Guideline-adherent care vs quality care in cancer patients: twins or distant cousins?

E veryone wants high-quality cancer care— patients want it, as do payers and policy makers, physicians, and other health care providers. For health services researchers, the challenge is: how do we measure quality? Perhaps the most intuitive metric is guideline adherence. For almost all types of cancer and cancerrelated conditions, including febrile neutropenia (FN), there are published evidence-based guidelines. I do not think anyone would argue with the merits of providing evidence-based medical care—the use of proved and effective treatments to patients and limiting the use of unproved therapies. As many recent studies have demonstrated, the use of expensive, yet unproved, therapies is highly prevalent in cancer care. There is emerging evidence that financial incentives in our health care system may partly contribute to this practice. Guidelines and research can help mitigate this large-scale problem. Therefore, the article in this issue of the journal by Wright et al is particularly timely. The authors used an administrative database that contained data from more than 600 acute care hospitals across the United States, representing approximately 15% of all hospitalizations, to examine guideline adherent and nonadherent care for hospitalized cancer patients with FN. A total of 25 231 patients were identified from January 1, 2000, through March 31, 2010. The authors used available data to stratify patients with “low-risk” and “high-risk” FN and reported treatments received and outcomes for the 2 groups. Overall, almost 80% of patients received guidelineadherent antibiotics. In low-risk patients, receipt of guideline-adherent treatment was associated with reduced inhospital mortality. There was a prevalent use of expensive but not clearly beneficial treatments, vancomycin (55% in 2010) and granulocyte colony-stimulating factors (GCSF) (55% in 2010). High FN-volume hospitals and high FN-volume physicians were more likely to provide guideline-adherent antibiotics; high FN-volume physicians were less likely to use vancomycin and high FNvolume hospitals less likely to use GCSF. Wright et al suggest that antibiotic choice may be used as a quality metric for the care of cancer patients with FN. How closely related are guideline adherence and highquality care? Are they more like twins or distant cousins? There are some important limitations to using guideline adherence as a surrogate for quality. To me, evidencebased guidelines are somewhat analogous to movies that are based on a true story. Because there are guidelines for almost every clinical scenario, but not every scenario has had the benefit of randomized or even prospective trials, guidelines often require expert consensus based on the best available evidence (even if scant) or opinion. In a recent analysis of the National Comprehensive Cancer Network (NCCN) guidelines, only 6% of recommendations were based on level 1 evidence. Should guideline recommendations that are based on a lower level of evidence be followed as strictly as those based on randomized trials? There is also the apparent conflict between strictly following guidelines vs individualized treatment decision making for each patient. Actual clinical scenarios can often be more complex than those described in guidelines, and patients can make informed decisions that are against physician recommendations. Given these uncertainties, it is unclear what level of guideline adherence should be acceptable to those who are measuring it. The answer is definitely not 100%, which would fail to acknowledge the complexity of clinical scenarios and patient autonomy. In this article, Wright et al deemed the finding of 80% guideline-adherent antibiotic use as “high”; I would agree. What about 70%, or 60%? Should the acceptable adherence level be based on the strength of evidence, the absolute benefit vs harm of the therapy in question, or both? Also, what if guidelines are inconsistent in their recommendations? In a meta-analysis, colony-stimulating factors were associated with a reduction in time spent in hospital but not mortality for cancer patients with FN, and some guidelines suggest that GCSFs can be considered. In this context, it is unclear if mortality is the only relevant end point and difficult to assess whether the 66% GCSF use in high-risk patients found in this study represents highor lowquality care. There are also strengths and limitations of using large administrative databases to assess quality cancer care. There is power in examining patterns of care across the United States to identify potential areas for improvement and/or specific patient groups vulnerable to receiving nonguideline-adherent care. However, administrative data can be subject to misclassification. In the study by Wright et al, the authors faced an important challenge of using administrative data to classify patients into highvs low-risk groups, which is critical in the clinical management of cancer patients with FN. They found that guideline-adherent antibiotic use was associated with reduced mortality in low-risk patients, but treatment received was not associated with outcome in high-risk patients. The authors are to be commended for taking the analysis to this next step to examine the association between guideline adherence and patient outcomes, but the results demonstrate the challenge of doing this with administrative data. Just as I would be hesitant to conclude that guideline-adherent antibiotic use has no benefit in high-risk patients (due to concerns for potential misclassification and unmeasured confounding), it is un-