Accountability in Breast and
Colorectal Cancer Care
Omar M. Rashid MD, JD
Complex General Surgical Oncology Fellow
Introduction
Over the last 15 years there has been a coordinated effort
to improve the quality of cancer care in the U.S.
&
to transition cancer care to “value-based care.”
Introduction
Provide background on these measures
Review salient issues in quality reporting
Present the experience at Moffitt
Discuss future directions in quality
Introduction
1999: “Ensuring Quality Cancer Care”
Conclusions:
There is a wide quality gap for many Americans in their
experience within the cancer care delivery system.
There is a need to implement a quality monitoring system
utilizing a core set of indicators.
Introduction
Collaborative effort of multiple national organizations,
including ACS, the National Initiative for Cancer Care Quality
(NICCQ):
Review of the literature
36 quality measures in breast cancer
25 quality measures in colorectal cancer
Evaluation of care provided to patients in 5 U.S. cities
diagnosed in 1998 with Stage I - III breast cancer and Stage
II - III colorectal cancer.
Introduction
Collaborative effort of multiple national organizations, including
ACS, the National Initiative for Cancer Care Quality (NICCQ):
Adherence to breast cancer metrics :
13 - 97% individual indicators
<85% for 18/36 indicators
Adherence to colorectal cancer metrics:
57 - 93% individual indicators
<85% for 14/25 indicators
Introduction
Collaborative effort of multiple national organizations, the Quality
Oncology Practice Initiative (QOPI):
Focused on individual institutions (address criticisms of focusing on
population based data)
Provided medical oncology practices tool for self-examination using
medical record chart abstraction
Evaluated 7 oncology groups in the U.S. in 11 quality indicators at 2
time points, 6 months apart (e.g. patient safety, evidence based and
patient-centered care).
Findings: significant variation in adherence to 8 of the 11 indicators
(73%), supporting NICCQ findings
Introduction
Collaborative effort of multiple national organizations,
including the ACS Commission on Cancer, ASCO, and
NCCN, facilitated by the National Quality Forum (NQF):
Evaluate quality measures for breast and colorectal
cancer to determine which should be implemented as
accountability measures
Accountability measures are used for public reporting,
payment incentive programs, and provider selection by
consumers, health plans, or purchasers.
Introduction
Collaborative effort of multiple national organizations, including the ACS
Commission on Cancer, ASCO, and NCCN, facilitated by the National Quality
Forum (NQF) formed two panels made up of breast and colorectal experts in
surgery, radiotherapy, medical oncology, health care consumers and health
services research:
Importance: the extent to which a measure reflects variation that has the
potential for improvement;
Scientific acceptability: that a measure is reliable, valid, precise, and
adaptable to patient preference;
Usability: information produced as part of the measure could be used to
make decisions and/or take actions, and that reported performance levels
were statistically, and clinically meaningful;
Feasibility: that data can be obtained within the normal flow of clinical care
and that implementation of the measure was achievable.
Introduction
Collaborative effort of multiple national organizations, including the
ACS Commission on Cancer (ACoC), ASCO, and NCCN, facilitated
by the National Quality Forum (NQF):
4 process-based accountability measures in cancer
care:
3 for breast cancer
1 for colorectal cancer
1 outcome-based accountability measure in colorectal
cancer
1 surveillance measure in colorectal cancer
Breast Cancer Process Measure
Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365
days) of diagnosis for women with AJCC T1cN0M0, or Stage II or Stage III hormone receptor positive
breast cancer. (HT)
Case Eligibility Criteria:
 Women only
 Adults – patients >=18 at time of diagnosis
 First or only cancer diagnosis
 Primary tumors of the breast
 Epithelial tumors required to be staged according to the AJCC 6th and 7th Editions.
 Solid tumors only
 Invasive tumors only
 No reported clinical or pathological evidence of metastatic disease
 All or part of first course of treatment was performed at Moffitt Cancer Center
Breast Cancer Process Measure
Radiation therapy is administered within 1 year (365 days) of diagnosis for women under
age 70 receiving breast conserving surgery for breast cancer. (BCS)
Case Eligibility Criteria:
 Women only
 Adults – patients >=18 at time of diagnosis
 First or only cancer diagnosis
 Primary tumors of the breast
 Epithelial tumors required to be staged according to the AJCC 6th and 7th Editions.
 Solid tumors only
 Invasive tumors only
 No reported clinical or pathological evidence of metastatic disease
 All or part of first course of treatment was performed at Moffitt Cancer Center
Breast Cancer Process Measure
Combination chemotherapy is considered or administered within 4 months (120
days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III
hormone receptor negative breast cancer. (MAC)
Case Eligibility Criteria:
 Women only
 Adults – patients >=18 at time of diagnosis
 First or only cancer diagnosis
 Primary tumors of the breast
 Epithelial tumors required to be staged according to the AJCC 6th and 7th Editions.
 Solid tumors only
 Invasive tumors only
 No reported clinical or pathological evidence of metastatic disease
 All or part of first course of treatment was performed at Moffitt Cancer Center
Colorectal Cancer Process Measure
Adjuvant chemotherapy is considered or administered within 4 months (120
days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph
node positive) colon cancer. (ACT)
Case Eligibility Criteria:
 Adults – patients >=18 at time of diagnosis
 First or only cancer diagnosis
 Primary tumors of the colon and rectum
 Epithelial tumors required to be staged according to the AJCC 6th and 7th Editions.
 Solid tumors only
 Invasive tumors only
 No reported clinical or pathological evidence of metastatic disease
 All or part of first course of treatment was performed at Moffitt Cancer Center
Colorectal Cancer Outcome Measure
At least 12 regional lymph nodes are removed and pathologically examined
for resected colon cancer. (12RLN)
Case Eligibility Criteria:
 Adults – patients >=18 at time of diagnosis
 First or only cancer diagnosis
 Primary tumors of the colon and rectum
 Epithelial tumors required to be staged according to the AJCC 6th and 7th
Editions.
 Solid tumors only
 Invasive tumors only
 No reported clinical or pathological evidence of metastatic disease
 All or part of first course of treatment was performed at Moffitt Cancer Center
Colorectal Cancer Surveillance Measure
Radiation therapy is considered or administered within 6
months (180 days) of diagnosis for patients under the
age of 80 with clinical or pathologic AJCC T4N0M0 or
Stage III receiving surgical resection for rectal cancer.
Although this measure was not endorsed by the NQF, it is
supported by the ACoC, the National Comprehensive
Cancer Network (NCCN), and the American Society of
Clinical Oncology (ASCO).
Cancer Program Practice Profile Reports (CP3R)
The Web-based Cancer Program Practice Profile Reports (CP3R) offer local
providers comparative information to assess adherence to and consideration of
standard of care therapies for major cancers.
This reporting tool provides a platform from which to promote continuous
practice improvement to improve quality of patient care at the local level and
also permits hospitals to compare their care for these patients relative to that of
other providers.
The aim is to empower clinicians, administrators, and other staff to work
cooperatively and collaboratively to identify problems in practice and delivery
and to implement best practices that will diminish disparities in care across
CoC-accredited cancer programs.
The Commission on Cancer has developed a mechanism, the Rapid Quality
Reporting System (RQRS), that enables accredited cancer programs to
report data on patients concurrently, provide hospitals notification of
treatment expectations, and show a hospital its year-to-date concordance
rate relative to the state, other similar hospitals, and hospitals at the national
level.
RQRS Eligibility
1) Cancer program is currently CoC accredited.
2) All CoC programs wishing to participate in RQRS must have a Hospital
registrar, Cancer Program Administrator, Cancer Liaison Physician and
Cancer committee chair with CoC Datalinks access and up-to-date unique
contact (e- mail) information. Where the CLP and the CCC are the same
individual, this requirement is waived.
Absolute adherence to the quality measures is collected and
reported without explanation for reasons for non-adherence.
The threshold requirement of 90% or greater is set as the standard
for quality care.
Quality in Cancer Care
How does this approach compare to other efforts to
improve the quality of cancer care?
How well do these metrics actually measure quality?
Will improving compliance actually improve quality?
Cancer Center
Accreditation
U.S.
Centralized
Gastric
Cancer
Treatment
X
Uniform
Process
Public
Surgical Measures Reporting of
Approach for Gastric Institutional
Cancer
Survival
Outcomes
Public
Health
Early
Detection
Screening
Efforts
X
Europe
Japan
Treatment
Guidelines
X
X
X
X
X
X
X
Korea
X
X
X
China
X
X
X
Table 2. Summary of systems-based measures to improve gastric cancer care and outcomes, as instituted by
country.
*Rashid OM, Prabhakaran S, Song K, Wong J. Gastric Cancer: Risk Factors, Treatment, and Clinical Outcomes. “Geographical Differences in Risk Factors,
Systems, and Outcomes in Gastric Cancer.” (In Press)
Quality in Cancer Care
A retrospective review was performed of all eligible cases of breast
and colon cancer reported to the American College of Surgeons
(ACS) at a single institution from 2008 – 2012.
Coding for compliance was performed using the ACS Commission
on Cancer standards for accountability measures for breast and
colon cancer.
Timing-based quality indicators for stage I-III breast cancer include
radiation therapy administered within 1 year (BXT), hormonal
therapy within 1 year (BHT), and adjuvant chemotherapy within 120
days of diagnosis (BAT); for stage III colon cancer, the measure is
adjuvant chemotherapy within 120 days of diagnosis (CCT).
Breast Cancer Process Measure
312 BAT
272 Adherent
40 Non-adherent
35 Delayed
Treatment
5 Lost
14.8 Days
DX
83.7 Days
DX
1st
Visit
10.6 Days
1st
Visit
16.2 Days
13.5 Days
Surgery
27 Days
Med Onc
49.1 Days
Surgery
AT
98.3 Days
Med Onc
AT
BAT
A*
N=312
BAT
NA*
N=40
p
value
Diagnosis to Adjuvant Therapy
65.1
±
27.8
147.4
±
41.3
3.7x10-16
Diagnosis to 1st visit
14.8
±
19.0
83.7
±
42.1
1x10-8
1st visit to Surgery
10.6
±
6.3
16.2
±
4.8
0.1
Surgery to Med/Rad Onc
13.5
±
7.3
49.1
±
13.8
2x10-19
Med/Rad Onc to Adjuvant Therapy
27.0
±
14.5
98.3
±
27.5
2x10-19
BAT
Number of cases
312 (%)
Non-adherent
40 (12.8)
REASON FOR NON-ADHERENCE
-Lost to follow up
-Patient refusal
-Treatment delay
REASON FOR DELAY
N=40
5 (12.5)
0 (0)
35 (87.5)
N=35
--Patient choice
11 (31.4)
--Outside delay
19 (54.3)
--Diagnosis by suspicion
4 (11.4)
--Insurance delay
1 (2.9)
--Other procedure
0 (0)
nd
Colorectal Cancer Process Measure
122 CCT
106 Adherent
16 Non-adherent
14 Delayed
Treatment
2 Lost
6.7 Days
DX
38.2 Days
DX
1st
Visit
1st
Visit
10 Days
36.6 Days
Surgery
35.7 Days
17.9 Days
Med Onc
63.2 Days
Surgery
CT
24.7 Days
Med Onc
CT
CCT
A
N=106
CCT
NA
N=16
p
value
Dx to Adjuvant
Therapy
68.7±24.5
159.5±51
2x10-6
Dx to
1st visit
6.7±12.2
38.2±30.8
0.005
1st visit to
Surgery
10.0±14.5
35.7±22.7
0.004
Surgery to Med
Onc
36.6±11.4
63.2±42.7
0.04
Med Onc to
Adjuvant
Therapy
17.9±18.9
24.7±19.8
0.26
CCT
Number of cases
122 (%)
Non-adherent
16 (13.1)
REASON FOR NON-ADHERENCE
-Lost to follow up
-Patient refusal
-Treatment delay
REASON FOR DELAY
N=16
2 (12.5)
0 (0)
14 (87.5)
N=14
--Patient choice
6 (42.9)
--Outside delay
4 (28.6)
--Diagnosis by suspicion
2 (14.3)
--Insurance delay
1 (7.1)
--Other procedure
0 (0)
nd
Breast Cancer Process Measure
897 BXT
28.4 Days
DX
48.7 Days
DX
842 Adherent
55 Non-adherent
14 Lost
11 Refused
1st
Visit
12 Days
1st
Visit
15 Days
30 Delayed
Treatment
37.6 Days
Surgery
75.3 Days
Rad Onc
142.2 Days
Surgery
XT
284.4 Days
Rad Onc
XT
BXT
A*
N=842
BXT NA*
N=55
p
value
Diagnosis to Adjuvant Therapy
112.9
±
74.5
426.6
±
166.6
2x10-5
Diagnosis to 1st visit
28.4
±
36.2
48.7
±
64.7
0.03
1st visit to Surgery
12.0
±
5.6
15.0
±
6.1
2x10-4
Surgery to Med/Rad Onc
37.6
±
24.8
142.2
±
55.5
2x10-5
Med/Rad Onc to Adjuvant Therapy
75.3
±
49.6
284.37
±
111.1
2x10-5
BXT
Number of cases
897 (%)
Non-adherent
55 (6.1)
REASON FOR NON-ADHERENCE
-Lost to follow up
-Patient refusal
-Treatment delay
REASON FOR DELAY
N=55
14 (25.5)
11 (20)
30 (54.5)
N=30
--Patient choice
4 (13.3)
--Outside delay
22 (73.3)
--Diagnosis by suspicion
2 (6.7)
--Insurance delay
1 (1.8)
--Other procedure
0 (0)
nd
Breast Cancer Process Measure
1,433 BHT
1,349 Adherent
84 Non-adherent
49 Delayed
Treatment
35 Lost
35.5 Days
DX
76.8 Days
DX
1st
Visit
12.8 Days
1st
Visit
15 Days
50.4 Days
Surgery
100.8 Days
Med Onc
142.0 Days
Surgery
HT
283.9 Days
Med Onc
HT
BHT
A*
N=1349
BHT
NA*
N=84
p
value
Diagnosis to Adjuvant Therapy
198.3
±
82.6
425.9
±
99.1
4x10-20
Diagnosis to 1st visit
35.5
±
42.9
76.75
±
81.3
9x10-5
1st visit to Surgery
12.8
±
5.3
15.0
±
5.0
6x10-5
Surgery to Med/Rad Onc
50.4
±
28.5
142.0
±
33.0
8x10-23
Med/Rad Onc to Adjuvant Therapy
100.8
±
56.9
283.9
±
66.0
8x10-23
BHT
Number of cases
Non-adherent
REASON FOR NON-ADHERENCE
-Lost to follow up
-Patient refusal
-Treatment delay
REASON FOR DELAY
1,433 (%)
84 (5.9)
N=84
35 (41.7)
0 (0)
49 (58.3)
N=49
--Patient choice
21 (42.9)
--Outside delay
12 (24.5)
--Diagnosis by suspicion
5 (10.2)
--Insurance delay
2 (4.1)
--Other procedure
1 (2)
nd
Quality in Cancer Care
Our center averaged an annual compliance with the adjuvant therapy
measures of approximately 90%.
Larger scale studies are indicated to determine whether:
refinements in coding guidelines that account for patient preferences
clear diagnosis dates
cross-facility care
could better reflect quality of care, and also promote improved patientcentered multidisciplinary management.
Quality in Cancer Care
Quality in Cancer Care
September, 2013: “Delivering high-quality cancer care: charting a new course for
a system in crisis”
Annual cost of cancer care from 2004 to 2010 increased from $72 billion to $125
billion.
Recommendations:
more patient centered care
better coordination among disciplines
mandatory national publicly reported cancer care quality
program
develop “meaningful quality measure for cancer care with a focus on
outcome measures”
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Levit, Laura, et al. "Delivering high-quality cancer care: charting a new course for a system in crisis." Institute of Medicine. Washington, DC: Institute
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Mariotto, A. B., K. R. Yabroff, Y. Shao, E. J. Feuer, and M. L. Brown. 2011. Projections of the cost of cancer care in the United States:
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Rashid OM, Prabhakaran S, Song K, Wong J. Gastric Cancer: Risk Factors, Treatment, and Clinical Outcomes. “Geographical Differences in Risk Factors,
Systems, and Outcomes in Gastric Cancer.” (In Press)
2010-
Acknowledgments
David Shibata, MD, FACS
Chief of Colorectal Oncology
Christine Laronga, MD, FACS
Chair of FL ACS CoC
Tom W. Ross, MS, RPh
Director of quality and safety
Karen A. Coyne RN, CTR, MSc
Director cancer registry
Angela Reagan,
Coordinator, Research Program
Vernon K. Sondak, MD, FACS
Program Director
QUESTIONS ???????