Former New York Mayor Ed Koch famously asked residents, “How’m I doin’?” Driven by a desire to improve service through transparency, Koch told NPR in 1981, “Do you know people in public life who are sufficiently secure to ask people to rate them?”
That kind of courage is rare in politics or health care. That’s why a report from the Hutchinson Institute for Cancer Outcomes Research (HICOR) is so remarkable. Committing to transparency as a catalyst for improvement, 27 hospital systems and cancer centers across Washington State bare all in the first public report to integrate clinic-level quality and cost data in oncology.
HICOR’s “Community Cancer Care in Washington State: Quality and Cost Report” is “one of a kind and revolutionary in cancer care,” says Veena Shankaran, MD, an oncologist at the Seattle Cancer Care Alliance and a HICOR faculty member. Based at Fred Hutchinson Cancer Research Center in Seattle, HICOR convenes meetings of clinicians, payers, and patients and conducts research aimed at reducing the economic burden of cancer and its effects on patients.
This graph from the HICOR report shows a wide range of quality scores and episode costs for the measure “hospitalization during chemotherapy.” Each point represents an individual clinic’s relative quality performance against the regional average and its episode cost for this measure. The general slope from upper left to lower right across clinics shows a negative relationship between cost and quality, suggesting that efforts to improve quality may also reduce the cost of an episode.
Adapted with permission from HICOR
Previous work by Scott Ramsey, MD, the institute’s director, and his colleagues documented two chilling effects of that burden. In a 2013 Health Affairs study, HICOR found that cancer patients were 2.5 times more likely than those without cancer to go bankrupt. Three years later, a follow-up study coauthored by Shankaran showed that those who did go bankrupt were 80% more likely to die within five years, possibly because of stress or lack of adequate treatment.
Against this backdrop, HICOR thought globally—crunching statewide registry and claims data—to prompt participants to act locally.
The report focuses on four priority areas: Receipt of recommended treatment; hospitalization or ED visits during chemotherapy; follow-up after treatment; and end-of-life care. Within these areas, HICOR identified six measures of clinical quality and developed clinic-level scores for each. A clinic’s average episode cost was also calculated for each measure. A clinic’s summary quality-and-cost data are plotted on Cartesian-style quadrant graphs for each measure.
Determining how to measure each metric was a challenge. “The metric may be broad, but you have to translate it into a way you can use claims data to measure a particular thing, like ED visits during chemotherapy,” says Shankaran. “What is the time window you’re looking out? How do you define chemo? All of these things had to be sorted out, and that took a really long time.”
“There is a lot of variability in quality scores, but also huge variability in cost,” says Veena Shankaran, MD, of the Seattle Cancer Care Alliance and the Fred Hutchinson Cancer Research Center.
Some of the findings suggest that many Washingtonians are getting the care they should. For instance, on average, 86% of patients treated for breast, colorectal, and lung cancer receive guideline-recommended care at diagnosis, with little variation across hospitals and cancer centers.
But some other findings reveal room for improvement. On average, more than half (52%) of patients with any cancer except leukemia were admitted to the hospital or had an ED visit within six months of starting chemotherapy. That may suggest a need for better symptom management or support services. On this measure, clinic-level episode costs ranged from $63,000 to $99,000. “That, to me, is one of the most frightening categories,” says Shankaran. “There is a lot of variability in quality scores, but also huge variability in cost.”
To that end, HICOR is working with Microsoft on a pilot technology project to track patients’ vital signs and identify those who might be headed for an ED visit or admission. It’s one of a number of ways participants are using the report to think about how best to address its quality and cost findings. In another example, says Shankaran, HICOR is proposing studies to understand variability in the use of serum tumor marker tests after breast cancer treatment. HICOR found that individual clinics order these tests between 3% and 47% of the time. Lower rates translate to higher quality.
“Breast cancer tumor marker testing is a tough one because it is a low-intensity test. It doesn’t cause much harm or trouble to patients. It’s not terribly costly, relative to advanced imaging,” says Shankaran. “But there’s not clear evidence that doing this helps to detect recurrence or improve outcomes. So this is a clear area for intervention.”
To her, the most striking—and disappointing—finding was the high degree of variability in end-of-life care across institutions. “I can think of many instances of patients who suffered at the end of life in the hospital and the ER, and that could probably have been avoided had we had more time to guide them through that process.”
To encourage continued collaboration, all parties agreed to a two-year moratorium on using the results for contracting purposes. In the meantime, discussion has begun about the next version of the report, which may include such metrics as appropriate biomarker-based treatment and use of patient-reported outcomes.