Using practice guidelines to assess cancer care quality.

Healthcare provided to patients in the United States neither parallels long-established best practices nor takes rapid advantage of important biomedical advances. The widely cited Community Quality Index study estimated the global gap between what is optimal and what actually occurs in practice. The investigators studied 439 separate processes of care covering both prevention and treatment of acute and chronic conditions, and found that only about half of the care patients received constituted best practices. This finding was relatively consistent across all measures. In this issue, Harlan et al conduct a similar analysis of cancer care, using data from the National Cancer Institute’s Patterns of Care study. They report on whether the initial treatment of patients with a broad range of cancer diagnoses follows widely accepted practice guidelines. In the study by Harlan et al, about two thirds of cancer patients receive care that parallels practice guidelines. The study by Harlan et al faced some methodologic challenges that are worth noting. The treatments provided to patients from 1995 to 1999 were compared with practice guidelines from a different era (2002); some practice standards must have changed during that time interval. In addition, it is always difficult to identify treatments provided to patients through chart review, and it is challenging to identify patients who refused treatment. I suspect that both of these limitations led Harlan et al to underestimate the percentage of patients who received guideline-based treatment. The study was also limited explicitly, in that it focused only on initial treatment of newly diagnosed patients. To capture more fully the quality of cancer care, all treatment courses should be scrutinized. A sizable share of cancer treatment is not initial treatment, but rather subsequent treatment (such as treatments after recurrence and second-line treatments). These minor issues do not reduce the importance of this study, which characterizes the shortfall between what could be provided to cancer patients in optimal circumstances and what occurs in practice. The sizeable gap the authors describe is made more important because of cancer’s high prevalence, and can reasonably be posited to be responsible for a large number of avoidable cancer deaths. Physicians, patients, and payers have all taken stock of studies such as this one, and have come to a common set of conclusions. The quality of care is too low as a result of care system fragmentation and a poorly designed payment system. For instance, patients’ medical records cannot be exchanged easily between physicians or care locations, leading to redundant care, elevated costs, and errors. Doctors and hospitals are paid for delivering services (ie, fee for service)—not for the quality of the care they provide or the outcomes their patients experience. However, this common consensus on the problems is not mirrored by consensus on the correct solutions. The one exception is that providers, payers, and patients all agree that we need to find ways of assessing care quality routinely. Some working models exist. Health plans have been reporting on their quality through the Health Plan Employer Data and Information Set measures for years. Hospitals and nursing homes more recently started reporting on specific processes of care in a uniform fashion. (To review the quality measures for individual US hospitals, refer to www.hospitalcompare.hhs.gov). Recent articles in the New England Journal of Medicine suggest that these quality reporting activities may be improving quality. One study found that hospitals that reported on the quality of care they delivered as part of the Joint Commission on Hospital Accreditation certification showed improvement across multiple measures over time. Another study examined Medicare managed care plans, and found that across multiple Health Plan Employer Data and Information Set measures, there were steady increases in performance over time, with concomitant reductions in treatment disparities. Interestingly, this latter study was published with two other articles that examined the same time period in the JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 36 DECEMBER 2