Richard M. Levine

Predicting the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment Scale for High‐Age Patients (CRASH) score

Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve.

Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators.

Objective: An American Psychosocial Oncology Society workgroup has developed indicators of the quality of psychosocial care that can be measured through review of medical records. The present report describes the first large‐scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings.

Degree of Variability in Performance on Breast Cancer Quality Indicators: Findings From the Florida Initiative for Quality Cancer Care

PURPOSE The Florida Initiative for Quality Cancer Care (FIQCC) comprises 11 Florida practice sites that participate in comprehensive reviews of quality of care specific to patients with cancer. Here, we examined site adherence to performance indicators to assess quality of care for patients with breast cancer (BC). METHODS Quality indicators were scripted on the basis of accepted guidelines from the Quality Oncology Practice Initiative, National Comprehensive Cancer Network, American College of Surgeons, and site-specific expert panel consensus. Comprehensive chart reviews, including both medical and surgical oncology quality measures, were conducted for patients with BC first seen in 2006 by a medical oncologist at one of the sites. Statistical comparisons were made by the Pearson χ(2) exact test, using Monte Carlo estimation. RESULTS Charts of 622 patients were reviewed. Of the 34 indicators, seven for medical oncology and four for surgical oncology fell below the 85% level of adherence. A statistically significant difference (P < .001) in variation of performance across the sites was found for the following medical and surgical oncology indicators: documentation of menopausal status, family history, informed consent, planned chemotherapy regimen and flow sheet, American Joint Committee on Cancer staging, HER2/neu status, reporting of margin orientation and inking of the margins, histological grade, having a sentinel lymph node biopsy for invasive BC, and obtaining a mammogram within 14 months of definitive surgery. CONCLUSION The FIQCC has identified how multiple aspects of BC care can be improved. Findings are being used at the participating institutions to guide quality improvement efforts.

Florida Initiative for Quality Cancer Care: Improvements on Colorectal Cancer Quality of Care Indicators during a 3-Year Interval

BACKGROUND The quality of cancer care has become a national priority; however, there are few ongoing efforts to assist medical oncology practices in identifying areas for improvement. The Florida Initiative for Quality Cancer Care is a consortium of 11 medical oncology practices that evaluates the quality of cancer care across Florida. Within this practice-based system of self-assessment, we determined adherence to colorectal cancer quality of care indicators (QCIs) in 2006, disseminated results to each practice and reassessed adherence in 2009. The current report focuses on evaluating the direction and magnitude of change in adherence to QCIs for colorectal cancer patients between the 2 assessments. STUDY DESIGN Medical records were reviewed for all colorectal cancer patients seen by a medical oncologist in 2006 (n = 489) and 2009 (n = 511) at 10 participating practices. Thirty-five indicators were evaluated individually and changes in QCI adherence over time and by site were examined. RESULTS Significant improvements were noted from 2006 to 2009, with large gains in surgical/pathological QCIs (eg, documenting rectal radial margin status, lymphovascular invasion, and the review of ≥ 12 lymph nodes) and medical oncology QCIs (documenting planned treatment regimen and providing recommended neoadjuvant regimens). Documentation of perineural invasion and radial margins significantly improved; however, adherence remained low (47% and 71%, respectively). There was significant variability in adherence for some QCIs across institutions at follow-up. CONCLUSIONS The Florida Initiative for Quality Cancer Care practices conducted self-directed quality-improvement efforts during a 3-year interval and overall adherence to QCIs improved. However, adherence remained low for several indicators, suggesting that organized improvement efforts might be needed for QCIs that remained consistently low over time. Findings demonstrate how efforts such as the Florida Initiative for Quality Cancer Care are useful for evaluating and improving the quality of cancer care at a regional level.

Initial Evaluation of Quality Indicators for Psychosocial Care of Adults With Cancer

BACKGROUND The American Psychosocial Oncology Society has developed the first indicators of the quality of psychosocial care for cancer patients. This report describes the initial evaluation of these indicators. METHODS Medical records of 388 colorectal cancer patients first seen by a medical oncologist in 2006 at seven practice sites were reviewed by trained abstractors whose accuracy was documented by periodic checks. RESULTS Rates of assessment of emotional well-being within 1 month of a patients first visit with a medical oncologist ranged from 6% to 84% (mean = 60%; P < .001). Among the 45 patients identified as having a problem with emotional well-being, rates of evidence of action taken (or explanation for no action) ranged from 0% to 100% (mean = 51%; P = .85). A direct comparison showed that pain was assessed more often than emotional well-being in these patients (87% vs 60%, P < .001). CONCLUSIONS Findings show these indicators can be measured easily and reliably, demonstrate variability across practices that suggests potential for improvement, and yield information that can be used to take actions to improve quality. Additional findings suggest that, to date, efforts to promote routine symptom assessment have been more successful for pain than for emotional well-being.

Measuring Quality of Care in the Treatment of Colorectal Cancer: The Moffitt Quality Practice Initiative

PURPOSE The Moffitt Quality Practice Initiative (MQPI) is a practice-based system of quality self-assessment, the ultimate goal of which is to improve the quality of cancer care at a statewide level. The initial phase of this project focused on developing procedures, determining feasibility, and evaluating utility for assessing quality of care for colorectal cancer within an existing affiliate network. PATIENTS AND METHODS Representatives from four oncology groups selected quality measures consistent with evidence-, consensus-, and safety-based guidelines that could be abstracted from medical records. Trained abstractors then reviewed records of all eligible colorectal patients seen by each practice in 2004. Frequencies of responses for each indicator were tabulated for overall and practice-specific level of adherence and were compared among practices. RESULTS Adherence was uniformly high for several indicators, including confirmatory pathology report, staging information, and chemotherapy discussion or recommendation. Lower adherence was evident across practices for performance of carcinoembryonic tests and complete colonoscopic evaluations. Significant variation among practices was evident only for consent for chemotherapy. CONCLUSION The initial phase of MQPI demonstrated the feasibility and utility of assessing quality indicators for colorectal cancer among members of an existing affiliate network. Findings identified areas where adherence to care was uniformly high, but also identified areas where both overall and practice-specific adherence were less than optimal. These efforts lay the groundwork for expanding MQPI in several directions that have in common the potential to improve the quality of cancer care on a statewide basis.

Evaluating the quality of colorectal cancer care in the state of Florida: results from the Florida Initiative for Quality Cancer Care.

PURPOSE The Florida Initiative for Quality Cancer Care (FIQCC) was established to evaluate the quality of cancer care at the regional level across the state of Florida. This study assessed adherence to validated quality indicators in colorectal cancer (CRC) and the variability in adherence by practice site, volume, and patient age. METHODS The FIQCC is a consortium of 11 medical oncology practices in Florida. Medical record reviews were conducted for 507 patients diagnosed with CRC and seen as new medical oncology patients in 2006. Thirty-five indicators were evaluated individually and categorized across clinical domains and components of care. RESULTS The mean adherence for 19 of 35 individual indicators was > 85%. Pathology reports were compliant on reporting depth of tumor invasion (96%; range, 86% to 100%), grade (93%; range, 72% to 100%), and status of proximal and distal surgical resection margins (97%; range. 86% to 100%); however, documentation of lymphovascular and perineural invasion did not meet adherence standards (76%; range, 53% to 100% and 39%; range, 5% to 83%, respectively). Among patients with nonmetastatic rectal cancer, documentation of the status of surgical radial margins was consistently low across sites (42%; range, 0% to 100%; P = .19). Documentation of planned treatment regimens for adjuvant chemotherapy was noted in only 58% of eligible patients. CONCLUSION In this large regional initiative, we found high levels of adherence to more than half of the established quality indicators. Although the quality of care delivered within FIQCC practices seems to be high, several components of care were identified that warrant further scrutiny on both a systemic level and at individual centers.

Quality of Care in Non–Small-Cell Lung Cancer: Findings From 11 Oncology Practices in Florida

BACKGROUND Limited data on the quality of care in non-small-cell lung cancer (NSCLC) are available. This study aims to assess the quality of care in NSCLC among 11 medical oncology practices in Florida and to explore the impact of practice volume on care. METHODS Clinical guidelines and existing indicators were reviewed, and an expert survey was conducted to identify a set of process-based quality of care indicators (QI). Medical records of new patients with NSCLC seen in 2006 were retrospectively reviewed for the adherence to these QIs. RESULTS We reviewed the compliance with a set of 11 QIs (four general and seven NSCLC specific) among 531 patients. The patient median age was 68 years; 51% were male, and 49% had advanced NSCLC. The median adherence rates to general QIs and NSCLC-specific QIs were 95% (range 69% to 99%) and 69% (range 29% to 91%), respectively. We identified three main areas of deficiencies: chemotherapy consenting (69%), brain staging for stage III NSCLC (59%), and performance status assessment for advanced stages (42%). Significant variation in the adherence rates across practice sites was observed in five of 11 QIs. CONCLUSION On the basis of this data set of participating institutions in Florida, several areas in the care of patients with NSCLC were identified as targets for future quality improvement efforts.

Changes in the Care of Non–Small-Cell Lung Cancer After Audit and Feedback: The Florida Initiative for Quality Cancer Care

PURPOSE Audit and feedback have been widely used to enhance the performance of various medical practices. Non-small-cell lung cancer (NSCLC) is one of the most common diseases encountered in medical oncology practice. We investigated the use of audit and feedback to improve the care of NSCLC. METHODS Medical records were reviewed for patients with NSCLC first seen by a medical oncologist in 2006 (n = 518) and 2009 (n = 573) at 10 oncology practices participating in the Florida Initiative for Quality Cancer Care. In 2008, feedback from 2006 audit results was provided to practices, which then independently undertook steps to improve their performance. Sixteen quality-of-care indicators (QCIs) were evaluated on both time points and were examined for changes in adherence over time. RESULTS A statistically significant increase in adherence was observed for five of 16 QCIs. Adherence to brain staging using magnetic resonance imaging or computed tomography scan for stage III NSCLC (57.8% in 2006 v 82.8% in 2009; P = .001), availability of chemotherapy flow sheet (89.2% v 97.0%; P < .001), documentation of performance status for stage III and IV disease (43.4% v 51.3%; P < .001), availability of pathology report for patients undergoing surgery (95.2% v 99.2%; P = .02), and availability of signed chemotherapy consent (69.5% v 76.3%; P = .04). There were no statistically significant decreases in adherence on any QCIs. CONCLUSION Audit with feedback was associated with a modest but important improvement in the treatment of NSCLC. Whether these changes are durable will require long-term follow-up.

Florida Initiative for Quality Cancer Care: Changes in Psychosocial Quality of Care Indicators Over a 3-Year Interval

PURPOSE Identifying and addressing psychosocial concerns is increasingly recognized as an important aspect of cancer care that needs to be improved. As part of the Florida Initiative for Quality Cancer Care, medical record reviews were conducted to evaluate cancer care, including psychosocial care, at oncology practices in Florida in 2006. Results were subsequently disseminated to the practices, and performance was reassessed at the same practices in 2009. METHODS Data were available for patients with colorectal, breast, and non-small-cell lung cancer first seen by a medical oncologist in 2006 (n = 1,609) and 2009 (n = 1,720) at the same 10 practice sites. Performance on each psychosocial indicator was evaluated for overall change over time and for variability in change based on practice site and cancer type. RESULTS The percentage of patients identified as having a problem in emotional well-being increased significantly over time, from 24% to 31% among those assessed (P = .002) and from 13% to 16% overall (P = .026). In contrast, there no significant changes over time in assessment of emotional well-being (53% to 51%, P = .661) or in action taken to address problems (57% to 45%, P = .098). CONCLUSION Findings suggest more intensive efforts than audit and feedback will be required to improve the quality of psychosocial care and that greater recognition of problems with emotional well-being may tax the ability of practices to link patients with appropriate services. Systematic research is needed to identify and disseminate effective strategies for implementing routine assessment of well-being and addressing the increased demands for care this will generate.