Participants in this PI initiative were able to implement and enhance their processes of care within select topic areas of improvement for their patients with CRC. Most notably, the largest gains in improvement were within the patient safety and supportive care topic. The performance of the participants improved significantly in the following two areas: documented quantified pain assessment and documented status of patient's emotional well-being. Only approximately one half of the charts reviewed indicated that pain and emotional well-being had been assessed by the participants before participation in the program. However, quantified assessments of pain increased by 30%, and psychological assessments of CRC patients increased by 34% after completion of the program.
Traditionally, supportive care issues have been considered beyond the scope of expertise for many medical oncologists. Unfortunately, as many as 40% of patients with cancer will experience emotional distress, yet as few as 10% of patients with cancer in need of psychological care are identified and referred for appropriate therapeutic intervention.19,20
In addition, 50% to 90% of patients will experience some form of pain.19
Pain is one of the most important independent predictors of survival in patients with cancer.21
Although physicians may address the issue of pain with their patients, they may not be appropriately quantifying and tracking pain intensities.22
In addition, visits with oncologists are short, particularly in an ambulatory setting, and psychological issues are often stigmatized such that patients do not share their concerns with their clinicians. If patients fail to receive appropriate treatment and support, pain and emotional distress can lead to poor adherence, poor quality of life, and dissatisfaction with care, which can ultimately result in negative outcomes.23
Participation in this program had a clear impact on the practices of those physicians who sought to improve the quality of their supportive care practices. What remains to be seen, however, are the responsive actions by oncologists who determine that a patient is in need of emotional and psychological support. Recent findings from the FIQCC study group found that, on average, only 58% (range, 13%–100%) of cases had evidence of action taken in patients with a documented emotional problem.24
This finding suggests that few practices had procedures in place to address the emotional needs of their patients. Whereas assessment and identification are key first steps to promoting emotional well-being, further education focusing on strategies to help patients address the problems identified may be indicated.
Regarding evidence-based treatment, participants significantly improved their assessment of KRAS
status in patients with metastatic CRC and tailored chemotherapeutic regimens accordingly. Of the several molecular markers that have been evaluated as prognostic and predictive indicators, only KRAS
mutational analysis is currently recommended for routine screening in patients with CRC.25
Tumors that contain mutated versions of the KRAS
gene are resistant to EGFR-targeted therapies. As a result of this program, we believe that better selection criteria were applied to this subset of patients; therefore, they are more likely to have an optimal treatment response. In turn, those patients who were not candidates for EGFR-targeted therapies were able to avoid unnecessary toxicities.
This initiative also showed changes in clinician performance in areas that have been the focus of many educational efforts (), namely in the evaluation of 12 or more lymph nodes, complete evaluation of the colon after diagnosis, and assessment of CEA levels before and after treatment.5,6,22
Although our program is similar to these other quality-improvement initiatives, knowledge and adaption of new practices is an ongoing and evolving process. Periodic episodes of self-assessment and feedback can help clinicians in their continued efforts to improve patient care. If the practice continues and evolves over time, then PI may also help clinicians strive even further to meet standards of high-quality care.
Comparison of CRC QI Initiative Outcomes
The limitations associated with this initiative are typical of those associated with other PI activities.10,26,27
Bias may have occurred with patient chart selection and self-reporting. This study did not distinguish between improvements in actual care processes and improvements in charting. However, given the number of significant changes observed over several performance measures, we believe that actual changes in practice did occur, despite improvements in charting efforts. Patient record numbers are frequently a limitation in oncology initiatives such as this, in which clinicians are asked to submit a number of charts that represent patients with different tumor types at different stages of disease. For this reason, sample sizes for the measures not applicable to all patients with CRC were limited. Finally, the generalities of the performance measures used cannot account for the complexities and individualization required for optimal treatment.
This initiative showed that quality improvement is an ongoing and gradual process that can be effective in bolstering national efforts to change the behavior of community clinicians through self-assessment of quality topics. In the United States, 84% of all those with cancer are treated in the community setting.28
Community practices have less access to large-scale quality-improvement programs, which require practices to provide additional operating expenses as part of their programs.29
In contrast, this program was made widely available through an unrestricted educational grant that funded the research and development of the benchmark measures data collection form, online data system, CME-certified print publication, and tools. The core educational component of this initiative was validated and evaluated for objectivity, balance, scientific rigor, and the potential for commercial bias by an independent, third-party review board. The program was free of charge to any individual practicing oncology clinician in the United States and provided an affordable opportunity for PI to those who treat the majority of patients with CRC. Participants were also able to use data from this initiative to complete the Self-Directed Performance Improvement Module and earn practice performance points for American Board of Internal Medicine Maintenance of Certification.
This study represents merely one snapshot of practice assessment for these clinicians, as clinicians must routinely update their medical knowledge and skills. Ideally, these participants will continue to seek out similar opportunities for self-assessment and performance improvement, with the goal of improving the quality of care provided to their patients.