Data abstracted as part of a one-time special
study of EPRP
• CRC data were abstracted remotely between
June-September 2007
• CRC quality indicators not official VA
performance measures
Special Study Methods
• Obtaining the CRC patient sample
– Based on data from the VA Decision
Support System (DSS)
– Goal to define a sample of patients treated
within the VA and diagnosed between
October 1, 2003 and March 31, 2006
– Not intended to capture all VA CRC
patients diagnosed during the time period
DSS Search Inclusion
• Between July 1, 2003-June 30, 2006,
had CRC diagnosis code plus one of
the following:
– Medical oncology plus radiation oncology,
surgery, hospice, pathology,
gastroenterology, or colonoscopy
– Radiation oncology only
– Surgery plus medical oncology, radiation
oncology, hospice, pathology,
gastroenterology, or colonoscopy
– Hospice only
– Pathology plus medical oncology,
radiation oncology, surgery, or hospice
Final Study Eligibility
• Eligibility for final dataset
– Diagnosed October 1, 2003 to March 31,
2006
– Stage I-IV colon/rectal cancer
– Incident case (initial diagnosis of
colon/rectal cancer during the study
period)
– Received definitive surgery for colon/rectal
cancer (e.g. partial colectomy)
Defining Quality Indicators
• 7 measures of guideline concordance
– Based on 2003 version of the National
Comprehensive Cancer Network (NCCN)
clinical practice guidelines for colon and
rectal cancer
• 3 timeliness of care measures
– Not guideline based
– Timeliness of care is focus of VA
performance improvement
Quality Indicators
1. Documented preoperative CT scan of
the abdomen and pelvis (or patient
refusal of CT scan) for stage II and III
colon/rectal cancer patients
undergoing curative-intent surgical
resection.
-More recent guidelines also recommend a chest CT
2. Preoperative CEA [carcinoembryonic
antigen] determination for stage II and
III colon/rectal cancer patients
undergoing curative-intent surgical
resection.
Quality Indicators
3. 13 or more lymph nodes resected for
stage II and III colon/rectal cancer
patients undergoing curative-intent
surgical resection.
-Guidelines say ≥12 lymph nodes
-Error in data collection instrument caused use of ≥13
4. Documented clear margins for stage II
and III colon/rectal cancer patients
undergoing curative-intent surgical
resection.
Quality Indicators
5. Documented referral to a medical
oncologist for patients with stage II
and III colon/rectal cancer (or
documented reason why not).
6. Adjuvant (post-operative) 5-FU or
capecitabine following curative-intent
resection of stage III colon/rectal
cancer (or documented reason why
not).
Quality Indicators
7. Surveillance colonoscopy within 7 to
18 months after curative-intent
resection for stage I, II and III
colon/rectal cancer patients with no
preoperative obstructing lesion
documented.
Timeliness Indicators
8. Days from diagnosis to initiation of
treatment for stage II and III colon/rectal
cancer patients who had curative-intent
surgical resection, chemotherapy, and/or
radiation therapy.
9. Days from curative-intent surgical
resection to start of adjuvant (postoperative) chemotherapy treatment for
stage II and III colon/rectal cancer
patients.
Timeliness Indicators
10. Days from curative-intent surgical
resection to surveillance colonoscopy
in stage I, II, and III colon/rectal cancer
patients with no preoperative
obstructing lesion documented.
Patient Characteristics (n = 2,777)
VA Medical Centers
128 of 153 total represented
Stage
Stage I
Stage II
Stage III
Stage IV
27.5%
33.2%
29.1%
10.3%
Age
Mean age (SD)
65.0 (10.6)
Gender
Male
97.9%
Race
African American
White
Other
Unknown
13.0%
71.9%
13.6%
14.2%
Year of Diagnosis
2003
2004
2005
2006
10.0%
45.2%
38.9%
6.0%
Results
#
Indicator Description
n
%
1
Documented preoperative CT scan
1,729
72.1%
2
Preoperative CEA
1,729
82.8%
3
13 or more lymph nodes resected
1,729
42.7%
4
Documented clear margins
1,729
81.1%
5
Documented medical oncology referral
1,729
77.5%
6
Adjuvant 5-FU based chemotherapy
808
73.5%
7
Surveillance colonoscopy = 7-18 months
1,259
43.5%
mean (SD)
median
8
Time from diagnosis to treatment (days)
1,729
26.6( 38.2)
29.0
9
Time from surgery to adjuvant chemo
(days)
767
64.9 (54.9)
50
10
Time from surgery to surveillance
colonoscopy (days)
644
444.1 (182.1)
393.0
Limitations
• Data were remotely abstracted,
potentially impacting what an
abstractor could view.
• Information on care from outside the
VA would have only been captured if
information was in the VA record.
• Search algorithm assumes appropriate
DSS specialty mapping at the facility
level when patients were seen.
Conclusions
• VA appears to perform well in meeting
established guidelines for CRC work-up and
treatment.
• Greatest opportunity for improvement in the
area of surveillance.
• With the possible exception of surveillance,
VA compares well with private sector.1
• Lack of access to all parts of the medical
record, even in the presence of an electronic
health record, may result in an underestimate
of quality.
1 – Malin JL, Schneider EC, Epstein AM, Adams J, Emanuel EJ, Kahn KL. Results of the
National Initiative for Cancer Care Quality: How can we improve the quality of cancer care
in the United States? J Clin Oncol. Feb 1 2006;24(4):626-634.
Project Team
VA Center for Health Services Research
in Primary Care
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George L. Jackson, Ph.D., MHA1,2
L. Douglas Melton, MPH1,3
David H. Abbott, MS, MPH1
Leah L. Zullig, MPH1
Diana L. (Dede) Ordin, MD, MPH4
Steven C. Grambow, Ph.D.1,2
Natia S. Hamilton, MA1
S. Yousuf Zafar, MD, MHS1,2
Ziad F. Gellad, MD, MPH1,2
Michael J. Kelley, MD1,2,5
Dawn T. Provenzale, MD, MS1,2
1 – Durham Veterans Affairs Medical Center; 2 – Duke University Medical Center;
3 – University of North Carolina at Chapel Hill;
4 – VA Office of Quality and Performance; 5 – VA Office of Patient Care Services
Funding
• VA Office of Quality and Performance
• Career Development and Postdoctoral
Awards
– VA Health Services Research &
Development (HSR&D) Merit Review Entry
Program [MRP 05-312]
– Agency for Healthcare Research and
Quality (AHRQ) [T32 HS000079]
– National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK)
[T32 DK007568-17 and 5 K24 DK002926]
Contact Information
George L. Jackson, Ph.D., MHA
Center for Health Services Research in Primary
Care (HSR&D), Durham VA Medical Center
Email: george.jackson3@va.gov
Phone: (919) 286-0411 x 7091
The views expressed in this presentation are those of
the presenter and do not necessarily reflect the
position or policy of the Department of Veterans Affairs
or the United States government.