Welcoming the era of quality improvement in neuro-oncology.

Adult gliomas are incurable tumors that have devastating consequences on patients and their families. Although advances in surgery, radiation therapy, and medical therapies have been made in recent years, median survival for a patient with a newly diagnosed glioblastoma was approximately 16 months in recent trials. Patients with low-grade glioma have the potential for long-term survival but virtually always succumb to the disease. At the same time, guidelines to help clinicians manage patients with glioma in a high-quality, cost-effective manner are lacking. The Glioma Outcomes (GO) Project reported in 2005 that care of patients with high-grade glioma is heterogeneous, with some patients receiving care that is consistent with published evidence and others receiving care that contradicts the medical literature. Furthermore, in the GO cohort, patterns of care varied significantly between academic and community settings. Despite a rapidly emerging awareness that quality improvement (QI) activities are critically needed in oncology, little QI work has been reported in neuro-oncology. In this issue of Journal of Oncology Practice, Riblet et al report on their experience using a formal QI approach to develop the initial phase of a clinical care pathway for patients with glioma who were treated at Dartmouth-Hitchcock Medical Center in Lebanon, NH. They assembled a multidisciplinary team to manage the project and worked with a coach trained in QI methodology. Because the literature fails to define metrics that are consistently associated with outcome, they defined their own measures that could be objectively assessed and related to “timely and comprehensive care. ” Using the well-described Plan-Do-Study-Act framework, the team identified hypothetical contributors to poor performance and systematically attacked them. Key interventions involved improving interdisciplinary communication and ensuring consistent care with a postoperative order set. Performance data were displayed in a dashboard that was reviewed regularly by the project leader, and individuals were held accountable for performance of the individual subcomponents of the QI project. To track performance over time, the team used a statistical process control chart in which each data point represented the proportion of applicable best practice measures that were met. Indeed, the authors found that the proportion of best practice measures that were met improved from a mean of 63% to 85% (P .003) after implementation of the QI project. Riblet et al should be commended for their elegant, sophisticated implementation of QI methodology. Their success illustrates that QI activities need not be hindered by incomplete evidence to determine best practice. The authors convened a multidisciplinary team that was empowered by the program to define best practice. In doing so, they created a benchmark against which individual and team performance can be measured and openly discussed. As the relevant evidence base evolves, the authors are well positioned to incorporate new data in a systematic manner. Furthermore, by prospectively measuring and reporting process measure data, they will generate evidence that can be used to refine their own best practice measures. Riblet et al avoided many of the common errors made in QI work. Chief among these is the failure to plan for sustainability. In this example, the authors demonstrate sustained benefits over a 2-year period. They achieved this by securing a permanent source of institutional funding and by sharing data openly at an existing clinical forum. In the course of their team-based efforts, they built camaraderie that engendered motivation to continue the project. Like many areas of oncology, neuro-oncology is complex and requires coordination between an array of subspecialists and support staff. Most neuro-oncology programs rely on processes that evolved organically as new team members and technologies were added. As a result, there are abundant opportunities for process optimization, and there are no individuals better suited for this type of work than the people who participate in the processes every day. The project reported by Riblet et al demonstrates the level of commitment and expertise that is required to complete a successful QI project, and it also hints at some of the intangible benefits: improved esprit de corps among clinical team members coupled with an orientation toward continuous quality improvement and excellence. As the authors point out, their work is limited by its inability to demonstrate improved clinical outcomes, reduced costs, or gains in patient or staff satisfaction. Although these facts may disappoint some readers, one would be hardpressed to find a patient who prefers treatment in a setting where delays are commonplace, interdisciplinary communication is poor, and providers disagree about how most patients should be routinely treated. Patients with brain tumors as well as those with cancer in general will benefit from this kind of work. Cancer programs that support individuals with an interest in QI methodology and foster QI projects like the one described by Riblet et al will be better positioned to deliver consistently high-quality, cost-effective care. Focus on Quality