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ASCO Quality Oncology Practice Initiative (QOPI) Quality Oncology Practice Initiative (QOPI) Oncologist-led, practice-based voluntary quality improvement initiative conceptualized by Dr. Joseph Simone “Unless one engages practicing physicians in the basic structure, quality will never become part of the fabric of practice, the only route to a sustainable quality effort” Goal: to promote excellence in cancer care by helping oncology practices create a culture of self-examination and improvement (80% of cancer care in the U.S. is provided in community settings) QOPI: Mission Develop a means to promote excellence in cancer care that… Is voluntary Is designed and run by oncology practitioners Is relevant and valuable to all practices Can be delivered anywhere Measures progress and allows comparison with peers Is simple and inexpensive to implement Is not a research project QOPI Background Information QOPI measures processes of cancer care in ambulatory care settings Pilot phase: 2002-2005 National rollout: March 2006 Three data collections completed Methodology: semi-annual chart abstraction at the practice level Methodology Practices identify cases of invasive cancer seen within the last six months Sample size based on location FTE’s Cases selected as needed to meet minimal requirements for disease-specific and domain-specific measures Practices abstract chart data based on questions provided either on a standard paper abstraction form or web-based form Practices enter de-identified date onsite via a secure web-based application developed by ASCO Sample Size Sample size targets depend on number of medical oncology FTEs in office (site/location) 1 med onc FTE: 2-3 med onc FTEs: 4-6med onc FTEs: 7+ med onc FTEs: 48 charts (24 per module) 64 charts (32 per module) 68 charts (34 per module) 80 charts (40 per module) Measures Initial measures were selected based on the following criteria: clinically intuitive applicable to a large portion of patients feasible to evaluate and measure accessible by chart abstraction amenable to improvement Measures Sources ASCO Practice Guidelines and Technology Assessments ASCO/NCCN Quality Measures National Initiative on Cancer Care Quality NCCN Clinical Practice Guidelines Consensus-based: Literature review Organizational priorities (e.g., pain assessment is a JCAHO standard) “Common sense” Measures by Category Core measures Documentation of care Chemotherapy planning and administration Pain assessment and control Disease-specific measures Breast cancer management Colorectal cancer management Non-Hodgkin’s lymphoma management Non-small cell lung cancer management Domain-specific measures Care at end of life Clinical trial assessment Symptom/toxicity management Core Measures: Examples Pathology report confirming malignancy available in the chart Explicit statement of staging within one month of first office visit Documented plan for chemotherapy, including doses and time intervals Flow sheet for chemotherapy with doses and blood counts available in the chart Some form of patient consent documented End of Life Measures Pain assessed on the last or second to last visit before death Pain rated numerically Patient enrolled in hospice or referred to palliative care specialist before death Patient enrolled in hospice more than 1 week before death No chemotherapy administration within the last two weeks of life Symptom/Toxicity Management Serotonin antagonists administered with first administration of highly emetic chemotherapy Corticosteroids added concurrently Aprepitant administered appropriately with highly emetic chemotherapy Prior to administration of erythropoietin or darbepoetin, documentation of hemoglobin < 11g/dL or anemia/low hemoglobin symptom Breast Cancer Measures Chemotherapy recommended/received for breast cancer patients less than 70 years of age with tumors >1cm or axillary lymph node involvement Trastuzumab recommended for Her2Neu positive breast cancer patients Tamoxifen or AI recommended for ER or PR positive patients Intravenous bisphosphonates given to breast cancer patients with bone metastases Renal function assessed between first and second administration of bisphosphonates for breast cancer patients with bone metastases Colorectal Cancer Measures CEA measured at least once within 9 months following curative resection for colon and rectal cancer Chemotherapy recommended for colon cancer patients with lymph node involvement Chemotherapy recommended for rectal cancer patients with lymph node involvement or penetration through intestine muscle Results: Enrollment of Practices 140 ASCO Rollout 120 100 80 60 40 20 0 Pilot 1 Pilot 2 Pilot 3 Open 3/06 Open 9/06 Open 3/07 QOPI: March 2006 Data Collection 87 practices entered data in March 2006 9,324 charts were abstracted Participants included independent practices, multispecialty groups, academic affiliates, and academic medical centers Results: Display Format Detail Source N QOPI Overall Mean Practice Median Box Plot 10% Mean Median Individual Practices · ·· · 10% 50% 80% Pathology Report Available in Chart Is there a pathology report confirming malignancy available in the chart? Consensus-based N= 9357 Mean = 96% Median = 97% Explicit Statement of Staging Is the patient's cancer stage documented within one month of his/her first visit to the office (according to any staging system or simply the comment that the cancer is advanced, metastatic or incurable)? Consensus-based N = 8641 Mean = 89.9% Median = 92.4% Documented Plan for Chemotherapy Is there a plan for the total amount of chemotherapy to be given, including doses and time intervals, which was documented before the chemotherapy was started? Consensus-based N= 6633 Mean = 76.3% Median = 87.7% Some Form of Consent Documented Is there a signed consent (by the patient) for treatment in the chart or a a practitioner's notation that chemotherapy treatment was discussed with the patient and that the patient consented to this treatment? Consensus-based N = 6633 Mean = 87% Median = 98% Pain Assessment on Last Visit Prior to Death Is there a practitioner's notation documenting the patient's physical pain or lack thereof on his/her last visit to the office before death? JCAHO N= 1962 Mean = 74.5% Median = 75% Hospice Enrollment: Timing Among patients enrolled in hospice, how many were referred more than one week prior to death? Evidence-based N = 988 Mean = 76.1% Median = 76.7% Chemotherapy Administration within the Last Two Weeks of Life • • • • • Did the patient receive his/her last dose of chemotherapy more than two weeks prior to death? Evidence-based N = 480 Mean = 86% Median = 87% Use of Serotonin Antagonist Antiemetics At the first administration of highly emetogenic chemotherapy , did the patient receive a serotonin antagonist type of antiemetic? ASCO Guideline (evidencebased) N = 5023 Mean = 97.7% Median = 100% Adjuvant Hormonal Therapy for Breast Cancer Was tamoxifen or an aromatase inhibitor recommended for women with ER + or PR + early stage breast cancer? ASCO guideline (evidencebased) N = 587 Mean = 96.9% Median = 100% 100%, n=5 Analysis of First Two Data Collections Round Participating Centers Total Charts abstracted March 2006 87 9,357 September 2006 113 14,291 Unique practices participating in both rounds 71 (Study Group) March September 7,624 10,240 Study Group Practice type: Independent private practice 54 (77%) Academically-affiliated private practice 7 (10%) Academic medical center 3 (4.3%) Other 6 (8.5%) Practice size Mean MD FTE 7.51 (range 1-34) Mean new patients/year 1751 (range 80-11,600) Means patients enrolled in clinical trials 100 (range 0-2300) All Practices – Mean Performance, All Measures Spring: Mean 78.7 Med 80.4 Fall: Mean 82.3 Med 84.0 (p <0.05 ) Spring Fall Improvement significant in 9 practices by paired T-test (None declined significantly) (p= 0.010) Bottom Quartile versus All Others by Practice Bottom Quartile Number of practices with improvement Number of practices with worsening All Others Number of practices with improvement Number of practices with worsening 12 0 1 0 (p < 0.05 by paired T-test) N= 27 measures * * * * * * * * *p < 0.05 by paired T-test Summary Voluntary participation in a chart-based practice quality measurement system is feasible Disease-based measures show high rates of compliance Stable performance or continued improvement seen with serial participation Practices performing in the bottom quartile demonstrated the most marked improvement, both in individual measures and in domains of care Limitations Data are self-reported. Verification audits have not yet been undertaken Stability of measures over time has not yet been demonstrated Relationship of measures to outcome is not definitely demonstrated Next Steps Verification audits Design and dissemination of oncology practice enhancement tools Integration of QOPI into electronic medical records QOPI: Value Added ABIM: QOPI participation meets practice improvement requirement component for recertification (20 points) CME credit ACGME: QOPI pilot underway for “practice-based learning” requirement for fellowship training Physician recognition status will be awarded by some insurers for participation