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© 2003 American Society for Clinical Oncology
Quality of Care in Prostate Cancer: Important to Start and Too Important to Stop HereCenter for Outcomes Research, MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA FEW BUZZWORDS can irritate me more than "quality of care," especially when someone else’s standards are applied to my clinical work. High-quality care is a worthy objective, of course, but I welcome another’s evaluation of my practice about as much as being asked by a payer to justify another hospital day for my patient. The only more annoying source of the evaluation would be an expert panel. In the current Journal of Clinical Oncology, Spencer et al1 have proposed just such a process, and it is a good thing. But the process shouldn’t stop here. Their project marshals expert opinion to identify process and outcome indicators of quality of care for early-stage prostate cancer, as well as other important covariates. After a structured literature review and patient and spouse focus groups, the investigators interviewed national leaders in prostate cancer care to identify candidate variables. Finally, an expert panel using a RAND protocol for developing consensus rated the validity and feasibility of each measure on a scale from 1 to 9. For inclusion, indicators required validity scores of at least 7, whereas criteria for feasibility were more relaxed. Ultimately, the process retained 28 quality of care indicators and 14 important covariates. The authors propose to validate and field-test them in the future. The report by Spencer et al1is an important first step toward measuring quality of care for prostate cancer, the most common cancer diagnosis, excluding skin cancer, in the United States. Their proposed list of quality indicators will start a necessary, vigorous conversation. What do these indicators signal? Do they assess care comprehensively? Which variables should have been left out or added back? Can we measure these indicators accurately and at reasonable cost? Would input from specialties other than urology and radiation oncology have altered the list? Initially, the conversations will be with peers, in the hallway or at meetings. But eventually we will discuss these issues with our patients. That step will begin to close the loop in measuring the quality of care, because the patient’s perspective is the hardest to bring in, the easiest to ignore, and, for early prostate cancer, crucial. However, these investigators’ work implies an additional agenda. For quality indicators to have an effect, key stakeholders, if not all stakeholders, must accept them or at least not be motivated enough to shoot them down. A persuasive case for setting standards is necessary to overcome the annoyance of external review, professional pride, and inertia. At a minimum, acceptable standards must be comprehensive, fair, and specific and must arise from a process transparent enough that we can understand, evaluate, and critique it. Patchy criteria can distort the system, taking resources from measured activities that could starve unmeasured but important areas. Criteria that play to arbitrary strengths, especially those attainable only by the large, specialized centers, may devalue the quality of the patient-provider interactions at the heart of good clinical practice, overemphasizing technological prowess and inciting institutional envy. However, exploring volume-outcome relationships, which often document a necessary floor of adequate ongoing experience,2,3 should not be off limits. Imprecise criteria can be misused. Broad language can create corrosive opportunities to game the system with distorted measures. An example illustrates the problem: one of the selected structural indicators in the Spencer article—knowledge of the treating institution’s outcomes—does not specify the source of the outcomes information. Many institutions purport to have knowledge of their outcomes and report them, but the reported outcomes may arise from a variety of sources, including the treating physicians. For early prostate cancer, patient quality of life is a particularly important component of outcomes. For most men, prostate cancer causes neither symptoms nor a near-term mortal threat, whereas the outcomes that matter are treatment-related symptoms and fear of recurrence; both affect the quality of life of most men. The only reliable assessment of these effects is patient report by using validated questionnaires, as Spencer et al1 specify. However, physicians have long reported much more favorable results—on their patients’ behalf—than their patients do. Several forces bias physician reports of patient quality of life upward. Patients self-censor their complaints when face to face with the doctor who treated their cancer, and treating physicians may use self-serving definitions of important outcomes while taking helpful factors such as patient selection for granted, perhaps with an eye to public relations. Such information led a California prostate cancer patient to sue his health plan to approve surgery at an academic center publicizing excellent but not well-documented outcomes. The Wall Street Journal thoughtfully accompanied its coverage of the case with an informational table presenting the excellent potency and urinary incontinence rates of selected, well-known urologists, which were far better than the published results of well-performed, direct surveys of diverse clinical populations.4–7 A footnote was not reassuring: "Source: the surgeons" (The Wall Street Journal, July 19, 2002:D1). Even direct patient survey results using validated instruments can be fudged. A high-profile urologic practice surveyed its patients by using the University of California, Los Angeles, Prostate Cancer Index, developed by Litwin et al.5 The Prostate Cancer Index produces scores for urinary and sexual function, but they were omitted from the published report,8 along with every item directly assessing urinary incontinence and erectile function. The authors’ discussion included unfavorable references to other surveyed populations without mentioning crucial differences in study parameters, such as the definition of symptom outcomes, differences in practice settings, patient selection, and duration of the postoperative recovery period. The resulting misleading comparison has been prominently disseminated.9 Adequate standards of quality of care should prevent such manipulation. A useful addition to a system monitoring quality of care might be identifying outlier outcomes for vetting by independent observers. Content of the standards aside, the most important issue is the transparency of the process that produced them. Standards arising from a black box, like rumored black helicopters, can cause paranoia. The provenance of the indicators must be sufficiently evident for the reader (and eventual subject) to apprehend and judge. Spencer et al1 set down clear procedural guidelines, and the net was cast widely for potential indicators, but the scoring process relied solely on expert opinion. In assigning precise numeric ratings of validity and feasibility, which are broad and elastic concepts, the experts had ample opportunity to exercise their prejudices. Evidence of instructions given to the panel to constrain or direct their deliberations would reassure the reader. Without that, we are left fearing the worst: a group of experts rated a large number of potential indicators, many quite similar, and selected some on the basis of their own idiosyncratic criteria. As the process producing the standards to judge our practices by, this may be a hard sell. In general, the difficulty with expert opinion-based results is that they embody and codify the currently accepted biases within the field. Such criticisms are particularly important in a field such as prostate cancer, in which well-documented, strongly held, widely divergent opinions can be explained largely by medical specialty.10,11 The approach in this article stands somewhere between a survey of practitioners and the workings of a committee following precise guidelines specifying, for example, the conceptual model linking key components of care; the prescribed use of evidence and how to indicate its absence; and a strategy for iterative reassessment, vetting, and revising the results on the basis of stakeholder feedback. This article represents a crucial first step in the necessary process toward valid and feasible guidelines to evaluate the quality of early prostate cancer care. There are other voices, perhaps better harnessed, to hear. REFERENCES
1. Spencer BA, Steinberg M, Malin J, et al: Quality-of-care indicators for early-stage prostate cancer. J Clin Oncol 21:1928–1936, 2003
2. Begg CB, Riedel ER, Bach PB, et al: Variations in morbidity after radical prostatectomy. N Engl J Med 346:1138–1144, 2002
3. Hu JC, Gold KF, Pashos CL, et al: Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol 21:401–405, 2003 4. Fowler F Jr, Barry MJ, Lu-Yao G, et al: Patient-reported complications and follow-up treatment after radical prostatectomy: The National Medicare Experience—1988–1990 (updated June 1993). Urology 42:622–629, 1993[CrossRef][Medline] 5. Litwin MS, Hays RD, Fink A, et al: Quality-of-life outcomes in men treated for localized prostate cancer. J Am Med Assoc 273:129–135, 1995[Abstract]
6. Potosky AL, Legler J, Albertsen PC, et al: Health outcomes after prostatectomy or radiotherapy for prostate cancer: Results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 92:1582–1592, 2000
7. Talcott JA, Rieker P, Propert KJ, et al: Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy. J Natl Cancer Inst 89:1117–1123, 1997 8. Walsh PC, Marschke P, Ricker D, et al: Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 55:58–61, 2000[Medline]
9. Walsh PC: Surgery and the reduction of mortality from prostate cancer. N Engl J Med 347:839–840, 2002
10. Moore MJ, O’Sullivan B, Tannock IF: How expert physicians would wish to be treated if they had genitourinary cancer. J Clin Oncol 6:1736–1745, 1988
11. Fowler FJ Jr, McNaughton Collins M, Albertsen PC, et al: Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. J Am Med Assoc 283:3217–3222, 2000 This article has been cited by other articles:
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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