How do you know if you or a loved one are getting quality cancer care?
That's an interesting question, although it isn't a new one. I have been asked that question on a number of occasions and in several media interviews, and quite frankly it's difficult to answer. In no small part because like many other things we do in medicine, true quality is difficult to measure with any certainty.
I was reminded of this dilemma last week in a posting by Gary Schwitzer (someone who is highly regarded in the medical media field) on his "Health News Review" blog . He related the story originally published in the St. Paul Pioneer Press of a woman with leukemia who wanted to get her care at one university hospital, but was told by her insurer that she had to go to another highly regarded hospital because the outcomes were better at the other institution. This was despite the fact that-according to the information provided in the blog-she had received all of her care to that point at university hospital #1.
The story went on to relate how the insurance company said they had the data to show that outcomes for her treatment were better at hospital B compared to hospital A. The assumption-and this is the key part of the discussion-was that the insurance company data was accurate and told the story truthfully. The blog went on to make the point that usually when a doctor or a hospital is subject to some outside measure of "quality" that the doctor or hospital who has the "inferior" measures of quality always blames the measuring system for failing to demonstrate their (the inferior doctor/hospital's) more difficult or complex patients, or taking into consideration other circumstances that may explain the discrepancy.
To a degree, that is a point appropriately taken. For years, as quality reports have been provided by various programs including insurance companies and Medicare, for example, the argument has always been made that "my/our patients are sicker and more complicated than their patients." Supposedly the results are corrected for this, but there remains considerable discussion within the medical and health outcomes research communities whether or not in fact all of the variables measured can be put into a simple formula that truly reflects quality differences between doctors and hospitals.
But the major question that has to be addressed is when an insurance company says "we have the data" that in fact they do "have the data"-beyond what it costs to treat a patient at a particular hospital or by a particular doctor. That's at the heart of the issue, since many hospitals and doctors believe that what the insurers are measuring is in fact the cost of care (dressed up as "resource utilization") as opposed to true outcomes, such as how many patients go into remission and perhaps are cured of their diseases, as would the case in the treatment of a patient with leukemia.
Getting our arms around true measures of quality has proven to be very, very difficult. It could be that we should be looking at how well doctors and hospitals adhere to some set of standard guidelines in their processes of providing care. Perhaps we should be looking at remissions and/or survival, adjusted for disease stage and severity. But gathering these types of data points is very difficult and beyond the capabilities of most of the systems currently in place. Not to mention that any one oncologist or hospital-with some exceptions-probably doesn't take care of a sufficient number of patients to provide a statistically valid sample for the quality treatment of any particular type of cancer.
What about survival statistics? Wouldn't that be the best measure of quality cancer care?
That would seem logical, but in fact it is much more complicated than it appears at first glance. There are questions of what we call "case mix," such as the specific diagnosis of the patient, the stage of their disease, where they live, whether or not they have insurance and what kind of insurance, and so on. There is the reality that many doctors and hospitals may be involved in the care of one particular patient, so their outcome may not reflect the decisions and recommendations of a specific oncologist. And then there is the question of tracking particular patients and linking them to specific physicians over years of time, in some cases decades.
We are left with the proverbial "head scratcher" question on this one. That doesn't mean there aren't many excellent researchers, committed doctors and dedicated organizations that are trying to work through these issues. It is just that accurately measuring the quality of cancer care is much more complicated than it seems at first glance. The National Quality Forum, the American Society of Clinical Oncology's QOPI® program (which is a voluntary program that measures the quality of care in oncologists' offices) and the widely accepted guidelines of the National Comprehensive Cancer Network (NCCN) are but three examples of organizations trying to address the quality of care for cancer patients
For better or worse, too frequently insurance companies want to give the impression that quality is associated with lower costs. Sometimes that may be the case, but not always. And more and more often I suspect we are going to see networks of care restricted on cost alone under the guise of "quality care", rather than making the best decision for the treatment of a particular patient based on their specific needs.
What we are probably going to be offered in the future is a method that at some level is looks at the processes of care offered by a particular doctor or hospital. That is pretty straightforward in some circumstances-such as at the very beginning of diagnosis and treatment of a particular cancer patient by answering the question "Are the right tests done and is the right treatment given at the right dose given for this particular patient with this particular cancer?"-but gets more complicated as the disease and its treatment continue down their respective paths.
So that leaves me with emphasizing that just because someone says one place is better than another, or one doctor is better than another it is important to keep in mind what information stands behind those statements, and how much transparency there is in the methods and the meaning of what they say. If "quality" it is based on lower costs alone, then that frequently is a non-starter since spending more or less money is not necessarily associated with "quality outcomes."
Ultimately-in my personal opinion--it is spending money appropriately and wisely that is the key to success in cancer treatment. How we measure that accurately and consistently continues to be a significant problem. The good news-as mentioned above-is many of us are aware of that and are trying to do something about it.
We can't let perfection be the enemy of the good, but as I have maintained for years, it would be terrific if the medical profession stood up and took charge of this issue, offered transparency into what they do and how they do it, and accept that we have a responsibility to our patients to hold ourselves accountable in some reasonable way to offer the assurances the care we provide our patients meets some fundamental measure of quality care. I believe our patients are entitled to no less. We need to measure and demonstrate our commitment to our mission and our patients' expectations. Just saying we give quality medical care does not make it so.
In the meantime, we will have to settle for whatever quality measures someone offers-even if they aren't necessarily the quality measures that really define the quality of care we offer or receive. A little transparency into the process would go a long way in providing insight into the accuracy of the data and the assumptions that are made based on that data.
Just saying you measure quality cancer care does not necessarily make it so.
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