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“It's important to see and hear from another source [outside your practice] from time to time, that what you're doing is appropriate.” That's how Stuart Feldman, MD, an oncologist with Westchester Medical Group, Westchester County, New York, summarized the benefit of taking part in ASCO's Quality Oncology Practice Initiative (QOPI).
In March 2006, the Westchester group and 86 other oncology practices abstracted and submitted to QOPI data from nearly 10,000 patient records. This marked the first round of data collection since enrollment was opened to all ASCO members in January.
QOPI is a practice-based system of quality self-assessment. Measures focus on processes of care, such as using chemotherapy flow sheets, documenting a patient's pain, or providing adjuvant chemotherapy. Unlike outcome measures, which can be difficult to measure, process measures are easily tracked; they provide feedback that can guide changes.1 The initial development of QOPI and its procedures has been described previously.2,3
Practices participating in QOPI had the option of submitting data from one or more sites within the practice, as well as the option of submitting physician-level data. Each practice received a confidential report of its results in comparison to aggregate data from the other participating practices.
Practices such as Feldman's found that QOPI data reinforced the decision to implement structural changes in the practice.
“We have certain reminders built into our electronic medical record [EMR] system,” Feldman noted. These consistently prompt the physicians to take action. Also, the EMR makes documenting care much easier than with a paper system. Ultimately, “you're measured according to how you document care,” he said.
Even well-documented and organized practices, however, found variability in the care they provided. Richard Levine, MD, an oncologist with Space Coast Medical Associates in Titusville and two other Florida locations, found that the six physicians in his practice didn't ask about pain as often as might be clinically beneficial. As a result, the group has added pain status to the Vital Signs form, reminding all physicians to ask every patient about his or her pain at each visit.
In fact, variability was a feature of many of the results. A subanalysis of end-of-life care, for example, found that the rate at which physicians documented level of pain at either of the last two visits for terminally ill patients ranged from never (0%) to always (100%).4
Even before QOPI, Levine's group devised several protocols to standardize aspects of care. After the group received QOPI data, one of Levine's colleagues began developing additional clinical pathways for the group.
“We want to have more homogeneous, evidence-based management of patients among all physicians in the group,” Levine said. “Ideally, all doctors in the practice would recommend similar care for patients with the same diagnosis and stage of disease.”
While QOPI is having an immediate impact on patient care in participants' practices, both Feldman and Levine see the program's broader context. Payers are increasingly requesting documentation of quality care and quality improvements. Physician-led quality improvement activities like QOPI could help meet those requirements.
QOPI is the only oncology-specific program to be approved by the American Board of Internal Medicine (ABIM) to meet its new practice performance requirements for maintenance of certification. Physicians in practices that collect QOPI data can report the results of five measures to the ABIM. The ABIM then prompts the physician to outline and implement improvement techniques for one measure, and report the results of the implementation to ABIM. Completing this process will earn a recertifying oncologist 20 points toward maintenance of certification.
Within ASCO, the QOPI program is expanding into a larger initiative. According to Joseph V. Simone, MD (President, Simone Consulting, Atlanta, Georgia), an active ASCO volunteer and the founder of QOPI, two associated work groups have been set up. The first is charged with updating the QOPI measures and developing additional quality measures. Preliminary plans call for several measure sets, some primarily focused on specific forms of cancer, such as care of patients with breast cancer. The second work group will develop online tools to help practices improve the quality of their cancer care.
“In many instances, we hope to go to physicians who are successfully using tools such as chemotherapy flow sheets or consent forms, and facilitate sharing them with colleagues,” explained Simone.
From the very beginning, QOPI has been physician driven. Levine, Feldman, and the other participants have suggested new measures, critiqued existing ones, and made suggestions for ways to enhance QOPI's usefulness. Ultimately, Simone said, ASCO may have set QOPI in motion, “but it's up to the physicians to control it. If we don't do something [to ensure continuous quality improvement], someone else will. Wouldn't you prefer to be in control of the process?”