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Originally published as JCO Early Release 10.1200/JCO.2008.18.2162 on November 10 2008 © 2008 American Society of Clinical Oncology.
Promoting Efficiency and Quality of Care in the Hummer Health Care System
Veterans Administration Greater Los Angeles Healthcare System and Geffen School of Medicine at University of California, Los Angeles, Los Angeles; and RAND Corporation, Santa Monica, CA Cancer care cost taxpayers in the United States approximately $72 billion in 2004,1 and the majority of dollars were expended for patients with advanced disease and for the care of patients during their last year of life.2 Particularly when patients are living with advanced or progressive disease, we should expect that care succeeds in improving quality as well as quantity of life. The difficulties faced by patients and their families living with cancer are substantial and well documented, and it is surprising that we lack evidence of having made headway in the health care system against such pervasive and distressing problems as cancer pain.3 Meanwhile, increasing fiscal constraints in the United States make a laissez-faire attitude about inefficient care more and more unsustainable. As with our unsustainable thirst for oil, the chances grow that we will have to face the health care–Hummer facts. The good news is that in many cases we may be able to achieve both higher quality and improved efficiency in late-life cancer care.4 As patients grow increasingly frail from burdensome illness such as advancing cancer, the laws of unintended consequences often come into play as the shrinking benefits of treatment have to be balanced against growing risks. Previous reports suggest that in many cases, the costs and intensity of late-life cancer care are increasing.5 Although the quality of evidence is limited, observational data suggest that hospice care saves money for patients with cancer by reducing inpatient hospitalizations, especially compared with noncancer conditions.6 At the same time, there is substantial evidence that a variety of supportive care interventions are helpful in improving health-related quality of life.7 These lines of evidence support more closely integrating palliative approaches in the cancer continuum and evaluating the impact on efficiency and quality. Meanwhile, we need to strengthen tools to evaluate current patterns of care and to gauge progress in achieving these goals. In this issue of Journal of Clinical Oncology, Setoguchi et al8 used indicators derived from linked cancer registries and administrative databases in New Jersey and Pennsylvania to evaluate overuse and underuse of care received by elderly patients with breast, colorectal, lung, and prostate cancer. Investigators evaluated the proportion of patients who used short- with long-acting opioids, who received chemotherapy within 14 days of death, who received new regimens within 30 days of death, who had more than one emergency department visit, who had more than one hospitalization, who had one or more intensive care unit admissions, those not admitted to hospice, those admitted to hospice within 3 days of death, and those who died in an acute setting of care. They compared these measures, prospectively identifying individuals with a cancer diagnosis and evaluating subsequent care versus retrospectively evaluating care received by decedents. The two cohorts demonstrated expected differences, with the retrospective cohort somewhat sicker, and both approaches revealed some useful patterns. In both cohorts, longacting opioid use was surprisingly low, in the range of 15% to 20%, and about one third of long-acting users were not prescribed a short-acting opioid. Hospice admission within 3 days occurred in about one fourth of patients, and among the sickest prospective patients and the retrospective cohort, about two thirds of patients did not use hospice. About one third of both cohorts died while hospitalized. The most notable differences in the results of the alternative approaches were in those related to emergency department, hospitalization, and intensive care unit use, as well as receipt of and toxicity from chemotherapy, where utilization across the board was considerably higher in the prospective than the retrospective cohort. Given that many patients may receive a trial of disease-modifying treatment, the authors suggest that these indicators may not be conceptually appropriate for prospective evaluation of care. However, given how common serious pain is among cancer patients and what is known about the benefits of hospice, these findings should prove useful as they suggest targeting activities to improve appropriate opioid use and to increase hospice referral. What would constitute ideal indicators of efficiency or quality of care? With regard to efficiency, an important concern includes the need to clarify which provider is responsible for a patient's use of a health care resource. Targeting an episode of care (eg, treatment and recovery from pathologic hip fracture) may be preferred to targeting a discrete test, procedure, or event such as hospitalization. An alternative to basing evaluation on episodes of care would be to evaluate utilization by patients with particular conditions. With regard to quality of care, it is not clear how some utilization-based indicators relate to improved longevity or quality of life. For example, the appropriateness of hospitalization per se depends on the reason and circumstances of admission, as well as the patient's preferences for care that would not be accounted for in a simple benchmark of the proportion of patients hospitalized. The importance of a range of attributes for any particular indicator is clearer if we place it in the context of a useful framework for considering how efficiency and quality relate to the goals of performance measurement as a whole.9 Because information about utilization is widely available and deriving information from administrative data is highly feasible, further refining such indicators and the databases from which they are derived to better capture information about quality and efficiency is important. An interesting example of a way forward that is not cancer-specific is the example of Queensland Health, which uses indicators with both quality and efficiency dimensions to trigger quality improvement–related activities in Australia. Because administratively derived indicators may have dimensions of quality despite the many uncertainties about their interpretation, they can be used to trigger an evaluative process. Queensland Health uses statistical process control techniques to monitor hospital performance continuously. Changes in expected performance trigger a review process that is intended to foster higher quality.10 Whether one believes in global warming or not, it's clear that $4.00 per gallon gas provided enough motivation for Americans to change their driving behavior. Similarly, the gap between what we achieve and the cost of health care in the United States is enough motivation to trade in our Hummers for hybrids, even while we wait for middle-market priced Teslas. These indicators are an important start. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: Karl A. Lorenz, Amgen Expert Testimony: None Other Remuneration: None ACKNOWLEDGMENTS Karl Lorenz, MD, MSHS, was the recipient of a grant from Amgen to RAND Health from October 2006 to December 2007 and was a Commonwealth Fund Packer Health Policy Fellow supported by the Australian Department of Health and Aging, Cancer Australia, and the Australian Palliative Care Outcomes Collaborative from 2007 to 2008. NOTES published online ahead of print at www.jco.org on November 10, 2008 REFERENCES 1. Cancer Trends Progress Report: 2007 Update. http://progressreport.cancer.gov 2. Yabroff KR, Lamont EB, Mariotto A, et al: Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 100:630-641, 2008 3. Priorities for National Action: Transforming health care quality. http://www.nap.edu/openbook.php?isbn=0309085438 4. Wennberg JE, Fisher ES, Skinner JS, et al: Extending the P4P agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Aff (Millwood) 26:1575-1585, 2007 5. Earle CC, Neville BA, Landrum MB, et al: Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315-321, 2004 6. Campbell DE, Lynn J, Louis TA, et al: Medicare program expenditures associated with hospice use. Ann Intern Med 140:269-277, 2004 7. National Institute for Health and Clinical Excellence. Improving supportive and palliative care for adults with cancer. http://www.nice.org.uk/csgsp 8. Setoguchi S, Earle CC, Glynn R, et al: Comparison of prospective and retrospective indicators of the quality of end-of-life cancer care. J Clin Oncol doi:10.1200/JCO.2008.16.3956 [epub ahead of print on November 10, 2008] 9. Duckett SJ, Ward M: Developing ‘robust performance benchmarks’ for the next Australian Health Care Agreement: The need for a new framework. Aust New Zealand Health Policy 5:1, 2008[CrossRef][Medline] 10. Duckett SJ, Coory M, Sketcher-Baker K: Identifying variations in quality of care in Queensland hospitals. Med J Aust 187:571-575, 2007[Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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