This article is more than 5 years old. Information may no longer be current.
Looking back in the future: More PROs than cons?
Last week, I met with our associate fellowship program director to discuss our program’s upcoming participation in QOPI, the Quality Oncology Practice Initiative. QOPI, as many of you know, is essentially a quality improvement project with application to both private and academic practice. Individuals from within a practice are asked to perform retrospective chart reviews to see if certain core and disease specific measures have been achieved in the course of providing routine patient care.
For example, core measures: Is there a pathology report in the chart confirming malignancy? Was there a documented plan for chemotherapy, including doses, route and time intervals? Or for non-Hodgkin’s lymphoma, for example: Was granulocytic growth factor administered with CHOP to patients over 65? Was rituximab (Rituxan, Genentech) administered when CD-20 antigen expression was negative or undocumented?
Aggregate scores can then be used as baselines for individual practices, which can attempt to modify their processes to achieve better future scores and in the process improve quality. Some might want to make general comparisons between groups of practices based on these scores, as well.
Self-improvement
The movement to better characterize quality care in oncology parallels, and in many ways lags behind, the quality movement in other areas of medicine. This is because this represents a culture change, and changing old habits is never easy.
To ASCO’s credit, the organization has recognized that changing habits early is easier and more effective over the long run than waiting until later. And so fellowship programs have been invited to participate in QOPI as part of practice-based learning and improvement. Oncology fellows can perform some of the retrospective chart reviews to assess the quality of cancer care delivery within their own institutions.
When I look back through the charts of lymphoma or breast cancer patients this coming fall, I’ll be interested to see whether or not we’re doing as well as we think we are when it comes to delivering oncologic care of some basic level of quality to our patients. But although the proper use of G-CSF, rituximab and trastuzumab (Herceptin, Genentech) are clearly important, we might imagine that the QOPI of 2019 or 2029 will include a good deal more than these basic measures.
QOPI of the future
What might the QOPI of the future contain? Certainly included will be ways to properly use and monitor new biologics and chemotherapeutics that we haven’t heard of today. But how about information from our patients, ie, what are increasingly commonly referred to as Patient Reported Outcomes (PROs)?
The possible PROs that QOPI looks at in the core measure set are pain and dyspnea — although these are clinician-assessed, rather than patient-reported. The absence of other PROs from the current QOPI, such as other symptoms or quality of life measures directly reported by patients, reflects the absence of these measures from most routine cancer care delivery today. PROs are not uncommonly used in research settings, and may accompany clinical trials, but it is hard for most oncologists to know how to use these measures or what to do with this information outside of research.
This may soon change. Several institutions, including Memorial Sloan Kettering Cancer Center, Johns Hopkins, Duke, University of North Carolina, and others have started to use technology that allows patients to enter PROs by computer either inside or outside the clinic visit. Investigators at Johns Hopkins recently published their experience with designing a system that integrates PROs into the electronic medical record, with visual outputs designed to be as clinically relevant and patient-friendly as possible.
In the end, the care we deliver is for and about our patients, and it only makes sense that key measures for the delivery of this care in the future should be reported by our patients themselves. I think — and hope — that as systems develop for the assessment and reporting of these measures, the next generation of QOPI will take note.
William Wood, MD, MPH, is a second-year Hematology and Oncology Fellow at the University of North Carolina at Chapel Hill and a member of the HemOnc Today Editorial Board.