Quality Matters: A View from the Seat at the Table
On November 29, the American Society of Clinical Oncology (ASCO) hosted a first-ever Quality Measures Summit to identify a set of cross-cutting quality measures applicable to all patients with cancer, irrespective of diagnosis or place along the disease trajectory. This meeting was in conjunction with the inaugural ASCO Quality Symposium, an educational and scientific meeting of over 600 oncology professionals in San Diego focused on quality, information technology, and health services research. The Academy was kindly asked to join the Summit by members of the Quality Care Committee of ASCO, and three members of the AAHPM Quality Task Force attended this meeting to represent the views of our membership and our discipline. On behalf of Dale Lupu and Kathi Bickel, I am presenting a brief update on the proceedings of this meeting and how Academy members can lend further voice to how cancer care quality will be assessed.
In parallel to national efforts to develop quality measures that are reflective of movements towards value-based care and avoidance of low-value services, AAHPM joined the American Society of Radiation Oncology (ASTRO), National Coalition for Cancer Survivorship, Oncology Nursing Society, Society of Surgical Oncology (SOS), California Healthcare Foundation, American Urological Association, American College of Surgeons Commission on Cancer, M.D. Anderson Cancer Center, and the Livestrong Foundation to propose a set of cross-cutting quality measures that evaluate quality from time of cancer diagnosis through end-of-life care and bereavement. Prior to the meeting, we were all asked to submit potential measure concepts. Using the framework of the National Quality Forum and Preferred Practices for Palliative Care from the National Consensus Panel, we advocated intensely for: the incorporation of systematic, comprehensive symptom assessment on every visit (and that goes beyond treatment-related side effects); access to consultative palliative care; caregiver support and assessment of satisfaction with care; timely discussion of hospice; assessment and management of psychological and social needs; information sharing and understanding, including that of prognosis; and patient and caregiver understanding of intent of cancer-directed therapies. These were presented with corresponding quality measure examples and supported by publications from palliative care literature.
In what still remains with me and my colleagues as the lasting impression of this meeting, is the acceptance of, at face-value and with minimal discussion, most of the palliative care quality measure concepts presented at the Summit. With the exception of a concept involving systematic assessment of symptoms, where an intense discussion ensued regarding the scope (i.e. which symptoms to address), frequency (i.e. which visits should assessments occur on), and methods (i.e. what tool to use, should we advocate for a specific tool) of a potential measure; concepts and principles addressing palliative and end-of-life care seemed as germane to the understanding of how high-quality cancer care should be delivered as radiologic imaging for staging of new disease. Moreover, once-foreign concepts such as attention to advance care planning and regular involvement of palliative care teams have become accepted components of cancer care delivery worthy of measurement, reporting, and improvement. Although domains such as assessment of caregiver satisfaction and psychosocial distress spurred lively discussion regarding details of the structures and specific tasks these would entail, it was clearly accepted that these areas are within the scope of practice of oncology care. Furthermore, we agreed with the other participants that logistics and details are important areas of discussion; even as a discipline, we are maturing our own processes to meet these areas of quality within secondary palliative care.
Currently, these proposed measures and concepts are now being distributed among workgroups to further hash out details of wording, scope, and essentials of measurement. These include defining populations and settings to which the measures would apply and describing steps for feasibility testing of the potential measures in real-life settings. As this moves forward, members of the Academy’s Quality Task Force will remain integral players in the world’s largest oncology membership organization initiative to develop cross-cutting quality measures. This initiative is also in-line with several efforts that involve the Academy and its members in working with ASCO in further integrating palliative care education into the continuing education of oncology professionals and the curriculum of oncology fellows. All of these efforts have strengthened the relationships between both AAHPM and ASCO, on the staff, investigator, and leadership levels. And this has created further avenues for cooperation on efforts that improve the care of all patients with cancer.
A common theme heard from speakers and attendees of the ASCO Quality Symposium was one that originates from the writings of Brent James, a noted policy expert on quality from Intermountain Healthcare. Colloquially, it goes something like this: “Quality is about enhancing reliability of delivery – you don’t have to get it right, just get it consistent first. Then, perfect the consistent care until it’s right.” In many ways, since the publications of the article by Jennifer Temel and the subsequent Provisional Clinical Opinion by Smith et al., we are transitioning from demonstrating the proof-of-principle that palliative care is valuable and needed in cancer. And now, we are evolving from proving our value, to – literally – having a seat at the table during important conversations of what ideal cancer care should look like. This involves ensuring that the spirit, principles, and expertise of palliative care are consistently and reliably interwoven into the tapestry of oncology care.
Since my youth, I’ve been taught that consistency builds trust. And ultimately, it is this trust that quality of life will be valued, improved, and preserved that our patients place in all of us. And it is nothing short of remarkable that, we are – in collaboration with our partnering professional organizations – getting closer to that ideal.
Arif Kamal, M.D.
AAHPM Quality and Standards Task Force
Director of Quality and Outcomes,
Duke Cancer Institute
Director, Palliative Care and Quality Research
Center for Learning Health Care, Duke Clinical Research Institute
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