Lending the Patient Voice to Oncology Quality Measurement

While value-based healthcare is not a new phenomenon, “we are coming to grips with the patient being a key part of the system,” said Ronald Walters, MD, MBA, MHA, MS, associate vice president of medical operations and informatics, The University of Texas MD Anderson Cancer Center. Walters was speaking at the National Comprehensive Cancer Network (NCCN)’s Oncology Policy Summit on Redefining Quality Measurement in Oncology, held September 25 in Washington, DC.

Noting this recent shift of placing the patient at the center of care and reimbursement, Walters said that initially, quality measures associated with reimbursement were primarily provider-centric.

“Why aren’t these measurements a key part of the health system yet?” Walters asked. He believes it is even more important to include measurements that are geared toward those who are not patients yet, meaning an emphasis on preventive care.

He then listed a set of provider-centric measures of value, which include training, education, certification, volume, and processes of care. “We know there is a definite relation between volume and patient outcomes,” Walters said, adding that over time, a physician’s experience and training play a significant role in determining outcomes. However, he warned that the provider-centric value equation can fail.

According to Walters, the most important quality measure for systems of care include cost, resource utilization (both over- and under-utilization), site of care and supportive information, and care coordination.

Cost. He emphasized that despite mixed opinions, cost is a real quality measure, because inefficiencies in a healthcare system can prove costly. “When you are the patient, price is not an issue when it comes to your [own] health,” Walters said. However, inefficient care delivery can have a big impact on the health system’s bottom line.

Resource utilization. Addressing the fact that there have been questions around whether managed care improves patient outcomes, Walters cited his personal experiences in the clinic around the use of positron emission tomography (PET) scans in patients with breast cancer. He cited examples of where patients demand a PET scan because a friend had good outcomes when managing their disease. Citing NCCN guidelines on PET scans and their routine use in the clinic—which do not recommend PET for noninvasive stage I, II, or operable II breast cancer for staging—Walters said, “How can we handle that normality equation?” so patients are assured that they are doing well without unnecessary scans.

Site of care. Walters explained that outcomes vary based on patient access to specific treatments and services. It is vital, he said, that a patient has access to all the providers that are necessary to ensure the best outcomes. “This will increasingly be a measure for an individual person or patient," he predicted.

Care coordination. “Do care providers talk to each other?” Walters asked, highlighting the importance of systems of information transfer to allow seamless exchange of patient information. “Large integrated healthcare systems do a very good job with this…but huge gaps exist in the community care setting,” he said.

He then shifted attention toward patient-centric measures of value, which include patient preferences and values, experience (including satisfaction), engagement, and outcomes. “Often, what’s entered in our system is the provider’s interpretation of the patient’s status,” he said. To overcome this gap, technology platforms are being developed that can capture patient feelings, he said. However, this is not an easy task, Walters added, explaining that “it takes time; it requires an active discussion [between the patient and the provider] and active listening.”

Outcomes measures, that focus on the patient’s preferences and values, have a few key requirements:

• Better integrated data systems
• Multi-system analytics
• Data transparency
• System attribution and accountability of outcomes
• Recognition of the fluid nature of measures over time.

NCCN is actively working on this, Walters said, with a focus on the entire spectrum of care continuum and active representation of the patient perspective on the committee that is developing these measures.