Clinical Interpretation of the ASCO Recommendations on Quality and Value

The American Society of Clinical Oncology (ASCO) recently published an update to the value framework, as the next step toward the goal of providing clinicians and patients with a tool for shared decision making. Providing an overview of the framework and ASCO’s quality program, the Quality Oncology Practice Initiative (QOPI), was the session Quality and Value: Measuring and Utilizing Both in Your Practice.

Anne C. Chiang, MD, PhD, Yale Cancer Center, provided an overview of the QOPI certification program and explained the impact that this certification could have on the quality of care provided by clinical practices. “The current landscape of oncology is a combination of new immunotherapeutic agents, genomics and precision medicine, technology, and big data,” Chiang said. This is a difficult process as we try to balance quality and value of these innovative treatments, she said.

“QOPI is ASCO’s signature quality program. Over 1000 practices with 7000 participants have participated in QOPI since 2006,” Chiang said. Chiang showed that there’s widespread geographic distribution of the practices within the United States that have registered with the program. Additionally, the QOPI program has crossed international boundaries, and 16 international practices have registered with the program in fall 2015.

So why does QOPI matter? “It’s not just about the cost,” Chiang said, “but it’s also about creating a culture of quality, tools for measurement, benchmarking and standardization opportunities, and driving performance improvement.” She provided an example of the Smilow Cancer Center at Yale, which implemented several quality improvement projects, including:

• EPIC, the electronic health record system
• QOPI certification
• An oral chemotherapy initiative
• SRC care center emotional distress project

The cancer center wanted improved standardization across its various sites of care. Following the integration of QOPI practices, a significant improvement in documentation of data was observed at the various clinical sites, Chiang said.

The QOPI certification program also touches on aspects of patient care, and it helps,

• Make the right diagnosis
• Determine the treatment plan
• Communicate with the patients
• Shared decision making.

According to Chiang, Smilow is using QOPI to raise the bar for disagreements on pathology referrals, especially when they are conducted at outside labs. “QOPI also provides important tools to comply with MACRA. The Physician Quality Reporting Pathway will help to comply with the requirements of MIPS, the merit-based intervention payment system.

“The QOPI/QCP community is both a quality forum and test ground for evolving solutions to MACRA and future challenges,” Chiang said.

The Value in the ASCO Value Framework, Lowell E. Schnipper, MD, PhD, Beth Israel Deaconess Medical Center discussed the nuances of the value framework. “The context in which we are entering this space is a new era of treatments that we are utilizing in clinical practice everyday,” Schnipper said. “Several of these treatments are game-changers in care. But these treatments are expensive, and insurance is getting unaffordable for most in the middle-income strata of society.”

“We anticipate that the tool we have developed can help patients and providers make treatment decisions. We hope to collaborate with software vendors who can help develop an app for use at the physician-patient interface,” Schnipper said. He went on to explain the Net Health Benefit score or NHB, which has numerous domains that are regularly used in the clinic, including clinical benefit, which is the biggest domain. When calculating the NHB, overall survival is valued above progression-free survival, which is above response rate (RR).

Schnipper acknowledged that he does realize that some of the newer drugs may not have data that compares them with the standard of care, and in that case RR would be considered. “Bonus points will be awarded to symptom palliation, improved quality of life, and extended survival. Additionally, toxicity subtracts points from NHB,” Schinpper said. The task force has developed a separate framework for adjuvant treatments.

Referring to some of the other value frameworks that have been developed, including the National Comprehensive Cancer Center’s Evidence Blocks and the Institute of Clinical and Economic Review’s tool, Schnipper said that the focus of ASCO’s framework is to have a shared decision making tool to help patients understand the impact of their treatment on their finances.

Some open questions that he believes remain open are:

• How much are we willing to pay for what amount of gain?
• Is there a role for paying for performance by therapies?

The last talk was by Steven L. D'Amato, BCOP, RPh, CEO of New England Cancer Specialists, who brought the community oncology perspective to the discussion. Their practice has been a part of the COME HOME project, to become a certified oncology medical home through the Commission on Cancer, and they recently also applied for their QOPI recertification.

QOPI is all about quality, D’Amato said. “It demonstrates commitment to excellence and quality of treatment. Especially as the outpatient setting becomes more prevalent in cancer care, maintaining the quality of care is quite essential,” he added.

Explaining some of the nuances of QOPI, he said that there are 5 modules that are evaluated for certification: care at EOL, symptom/toxicity management, breast cancer, colorectal cancer, and non-small cell lung cancer. “The clinical practice is scored on 26 designated measures, to get an overall quality score, and should meet at least 75% to be certified,” D’Amato said.

Site assessment is the second component of certification, which is focused on several key areas of patient care such as staffing, treatment planning and chart documentation, oral adherence, patient education, drug prep, etc.

The goals of QOPI certification, D’Amato said, are providing the highest quality care, provide trusted solutions to satisfy the demands for quality activities, 3-year designation of QOPI certification, and to provide good quality care to the local community. What would be the cost to the practice to apply for this quality certification? “It’s a combination of monetary value and the staff time required for training and policy/procedure development.”

Is this valuable for patients? That remains an open question, according to D’Amato. “Payers are definitely interested in quality information, and provider and staff at the practices do understand the value of this certification,” he said.

He added that QOPI certification has definitely improved their own practice at New England Cancer Specialists—it has allowed standardization across their sites and improved their documentation procedures. It also helped them identify areas of focus for each practice.

D’Amato listed several challenges moving forward:

• Communicating quality and value to all
• Can payers be made to compensate for the value added?
• How can certification be made more efficient? Maybe through eQOPI?
• How can the QOPI certification program providers become preferred providers?