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Quality Measures for Symptoms and Advance Care Planning in Cancer: A Systematic Review

Karl A. Lorenz, Joanne Lynn, Sydney Dy, Anne Wilkinson, Richard A. Mularski, Lisa R. Shugarman, Rhonda Hughes, Steven M. Asch, Cony Rolon, Afshin Rastegar, Paul G. Shekelle

From the Veterans Affairs Greater Los Angeles Healthcare System; Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Southern California Evidence Based Practice Center, Santa Monica, CA; Agency for Healthcare Research and Quality, Rockville; and Johns Hopkins University School of Public Health, Baltimore, MD

Address reprint requests to Karl A. Lorenz, MD, MSHS, VA Greater Los Angeles Healthcare System, Division of General Internal Medicine, 11301 Wilshire Blvd, Code 111-G, Los Angeles, CA 90073; email: karl.lorenz{at}med.va.gov

PURPOSE: Measuring quality of care for symptom management and ascertaining patient goals offers an important step toward improving palliative cancer management. This study was designed to identify systematically the quality measures and the evidence to support their use in pain, dyspnea, depression, and advance care planning (ACP), and to identify research gaps.

METHODS: English-language documents were selected from MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO (1995 to 2005); Internet-based searches; and contact with measure developers. We used terms for each domain to select studies throughout the cancer care continuum. We included measures that expressed a normative relationship to quality, specified the target population, and specified the indicated care. Dual data review and abstraction was performed by palliative care researchers describing populations, testing, and attributes for each measure.

RESULTS: A total of 4,599 of 5,182 titles were excluded at abstract review. Of 537 remaining articles, 19 contained measures for ACP, six contained measures for depression, five contained measures for dyspnea, and 20 contained measures for pain. We identified 10 relevant measure sets that included 36 fully specified or fielded measures and 14 additional measures (16 for pain, five for dyspnea, four for depression, and 25 for ACP). Most measures were unpublished, and few had been tested in a cancer population. We were unable to describe the specifications of all measures fully and did not search for measures for pain and depression that were not cancer specific.

CONCLUSION: Measures are available for assessing quality and guiding improvement in palliative cancer care. Existing measures are weighted toward ACP, and more nonpain symptom measures are needed. Additional testing is needed before the measures are used for accountability, and basic research is required to address measurement when self-report is impaired.

Supported by a Veterans Affairs Health Services Research and Development Research Career Development Award (K.A.L.); National Cancer Institute K-08 (S.D.); and the Agency for Healthcare Quality and Research.

Presented at the February 2006 meeting of the American Academy of Hospice and Palliative Medicine, Nashville, TN, February 8-11, 2006.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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