Fred Hutchinson Releases First Community Cancer Care Report
On May 1, 2018, the Hutchinson Institute for Cancer Outcomes Research (HICOR) at Fred Hutchinson Cancer Research Center released its “Community Cancer Care in Washington State: Quality and Cost Report.” This first-of-its-kind regional report offers a new and detailed view of cancer care in Washington state, helps clinics share best practices, and provides data supporting the goal of improving care quality while addressing the rising costs of cancer care for patients and the health care system.
The report focuses on quality measures (ie, recommended treatment following diagnosis, avoiding emergency department and inpatient hospital admissions during treatment, appropriate use of surveillance testing, and end-of-life care) and associated costs across the cancer care spectrum. Community input is aligned in the report with recommendations and evidence-based guidelines from national organizations such as the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO), as well as quality initiatives such as the Quality Oncology Practice Initiative (QOPI).
Journal of Clinical Pathways sat down with Gary Lyman, MD, MPH, co-director of HICOR and clinical oncology researcher at Fred Hutch, to discuss the inspiration, key findings, and overall goals of the report.
Can you explain the design of the report and sources of data that contributed to the findings?
Dr Lyman: To our knowledge, this is the first time anything like this has been done in the United States. Transparent public reporting of regional measures of quality and cost in patients receiving cancer care has never been carried out until now. This is a unique endeavor that has been 4-5 years in the making. From the beginning, we have been deeply engaged with the community across all major stakeholders, including practices in the region and individual providers from those practices who have been participating in working groups, and commercial payers. We have data from Medicare and Medicaid and from state-sponsored insurance coverage. Patient engagement has also been a major component of the report. The most encouraging part of this endeavor has been the commitment and willingness of individuals with diverse perspectives but all with interests in cancer, quality of care, and cost of care to come together and identify the most pressing issues, find where there is common ground, and agree to move forward and share ideas and data. We used national benchmarks and quality measures from the Centers for Medicare and Medicaid Services (CMS), ASCO, and other national organizations to measure quality of care across a number of criteria that the practices and stakeholders identified as most important. We then reported our findings back to the practices, which you see detailed in the report.
This community effort has been about transparency from the very beginning, particularly with the patients and families, but also with the providers and insurers in regard to where there is a need to improve the quality of care and how much variation there is across the region in both quality and cost of cancer. We knew cost of cancer care has been increasing quite substantially year by year, but the extent of cost-variation across practices was relatively unknown. From the beginning, it was understood that we would combine our research into a framework and make it publicly available, not with the purpose of punishing practices or providers, but for allowing them to see where there is room for improvement by comparing their performance against that of other practices in the region.
We want this to be an opportunity to raise the quality bar for cancer care delivery and outcomes throughout the region. Despite it having taken us a good 4-5 years to arrive here, we consider this just the beginning. We were fortunate to take advantage of two major advantages along the way, one being the deep engagement of the major stakeholders to share data and work together and the other being the ability to link data from the insurers and Medicare with tumor registry data from the Surveillance, Epidemiology, and End Results (SEER) program, which covers much of the state of Washington. We also have a separate Washington tumor registry that covers the rest of the state, so we are able to merge data from the insurance company data with the clinical data from the tumor registry, accounting for over 70% of the state residents.
What are some of the key highlighting points of this year's report?
Dr Lyman: What you will find in the report is the variation of quality, as measured by national benchmarks, as well as even wider variation of cost across the participating practices. For example, in recommended treatment for breast, colorectal, and lung cancer combined, there is little variation in quality because most practices use standard guidelines or nationally recommended treatments. However, we do see a large variation in cost for the same treatments across the different practices. When we focused specifically on breast cancer, we noticed a similar trend (ie, not too much variation in the quality of care, but considerable variation in cost).
For other measures, such as hospitalizations or emergency room visits during the first 6 months of chemotherapy, we observed substantial variation in performance based on standard quality measures with patients often ending up in the hospital or the emergency room for complications related to their treatment. The same wide variation in quality was noticed in end-of-life care.
The primary goal of this effort is to assist practices that are below expectations for quality for a specific measure to identify areas that are in need of improvement and demonstrate improvement in future reports. It is important to note that no practice has perfect performance scores on every measure and no practice has terrible performance scores on every measure. For each measure, there is a different mix of practices performing well and those that are not performing as well. Therefore, every practice in our region has ample opportunity for improvement. By the time a future report is released, the bar will again be raised in terms of quality of care across the region.
The cost issues are more challenging, especially because cancer care costs are rising very quickly. In addition to the sharply rising price of cancer treatments, increasing costs are also ween for hospitalization, diagnostic tests, and ancillary procedures as well. Cost of cancer care will be a significant challenge to improve upon, but we certainly want to see that the quality of care is high, patients are treated by recognized standards of quality, and they receive the treatments the need and deserve.
You said that practices can use this report as a way to compare their performance on quality measures against that of other practices. Why are community cancer care reports like this so invaluable for payers, providers, patients, and stakeholders? What is the ultimate goal of a quality and cost report like this?
Dr Lyman: The ultimate goal is to drive improvement in the quality of care. Most practices had no idea where they fared compared to their peers before the release of this report. We are hoping this will drive the use of validated pathways or guidelines from ASCO or other professional organizations. There are always going to be exceptions, but in terms of routine care, there should be a certain level of adherence to these guidelines. For smaller practices that are not using those tools, they can then implement mechanisms (ie, peer-review or guidelines/pathways) to improve the quality of care, and we will be able to provide feedback to them next year and in coming years in regard to how much improvement they have seen from these efforts. We have begun linking poor performing sites with higher performing sites for specific measures. This allows high performing sites to show what they are doing leading to subsequent good results as an option for low performing sites. We have seen some of this already taking place, which hopefully will raise the quality of care throughout the region.
Participating practices can also perform some additional analytics. For instances, they may be interested in how many older patients they have compared with their competitors or how much racial/ethnic variation they have within their patient demographic.
You mentioned a few times that there will be future reports and you will continue to release these reports fairly often. How often do you anticipate these reports being released?
Dr Lyman: We receive data updates on a quarterly basis. Participating practices have access to their own data through our data repository, "HICOR IQ," which they can use to search the most recent data down to the provider level and compare themselves across quality measures to other practices in the region. Practices have access to fairly up-to-date data to see how they compare and are improving. There is a massive amount of effort that goes into the reports, with data being updated on a regular basis. The reports take a fair amount of additional effort and staff time. Ideally, we will be doing this once a year.
We released this report 2 days before our fifth annual summit, which included over 250 providers, patients, patient advocates, and payers. What we would like to continue doing is releasing and discussing the updated data annually at this summit. The engagement and support we have received from the community has only become greater and greater, and we hope to see measurable change in the right direction over time.
Are there any other important points you would like to make that have not been discussed?
Dr Lyman: I would like to add that over the course of my career, I have served as a practicing medical oncologist for decades, collaborated with ASCO and NCCN on guideline and clinical pathway panels, and have published in the pathways literature. In all of the spaces that I have worked in my professional career, my peers and I have shared the same goals of improving the quality of care, adherence to quality measures, and overall care.
This has been a thrilling experience, particularly because of the willingness and genuine eagerness of the providers, patients, and payers in the region to participate. I see no reason why this cannot be replicated in other regions in some form. If you can get all the stakeholders together on the same page, sitting around the table discussing their individual and shared needs, regional reports such as ours can be made much more commonplace. We do have the unique advantage here in the northwest of the SEER data from the NCI, statewide registry, and very cooperative stakeholders. We have an confluence of opportunities that have helped us be the first out of the gate. That being said, we have been contacted by other colleagues from various regions throughout the country who are all interested in replicating this style of transparent reporting of cancer care quality.
The response since the release of this data has been positive, even from those practices performing on the lower side for some measures. We are very encouraged with the response and the opportunity to continue this work and helping others do similar work.