Oncology Pathways and Metrics: A Taxonomy of Leading Oncology Organizations
By Wes Chapman, Steve Maker, and Mario Martinez
This paper is a short catalog of organizations that we believe are the most significant clearinghouses of clinical pathways and quality metrics for oncology. Our goal is to provide some insight into the organizations that influence oncology clinical pathways and quality measures, by briefly describing what they specifically address, how they interact with each other, and their different approaches to improving oncology care.
In the past decade, quality improvement has become a focus in health care, driven in large part by efforts at the Center for Medicare and Medicaid Services (CMS) to reduce Medicare and Medicaid payments, while simultaneously increasing the perceived value of health care services; in other words, improving patient outcomes. One component of the effort is to increase efficiency and reduce errors during treatment. Another is to document and promulgate best practices in clinical pathways by endorsing a chosen set of pathways as guidelines for approved practice. These two components are linked by quality metrics that measure how well the chosen clinical pathway has been followed and, in the fullest implementation, how well patient outcomes compare to those achieved by similar healthcare providers following the same pathways.
CMS has also announced plans to shift payments from a fee-for-service basis to a pay-for-performance basis (P4P), and has run trials to test the efficacy of the shift. In order to work, P4P requires healthcare providers to use CMS-approved clinical pathways and to document fidelity by using approved sets of quality metrics. CMS is choosing its approved pathways and metrics from a number of organizations, some of which also provide some form of certification for healthcare providers; essentially, an official stamp of approval that has the potential to raise a provider’s level of payment, not only from CMS but also from other payers.
Additionally, CMS, through its Center for Medicare & Medicaid Innovation, has begun large scale testing of Accountable Care Organizations (ACOs) and various Bundled Payment Initiatives (BPIs) targeted at specific medical procedures and conditions. In every case, the ACOs and BPIs are required to submit extensive quality reporting – on both process and outcomes. Under section 3022 of the Affordable Care Act, the Department of Health and Human Services has established the Medicare Shared Savings Program, which allows ACOs to receive up to 60% of any cost savings they achieve for Medicare beneficiaries, provided they also score well and show improvement on a specific set of 33 quality reporting and performance metrics. While the majority of the metrics are not specific to oncology, two are (screening for colorectal and breast cancers), and the current metrics set also includes patient evaluations of the performance of their physicians, including oncologists. Significantly, the program relies on at least one newly derived metric (an ACO-specific Consumer Assessment of Healthcare Providers and Systems survey), and it increases the performance requirements over the course of three reporting periods. Future iterations also call for the inclusion of more metrics focused on specialty care. In other words, the future of P4P will be more specific, more detailed, and more rigorous in its dependence on quality metrics.
Thus, it has become very important for healthcare providers to know which organizations produce and publish the approved guidelines for clinical pathways and quality metrics and which provide certification for quality in clinical practice. When P4P is finally implemented, these organizations will influence not only a provider’s revenues but also its reputation.
Making the Cut: the Anna Karenina Principle
Currently, there are hundreds of healthcare organizations developing clinical practice pathways or sets of quality measures or both. These include at least a hundred with some focus on oncology, which is our area of concern. Luckily, only a few of these organizations currently have the reach and stature to be recognized by CMS and private payers, which will make the search for accepted pathways and metrics much easier to complete. The hard step is the first one: identifying the key organizations.
We took direction from an unlikely source, Leo Tolstoy, who stated the situation this way:
Happy families are all alike; every unhappy family is unhappy in its own way. (From Anna Karenina)
There are hundreds of individual quirks that must all be right for a family to be happy, but if any one quirk is not right, dysfunction ensues. The same principle has been broadly adopted as a statistical methodology, and applies directly in taxonomy: To be included in the happy family of a species, an organism must express every characteristic in a specific set. Restated in terms of oncology organizations, the Anna Karenina Principle tells us that the key organizations will be the only ones that meet a specific set of criteria. We define these must-have characteristics as:
1) Clearly focused on oncology (or with a subgroup focused on oncology)
2) Provides a clearinghouse of clinical pathways or quality metrics or both
3) Is frequently referred to or partnered with other healthcare organizations
4) Has clear links to/from CMS
5) Has a large or prestigious membership with national reach
6) Makes its pathways and metrics available to the public
Using these criteria, we identified eight organizations that we can label as significant clearinghouses of oncology pathways or metrics or both. Two of these are governmental organizations: CMS and the Agency for Healthcare Research and Quality (AHRQ). The other six are non-governmental organizations that mostly take the form of professional associations or networks:
- American Society of Clinical Oncology (ASCO)
- American Society for Radiation Oncology (ASTRO)
- American College of Surgeons Commission on Cancer (ACS CoC)
- Association of Community Cancer Centers (ACCC)
- National Comprehensive Cancer Network (NCCN)
- National Quality Forum (NQF)
Obviously, some big names in healthcare are missing. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP), for example, lacks an oncology focus. The AMA has endorsed oncology quality measures produced by other organizations, but it does not provide a clearinghouse. The American Cancer Society has the oncology focus, but also does not provide a clearinghouse.
That said, none of the eight key organizations has a perfect match on every characteristic, as the following table shows. AHRQ and the NQF are definitely clearinghouses, for example, with many pathways and metrics in their databases, while ASTRO and ACCC have but a few each. Some are better known and more often referred to than others. Then there is CMS, which we have included because it is the regulating body that will ultimately identify what pathways must be followed and what metrics must be collected in order to be certified for payment under Medicare/Medicaid (followed quickly by private payers). These differences are detailed in the catalog that follows, and made more obvious in a set of contrasting tables at the end of the paper. (There is a list of acronyms there, too.)
|Oncology Focus||Clearinghouse||Referred to||CMS Link||Members, Reach||Open to Public|
|CMS||Subgroup||Sets payment standards||Very frequently||N/A||N/A||Yes|
What You’ll Find There
All of the organizations use the web to announce and distribute their sets of pathways and metrics. In some cases, the websites contain an online, searchable database, and in other cases they provide a way to download their guidelines in a large PDF document. These differences are relatively minor. There are more serious usability issues to deal with.
Despite over a decade of discussion in journals, conferences, consensus groups, press releases, blogs, and governmental pronouncements, the healthcare community has made only slow progress on developing accepted sets of clinical pathways and quality metrics. The terminology has not even had time to settle on an accepted nomenclature. “Clinical pathways,” for example, are often referred to as “clinical practices,” and also as “protocols” and “treatment plans”. The most common term you’ll see to identify a set of endorsed clinical pathways is “guidelines”. For metrics, the most common term seems to be “quality measures,” but you will also see “quality indicators,” and both appear on the AHRQ website. Drilling down through the large AHRQ database can also be tricky, requiring close attention to topic areas and search terms.
A more fundamental problem is the relative incompleteness of the guidelines and particularly the measures, and in the links between them. In the best of all possible worlds, you would be able to search on a term like “staging metrics stage IV non–small-cell lung cancer” and immediately find one or two CMS-endorsed, evidenced-based, best-practice clinical pathways that clearly define all the steps in the treatment. In addition, each pathway would automatically be linked to an endorsed set of quality measures that will not only document adherence to the pathway and help to insure the best possible outcome, but also provide data to support quality improvement.
The system is not there yet, but there are indications that it is at least heading in that direction, and not in separate winding routes mapped out by each organization. These key players have been forming partnerships, both among themselves and with other healthcare and oncology organizations, to achieve a broader consensus of approval of their guidelines and quality measures. Perhaps the best example is a pair of simultaneous initiatives, one undertaken by ASCO and NCCN, the other by the ACS CoC, to develop quality measures for breast and colorectal cancer. The CoC submitted their measures to the NQF for endorsement as part of the NQF’s Cancer Project. The NQF is now facilitating a collaboration among the three organizations to synchronize the measures and present a unified set to the public. (For details, visit this page on the NCCN website: http://www.nccn.org/professionals/quality_measures/.)
We can only hope this trend continues and accelerates.
What You’ll Find Here
For each organization, we provide the following information.
- Name and relevant web addresses
- Mission statement and/or goals
- Membership requirements and number of members
- Certifications offered
- Key partnerships (regarding pathways, metrics, and accreditation)
- Journals and Newsletters
- Stance on patient education, palliative care, and multimodal care
- Pathways/Guidelines: purpose and general description
- Metrics: purpose and general description
A set of tables comparing basic data for each organization appears after the detailed descriptions.
The Family of Organizations
Center for Medicare & Medicaid Services (CMS)
Mission Statement: CMS currently specifies reporting requirements through the Physician Quality Reporting System (PQRS), “a reporting program that uses both incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides a payment to practices with professionals who satisfactorily report data on quality measures for covered physician fee schedule services furnished to Medicare part B Fee-for-Service beneficiaries. In 2015 the program will also apply a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services.” As described in the Background section, CMS has just initiated the Medicare Shared Savings Program, which requires ACOs to report specific quality measures and eventually achieve performance standards.
Memberships: There is no membership program per se. Physicians, groups, etc. who wish to take part must register and go through several steps to confirm eligibility. Technically, every provider in the U.S. and its territories that accepts Medicare/Medicaid patients will eventually need to take part in this or an equivalent program for P4P.
Certifications offered: None. CMS provides payment incentives for physicians who are board certified and take part in a certification maintenance program, but they endorse qualified certifying entities rather provide their own certification.
Key Partnerships: CMS endorses pathways and metrics developed by a number of organizations, along with qualified entities that provide board certification in a number of clinical areas. However, they do not themselves partner with other organizations to create pathways or metrics or to certify physicians.
Journals and Newsletters: None
Stance on Patient Education/Involvement: No stated position.
Stance on Palliative Care: Endorses metrics related to pain control, palliation, and end-of-life care.
Stance on Multimodal Care: Recent Bundled Payment Initiatives show an increasing awareness of and support for multimodal care; however, current regulations and programs do not fully support it in practice.
Pathways: CMS does not publish guidelines for clinical practice. Instead, it relies primarily on the National Guidelines Clearinghouse (NGC) maintained by AHRQ (http://guidelines.gov), and on the endorsements provided by the NQF.
Metrics: Purpose: To collect quality data documenting that physicians have followed prescribed pathways and are eligible for payment under the Medicare/Medicaid system. PQRS specifies both the financial carrot and stick to encourage physicians to collect and report this data. The physicians are under no requirement to use the data for any other purpose, such as quality improvement. The Medicare Shared Payments Program for ACOs does require care providers to meet specified performance standards and show improvement. As with pathways, CMS does not publish metrics, referring users to AHRQ’s National Quality Measures Clearinghouse (NQMC: http://qualitymeasures.ahrq.gov) and the NQF.
Agency for Healthcare Research and Quality (AHRQ)
Mission Statement: “To improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ’s research helps people make more informed decisions and improve the quality of healthcare services.”
Memberships: No memberships; all information is free and accessible by the public. “Customers” include clinicians and other healthcare providers, consumers and patients, healthcare policy-makers at federal, state, and local levels, purchasers and payers, and other hospital officials.
Certifications offered: None
Effective Health Care Program National Partnership Network (232 partners). “These organizations have joined us in promoting patient centered outcomes research in patient and professional communities across the United States. By becoming partners, they have become part of a growing partnership network committed to improving the quality of health care through informed decision making.” http://www.ahrq.gov/clinic/partners/partners.htm
Journals and Newsletters: Two digital newsletters, free to the public, register on the site
Research Activities (email updates that summarize latest findings from AHRQ-funded studies, announce AHRQ publications, funding opportunities, events, etc.)
Inside Track (email and online, provides news and developments from AHRQ’s Effective Health Care program)
Stance on Patient Education/Involvement: Actively promotes educating patients and involving them in decision-making.
Stance on Palliative Care: No stated position. Various reports and presentations have addressed the issue, but they do not yet have categories for palliative care in their guidelines or quality measures clearinghouses. One advisory council member urged the group in 2011 to create a separate clearinghouse for end-of-life and palliative care practices.
Stance on Multimodal Care: No stated position.
Pathways: AHRQ hosts and maintains the National Guideline Clearinghouse (NGC), a database of evidence-based clinical pathway guidelines submitted by clinical research centers and professional clinical organizations. AHRQ does not create guidelines; it endorses them and makes them available to clinicians. Currently, there are 936 pathways found with the search text of “oncology or cancer”.
Purpose: “…to provide physicians and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.”
Metrics: AHRQ hosts and maintains the National Quality Measures Clearinghouse (NQMC). As with the guidelines clearinghouse, AHRQ endorses metrics submitted by other organizations. AHRQ has also developed a set of metrics on its own, which are cataloged in the NQMC without any special priority or endorsement. Currently, the NQMC holds 332 measures that can be found with the search text of “oncology or cancer”. (For each clinical pathway guideline, the Guidelines Clearinghouse displays a link labeled “Related NQMC Measures”; however, it appears to return the same small set of metrics every time.)
Purpose: “Health care delivery measures are used to assess the performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees. Population health measures are applied to groups of persons identified by geographic location, organizational affiliation or non-clinical characteristics, in order to assess public health programs, community influences on health, or population-level health characteristics that may not be directly attributable to the care delivery system.” The clearinghouse includes both types of measures, broken into these sub-groups: quality measures, related health measures, and efficiency measures. (More information on the Domain Framework and inclusion criteria will be found here:
American Society of Clinical Oncology (ASCO)
Mission statement: ASCO is “a professional oncology society committed to conquering cancer through research, education, prevention and delivery of high-quality patient care.”
Vision statement: “All cancer patients will have lifelong access to high quality, effective, affordable and compassionate care; The most accurate cancer information will be available so that patients and physicians can make informed decisions about cancer prevention and treatment; Information we learn from every patient will be used to accelerate progress against cancer; Resources will exist to attract the best clinicians and investigators to provide optimal patient care and to conduct transformative research; ASCO will be recognized as the most trusted source of cancer information world wide.”
Memberships: Full member, Member in training, Allied Physician/doctoral scientist, Affiliated health professionals, Internal corresponding, Student/non-oncology resident (dues vary by category). Full members are licensed physicians or other health professionals at the doctoral level of a nation who devote a majority of their professional activity to cancer patient care and/or research. Number of members: 30,000 individual members from every oncology subspecialty.
Certifications offered: Quality Oncology Practice Initiative (QOPI) Certification Program
- ACS CoC
- ONS (Oncology Nursing Society)
Journals and Newsletters:
Journal of Clinical Oncology: Three times monthly (36 times a year); on the 1st, 10th, and 20th each month. Circulation: 23,809 (16,190 domestic, 7619 international; 20,653 member, 3,156 non-member)
Journal of Oncology Practices: Bi-monthly (6 times/year in odd-numbered months). Circulation: 16,883 (16,165 domestic, 718 international; 16,656 member, 227 non-member)
Stance on Patient Education/Involvement: Part of their vision statement.
Stance on Palliative Care: No stated position, but has metrics for palliative and end-of-life care
Stance on Multimodal Care: No stated position
Pathways: Purpose: ASCO maintains a list of clinical pathway guidelines that “…address specific clinical situations (disease-oriented) or use of approved medical products, procedures, or tests (modality-oriented) … Topics for guidelines are selected on the basis of significant clinical or economic importance; presence of variations in patterns of, or access to, care; availability of suitable data; and ethical considerations.” Currently, there are 37 guidelines, sorted into these categories:
- Assays and Predictive Markers
- Breast Cancer
- Gastrointestinal Cancer
- Genitourinary Cancer
- Head and Neck Cancer
- Hematologic Malignancies
- Lung Cancer
- Supportive Care and Quality of Life
- Treatment-Related Issues
A full list of guidelines is available here:
Metrics: Purpose: To aid oncology practices in quality self-assessment.
Core oncology metrics (required for QOPI certification):
- Documentation of care
- Chemotherapy planning, administration, and treatment summary
- Pain assessment and control
- Smoking cessation
- Psychosocial support
- Breast (as applicable to practice)
- Colorectal (as applicable to practice)
- Non-Hodgkin’s Lymphoma (as applicable to practice)
- Symptom/Toxicity Management
- Care at the End of Life
(Download this document to see the full list of certification metrics: http://qopi.asco.org/Documents/QOPICertificationMeasuresasof3.2012_000.pdf)
American Society for Radiation Oncology (ASTRO)
Mission statement: Dedicated to improving patient care through education, clinical practice, advancement of science, and advocacy.
Memberships: Active members must be physicians certified in radiation oncology or therapeutic radiology, or a radiation physicist certified in radiological physics or therapeutic radiological physics, or a radiation or cancer biologist with a PhD who dedicates significant time to radiation oncology or sciences. Other types of membership include affiliate, international, corporate, etc. Number of members: More than 10,000.
Certifications offered: Accreditation offered jointly with American College of Radiologists (ACR)
- Physician Consortium for Performance Improvement (PCPI)
- American Association of Physicists in Medicine (AAPM)
- Affiliates: Association of Residents in Radiation Oncology (ARRO), Society of Chairmen of Academic Radiation Oncology Programs (SCAROP), ASTRO Radiation Oncology Nurses (ARON), and Association for Directors of Radiation Oncology Programs (ADROP).
Journals and Newsletters:
Red Journal: Published online 15 times per year; Monthly unique visitors: 15,681; Email distribution: 10,823
Practical Radiation Oncology (PRO): Published quarterly; Circulation: 6,705
ASTROgram: weekly e-mail to members
ASTROnews: quarterly emagazine
Stance on Patient Education and Involvement: No formal statement; however the ARON affiliate section of the web site has patient education resources, and they maintain a separate patient website, www.RTAnswers.org, “…a resource for patients and caregivers to find detailed information about radiation therapy; what to expect before, during and after treatment; questions for patients to ask about radiation safety and a dictionary to help patients with terms they will hear.”
Stance on Palliative care: No stated policy, but two of their five guidelines are related to palliative treatment.
Stance on Multimodal Care: Participates in two multidisciplinary symposiums
Pathways: Their website has separate sections on Guidelines and Best Practices; both appear to be in their infancy. The guidelines section currently has 5 guidelines (Breast Cancer, Palliation (2), Thoracic Malignancies, and Brain Tumor). The best practices page has a stated purpose but no content. (Development is scheduled to start some time in 2012.)
Metrics: Actively promotes use of CMS’ PQRS measures. In addition, ASTRO partnered with the AMA, ASCO, and PCPI on 10 quality measures that are included in the AHRQ’s National Quality Metrics Clearinghouse.
American College of Surgeons, Commission on Cancer (ACS CoC)
Mission statement: “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”
“The Commission on Cancer (CoC) is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.”
Memberships: CoC membership is composed of 100 individuals who are either surgeons representing the American College of Surgeons or representatives from the 49 national, professional organizations or member organizations affiliated with the CoC. Applicants must demonstrate involvement in one or more of the following areas within the field of oncology: Cancer registration and/or surveillance, Cancer patient care services, Patient advocacy (oncology-focused across all cancers), Cancer control & prevention efforts, Professional education in oncology, and Oncology research. In addition, the CoC’s Cancer Liaison Program is a network of 1,500 Cancer Liaison Physicians serving CoC-accredited cancer programs.
Certifications offered: Yes. “The CoC Accreditation Program encourages hospitals, treatment centers, and other facilities to improve their quality of patient care through various cancer-related programs. These programs focus on prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, surveillance for recurrent disease, support services, and end-of-life care.”
- Alliance for Clinical Trials in Oncology (ACTO)
Journals and Newsletters:
CoC Flash: Published monthly online and via email (by free subscription)
Stance on Patient Education/Involvement: No stated position; however, they provide some informational resources for patients.
Stance on Palliative care: Standards in their accreditation program focus on palliative and end-of-life care.
Stance on Multimodal Care: Standards in their accreditation program focus on encouraging multimodal care. In their own words, “Recognizing that cancer is a complex group of diseases, the CoC Cancer Program Standards promote consultation among surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists, and other cancer specialists. This multidisciplinary cooperation results in improved patient care.”
Pathways: “The Commission on Cancer does not endorse any specific guideline, but has elected to make guidelines from various national organizations available through this Web site for informational purposes only. Inclusion on this Web site does not constitute a guarantee or endorsement of these guidelines by the Commission on Cancer or the American College of Surgeons.”
That said, the standards that the CoC sets for accreditation include both pathways and related metrics (see below). Finally, the CoC maintains a Best Practices Repository that contains “Tools and best practice resources designed to help cancer programs meet the CoC Cancer Program Standards” in order to become accredited or maintain accreditation.
Metrics: The primary set of metrics is part of the extensive requirements for accreditation (core metrics). They are described in detail on pages 63-92 in this document:
The CoC developed a separate small set of metrics – the Quality of Care Measures – that focuses on breast and colorectal cancer. These standards parallel a set developed jointly by ASCO and NCCN. Facilitated by the NQF, the three organizations have agreed to synchronized their developed measures to ensure that a unified set are put forth to the public.
Association of Community Cancer Centers (ACCC)
Mission statement: “The ACCC is a national multidisciplinary organization that promotes the entire continuum of quality cancer care for our patients and our communities.” Its core purpose is “to be the leading education and advocacy organization for the cancer team.”
Memberships: There is an application process, but the organization is open to almost anyone involved in the broad area of cancer research, diagnosis, treatment, care, administration, and support. There are 17,000 individual members, 28 chapters, and 700 cancer programs affiliated with the ACCC.
Certifications offered: No
- National Cancer Advisory Board (NCAB)
Journals and Newsletters:
Oncology Issues magazine: Published bimonthly by subscription; circulation: 16,881
ACCConnect: Bi-weekly newsletter distributed to members via email and available on the website.
Stance on Patient Education/Involvement: No stated policy. They have a publication called the “Patient Assistance Guide” that focuses on supplementary services and reimbursement resources.
Stance on Palliative care: Their cancer program guidelines discuss palliative care “…to assist patients in achieving maximum comfort and relief of suffering at the end of life.”
Stance on Multimodal Care: Their cancer program guidelines emphasize the “multidisciplinary Team.”
Pathways: None. The ACCC publishes a set of Cancer Program Guidelines that are structural rather than clinical: “The Association of Community Cancer Centers Cancer Program Guidelines have been established to assist cancer programs that want to develop and/or maintain a comprehensive interdisciplinary program that meets the needs of cancer patients and their families. These guidelines were developed to reflect the optimal components for a cancer program. The guidelines are not intended to act as an accrediting or credentialing mechanism and are not a list of standards, such as those published by the American College of Surgeons Commission on Cancer. The guidelines should not be a surrogate for independent medical judgment; they serve only as the term implies: as guidelines to help programs meet the optimal attributes.”
Metrics: None. The final section of their cancer program guidelines names Quality Improvement as a requirement for a successful program and describes what a QI system should look like in the broadest terms. No actual metrics are included.
National Comprehensive Cancer Network (NCCN)
Mission Statement: “Dedicated to improving the quality and effectiveness of care provided to patients with cancer.” Develops resources to present information to those who deliver health care. They help promote continuous quality improvement through the creation of clinical practice guidelines. NCCN’s primary goal is to “…improve the quality, effectiveness, and efficiency of oncology practices so patients can live better lives.”
Memberships: All member institutions are major cancer centers; there are currently 21 members. Member institutions pay dues that support the development of their guidelines, which are available to the public for free.
Certifications offered: No
- ACS CoC
- NCCN Health IT Licensees: 13
- NCCN website supporters: 5
Journals and Newsletters:
- NCCN Flash Updates™ – a timely notification of changes and updates to the NCCN guidelines
- eBulletin newsletter: Every other Monday; Circulation 75,000-plus, including 26,000-plus physicians (for all registered U.S. users on nccn.org)
- Journal of the National Comprehensive Cancer Network (JNCCN): Monthly, by subscription; Circulation 23,143 (21,00-plus physicians, physician assistants, and nurse practitioners)
Stance on Patient Education/Involvement: Has guidelines created specifically for patients, with a separate web site aimed specifically at patients, families, and caregivers. (www.nccn.com)
Stance on Palliative care: Has guidelines specific to palliative care.
Stance on Multimodal Care: According to the website, NCCN member institutions pioneered the multidisciplinary teams approach.
Pathways: Purpose: To show consensus from leading cancer treatment institutions on how to treat specific kinds of cancer. Metrics and pathways are categorized based on level of evidence and degree of consensus. The guidelines are free, but visitors to the website must register in order to view or download them. The guidelines are sorted into these categories:
- Treatment of cancer by site (48 diagnostic areas in 6 procedural areas)
- Detection, prevention, and risk reduction
- Supportive care (includes palliative care)
- Age-related recommendations (adolescent/young adult and senior)
- Guidelines for patients
Metrics: Purpose: The same as for Pathways. NCCN partnered with ASCO to develop quality metrics for breast and colorectal cancer, and the two are now working with the ACS CoC and NQF to bring their separate guidelines in these areas into sync. Details are given on this web page: http://www.nccn.org/about/news/newsinfo.asp?NewsID=79.
National Quality Forum (NQF)
Mission statement: “The National Quality Forum is a nonprofit organization that operates under a three-part mission to improve the quality of American healthcare:
Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them
Endorsing national consensus standards for measuring and publicly reporting on performance
Promoting the attainment of national goals through education and outreach programs”
Memberships: Membership is open to healthcare organizations with an interest in quality improvement. Individuals in the field who are not currently employed by such an organization may apply as individuals. The membership includes consumer organizations, public and private purchasers, physicians, nurses, hospitals, accrediting and certifying bodies, supporting industries, and healthcare research and quality improvement organizations. Current number of member organizations is 370.
Certifications offered: None
- The National Priorities Partnership (NPP) – “…offers consultative support to the Department of Health and Human Services on setting national priorities and goals for the HHS National Quality Strategy.” (Currently 51 members)
- The Measure Applications Partnership (MAP) – “…provides multi-stakeholder input to HHS on the selection of performance measures for public reporting and payment reform programs.” (Approx. 110 members)
- Dept. of Health and Human Services (HHS)
- ACS CoC
Journals and Newsletters: None
Stance on Patient Education/Involvement: The website has topic section focusing on Patient and Family Engagement, and they have announced the recent endorsement of 45 practices to guide healthcare systems in providing culturally competent care; however, there are no clearly identifiable standards related to patient education.
Stance on Palliative care: Endorses measures that deal with palliative care. Members have access to a “National Framework and Preferred Practices for Palliative and Hospice Care Quality.”
Stance on Multimodal Care: Have standards regarding different types of treatment, including surgery, chemotherapy, and hormonal therapy.
Pathways: Currently none, although the introduction to their performance standards includes this statement: “NQF also endorses other types of consensus standards, including preferred practices and measurement frameworks. Information about these other types of standards will be added in the coming months.”
Metrics: NQF endorses quality measures submitted by other organizations, which it makes publicly available in an online database called the National Voluntary Consensus Standards for Quality of Cancer Care. Stated purpose: “…to facilitate the comparison of cancer care providers for the purpose of accountability, quality improvement and surveillance and can be used by consumers, providers, federal and private purchasers and researchers.”
The NQF’s partnerships with HHS make it a key player in healthcare quality improvement. The National Quality Measures Clearinghouse maintained by AHRQ has a navigation link specifically for NQF endorsed measures. (Currently, AHRQ shows 444 NQF endorsed measures, while a search on the NQF site shows 734.)
These three tables provide a quick comparison among the members of our taxonomy. The data points are all taken from the preceding descriptions of the organizations.
|Comparative Table: Members and Partners|
|Professional Members||Member Institutions||Key Partners|
|CMS, NQF, plus 232 in the EHC program|
|ASTRO, CoC, NCCN, NQF, PCPI, ONS|
|ASCO, NCCN, ACCC, ACTO|
|ASCO, ACR, AMA, PCPI, AAPM, plus 4 affiliates|
700 affiliated cancer programs
|ASCO, CoC, NQF|
|CMS, ASCO, AHRQ, CoC, NCCN, NPP, MAP, HHS|
|Comparative Table: Reach|
|Accreditation or Certification||Endorsed by health plans||Newsletters/Journals|
|CMS||No: endorses certifying boards||
|AHRQ||No||Endorsed by CMS||2 digital newsletters: Research Activities, Inside Track|
|ASCO||QOPI: 138 Certified, 780 participating||Yes: more than 60||Journal of Clinical Oncology
Journal of Oncology Practices
|ACS CoC||Yes (ACS): 1,500 certified||No||CoC Flash|
|ASTRO||Yes, with ACR: 300+||No||Red Journal,
Practical Radiation Oncology,
|NCCN||No||No||NCCN Flash Updates,
Journal of the NCCN
|NQF||No||Endorsed by CMS||None|
|Comparative Table: Pathways and Metrics|
|Pathways/Metrics||For Patient ed & involvement||For Palliative care||For Multi-modal care|
|CMS||Endorses metrics||Yes||For end of life||Yes|
|AHRQ||Develops and endorses both||Yes||For end of life||Yes|
|ASCO||Develops both||Only a few||Yes||Some|
|ACS CoC||Lists but does not endorse. Includes both in accreditation standards||Some patient resources||Some||Some|
|ASTRO||A few guidelines. Promotes PQRS; 10 metrics developed with PCPI on NQMC||Some patient resources||Yes||No|
|ACCC||Structural guidelines, no metrics||Limited||Yes||Yes|
|NCCN||Develops both: a few metrics so far||Yes: extensive resources||Some||Yes|
|NQF||Endorses: many metrics, few pathways||Some||Yes||Yes|
The eight chosen organizations that meet the requirements of our taxonomy show an encouraging similarity of purpose: All of them agree that the use of evidence- or consensus-based pathways and metrics will lead to better patient care and outcomes. It is also encouraging that, with two organizations focused on medical oncology, one on surgical oncology, and one on radiation oncology, all of them endorse the concept of multimodal treatment plans. Most of them also make a clear statement in support of patient education and involvement, and some provide extensive patient resources. This is strong evidence for positive trends toward quality improvement in treatment and also toward more patient-centric care.
Our taxonomy also reveals a pyramidal hierarchy in the development and endorsement of pathway and metrics that puts the largest payer for healthcare in the world – CMS – in a key role in selecting pathways and metrics that correspond to payment:
As the regulating body, CMS specifies that treatment must meet certain standards, to ensure meeting payment requirements. CMS chooses which quality measurement tools will be used to demonstrate that the standards are being met, drawing from the endorsed catalogs maintained by AHRQ and NQF. These two clearinghouses, in turn, choose the best practices submitted by the research centers and clinics that make up the broad base of the pyramid.
The organizations at the base are labeled “stewards” of the pathways and metrics that they develop; by implication, they will watch over their products and update or retire them as new evidence comes to light. The remaining five organizations in our taxonomy – ASCO, ACCC, ACS CoC, ASTRO, and NCCN – form an upper tier among the stewards for oncology pathways and metrics. They endorse metrics submitted by their members and by affiliated organizations of smaller reach and output.
As a final note, it is striking that, of the thousands of pathways, metrics, and patient educational materials developed at the level of the steward organizations, CMS has reduced the number actually utilized to determine and/or influence payment to a few dozen. For metrics and pathways to have a broad-based impact, this number will have to increase dramatically, and pathways will have to become much more broadly utilized to influence payment.