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Originally published as JCO Early Release 10.1200/JCO.2005.05.034 on August 8 2005 © 2005 American Society of Clinical Oncology.
Practice Variation: The Achilles' Heel in Quality Cancer CareCenter for Management Research in Healthcare, Owen Graduate School of Management; Management of Technology Program, School of Engineering, Vanderbilt University, Nashville, TN Quality cancer care does not depend only on research findings, treatment improvements, and practice guidelines, because they are all for naught unless they are converted into day-to-day practice by clinical oncologists. Although patients' adherence to medical recommendations is much studied (see DiMatteo1 for a review of 50 years of such research), the investigation of physicians' adoption of guidelines is significantly more limited.2 Unless there is such adherence, a guideline will not improve the quality of cancer care; to paraphrase Peter F. Drucker, the father of modern management, the best guideline is only a good intention unless it degenerates into clinical care.3 Indeed, Medicare is investigating how to incorporate performance-based payments based on guidelines into their reimbursement systems.4 A primary question then becomes: how well are such guidelines translated into ongoing clinical care? This question must be coupled with a second question: does the quality of care received by a cancer patient, as measured by practice guidelines and expert opinion, vary depending on where a patient receives care, suggesting that some practices are better at implementing guidelines than others? In this issue of the Journal of Clinical Oncology, Neuss et al5 attempt to answer both questions by presenting the Quality Oncology Practice Initiative (QOPI). This first-step initiative began by using snowball sampling6 to identify board-certified oncologists interested in design and measurement of practice quality. Using this group of oncologists, they developed yes/no quality measures based on expert opinions, practice guidelines, and Joint Commission on Accreditation of Healthcare Organizations–like questions regarding patient/physician interactions. These items were then administered at seven practices in two rounds using reviews of up to 85 sequentially selected charts per practice.
Their findings clearly show that there are high variations among oncology practices. For example, the range for granulocyte colony-stimulating factors given per guideline was from 0% to 88%. This is particularly troublesome because most practices in the sample had active clinical research or quality improvement programs. Only three of the 11 measures were not statistically significantly different among practices at Even more disturbing from a process-control standpoint is that there was no consistent improvement in use of QOPI quality indicators from round 1 to round 2. Although most measures had increased compliance (but not significantly), there were two statistically significant changes between rounds, and one of those was a decline (erythroid growth factors, from 72% to 60%)! The old saying in management that "you get what you measure" appears not to be the case in quality practices in some oncology practices. Although there are additional limitations to the research (such as no mention of inter-rater reliability, lack of representative samples, using charts instead of oncologists as the unit of analysis, not using all eight Institute of Medicine areas), there is some good news in the findings. First, and foremost, the research demonstrates that it is possible to do process quality benchmark studies, such as those found in other industries,7 in oncology practices. This is important because clinical oncologists can then translate the lessons found in other industries rather than delaying practice changes by attempting to learn only from their own practices or those only found in the medical arena. Second, the paper shows that process quality evaluation can be done in a rapid and cost-effective manner; the costs associated with the reviews were relatively inexpensive at just over $1,000 per practice for two rounds of chart abstractions. Finally, the research highlights that in even a small sample of self-selected, high quality practices, there are significant practice variations. It is important that future phases of this work expand to include more typical clinical practices and additional physician demographic, volume, and practice data. Interestingly, there appear to be conflicting views with regard to experience: volume-based measures would imply that the more experience an oncologist has, the better the care,8 whereas a recent systematic review has determined that physicians with more experience have decreasing performance on certain outcome measures.9 The QOPI should gain knowledge from the process standards that deal with practice variation, which have been completed in the manufacturing and service arenas. The most widely adopted of such standards is the International Organization of Standards (ISO) 9000 series that has been adopted by 159 countries, with more than 550,000 certificates issued worldwide.10 This standard has become a de facto requirement for industries to compete in the European Union and it is a source of pride for those plants who receive certification. Indeed, many firms prominently post banners declaring they are "ISO 9000 Certified." Imagine a world where oncology practices would proudly declare "QOPI Certified." One other extensively used measurement system in management is that of the Balanced Scorecard.11 This system uses key performance indicators (KPIs) in four areas—financial, operational, customer (or, in oncology, the cancer patient), and innovation and learning—in order to achieve a balance among competing requirements. Such competition is also present in oncology, where, for example, optimal treatment options must be balanced with insurance and reimbursement requirements. With the creation of a set of practice guidelines that acknowledge the importance of a balance of critical dimensions of quality of cancer care, the likelihood that such guidelines will be adopted may increase dramatically.2 Two cautions that should always be remembered with regard to quality processes are: guidelines may limit innovation, and care must be taken not to confuse effectiveness with efficiency. Quality guidelines, by their very nature, are historical and, unless they are continuously updated to reflect new research, they can hinder, not foster, improved quality of care. All knowledge becomes dated, and individualized treatments must always be considered in the complexity of patient-centric healthcare. Finally, if practices focus too closely on achieving the measure, they may become very efficient at the measurement at the expense of quality patient care, in much the same manner that students can concentrate so industriously on achieving a good grade that they kill learning. Again, quoting Drucker: "There is surely nothing quite so useless as doing with great efficiency that which should not be done at all."12 Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest REFERENCES 1. DiMatteo MR: Variations in Patients' adherence to medical recommendations: A quantative review of 50 years of research. Med Care 42:200-209, 2004[CrossRef][Medline] 2. Davis DA, Taylor-Vaisey A: Translating guidelines into practice. CMAJ 157:408-416, 1997[Abstract] 3. Drucker PF: Management: Tasks, Responsibilities, and Practices. New York, NY, Harper Business, 1993, p 128 4. Lueck S, Dumcius G: Push for performance-based pay in health care receives a boost. Wall Street J. May 4, 2005, p D5
5. Neuss MN, Desch CE, McNiff KK, et al: A Process for Measuring the Quality of Cancer Care: The quality oncology practice initiative (QOPI). J Clin Oncol 23:6233-6239, 2005 6. Lohr SL: Sampling: Design and Analysis. Pacific Grove, CA, Duxbury Press, 1998 7. Laugen BT, Acur N, Boer H, et al: Best manufacturing practices: What do the best-performing companies do? Int J Oper & Prod Mgmt 25:131-150, 2005[CrossRef]
8. Vardy J, Tannock IF: Quality of cancer care. Ann Oncol 15:1001-1006, 2004
9. Choudhry NK, Fletcher RH, Soumerai SB: Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med 142:260-273, 2005 Feb 15 10. International Organization of Standardization: The IS. http://www.iso.ch/iso.en/isn9000-14000/pdf/survey12thcycle.pdf 11. Kaplan RS, Norton DP: The Balanced Scorecard: Translating Strategy into Action. Boston, MA, Harvard Business School Press, 1996 12. Drucker PF: Peter Drucker on the Profession of Management. Boston, MA, Harvard Business School Press, 2003, p 67 Related Article
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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= .10 level. Imagine what the differences would have been had the "typical" oncology practice been evaluated instead of those at the high end of compliance! 
