CHICAGO—Providing feedback on quality of care to physicians in cancer practices can markedly increase assessments of their patients' emotional well-being, and in turn, lead to more actions to address the problems patients face with emotional well-being. That was the conclusion of a study reported here at the ASCO Annual Meeting.
“There is a need to raise awareness about psychosocial care and generate greater interest among providers in adopting existing guidelines and recommendations,” said Paul Jacobsen, PhD, Chair of the Department of Health Outcomes & Behavior at H. Lee Moffitt Cancer Center and Research Institute.
Setting the stage for the background of the study, Dr. Jacobsen noted that in 2007, the Institute of Medicine published a report entitled “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs” (OT, 12/10/07). The report provided a model for effective delivery of psychosocial services, and concluded that attending to patients' psychosocial health needs should be an integral part of quality care in cancer.
Included in the suggestions were that practices identify psychosocial needs and then develop and implement a plan to provide personalized information, strategies to address needs, provide emotional support, help manage health and illness, and then follow-up and re-evaluate.
These recommendations, Dr. Jacobsen noted, are similar to the National Comprehensive Cancer Network (NCCN) Distress Management Guidelines first issued in 1999, and updated annually. The key features of these guidelines include putting in place procedures to identify patients experiencing moderate to severe emotional distress, and then having these patients undergo further evaluation that might lead to referral to health professionals.
For the study reported at the ASCO meeting, a survey was sent to each of the 18 panel representatives in the NCCN Distress Management Guidelines Panel. “We received responses from 15 panel representatives, and found that only 53% of centers were doing any routine screening of any patients in their center,” Dr. Jacobsen said. “Moreover, only 3% were screening all patients who walked through the door.”
On the positive side, though, almost all centers routinely referred patients in distress to a mental health professional.
A 2007 survey of 1,000 randomly selected ASCO oncologists—about two-thirds community-based and about one-third cancer center-based—received 448 responses. Two-thirds of the respondents said they routinely screened for distress. “It was disconcerting that there was little familiarity with the NCCN Distress Management Guidelines,” Dr. Jacobsen said. About one-third of participants indicated that they were not at all familiar with the guidelines and about another one-third had heard of but not seen the guidelines.
2 Key Elements in Providing Good Psychosocial Care
The American Psychosocial Oncology Society recently formed a workforce attempting to develop performance indicators for the quality of psychosocial care. “We reviewed the IOM and NCCN documents and identified two key elements in providing psychosocial care: identifying distressed patients and developing a care plan for distressed patients,” he said. He and his colleagues developed methods to code for these processes of quality indicators in medical records and have recently finished a full-scale field test conducted in Florida using the resources of the Florida Initiative for Quality Cancer Care in 11 centers that represent a mix of academic centers and community practices.
The quality indicators were embedded in a larger study looking at quality of care for colorectal, breast, and lung cancer patients first seen by a medical oncologist in 2006. So far, the researchers have audited 1,660 cases. The first quality care indicator—Is there evidence in the medical chart that current emotional well-being is assessed within one month of the first visit to a medical oncologist?—led to wide variability, with a performance rate ranging from 12% to 86%, Dr. Jacobsen reported.
The median was a “disappointing” 47%, he said. In contrast, pain assessment had a median 87% performance rate.
The second quality indicator—evidence of action taken to address a problem in emotional well-being—also had wide variation from 13% to 100% and a median of 57%.
Dr. Jacobsen related that following publication of the IOM report in 2007, the ASCO Quality Oncology Practice Initiative (QOPI) steering committee sought indicators of quality of psychosocial care. After some pilot testing, the committee adopted those two quality indicators for its core battery in the fall of 2008.
From this data, Dr. Jacobsen has identified 166 Florida practices that include 30,853 patients that measured performance on psychosocial care indicators then (average of 90 patients per practice) and in 2009 (average of 95 patients per practice).
As part of QOPI, all the practices got feedback about their performance on each indicator and in comparison to all other QOPI practices. “Psychosocial indicators tend to be among those that practices perform the poorest,” he noted.
Although in Fall 2008, only 64% of charts had evidence that psychosocial well-being was being addressed, by one year later, the practices had increased significantly to 73%. The average number of patients a practice identified with a problem of emotional well-being increased from 13% to 17%, reflecting a greater use of indicators.
Action taken—a referral to an in-house or external support group—among patients with a problem increased minimally from an average of 74% to 76%. “This is one aspect of performance that is not improved just by providing feedback,” Dr. Jacobsen said. Reflecting the higher percentage of patients being assessed, action taken among all patients with a problem in emotional well-being increased significantly from 9% to 13%.
Two Keys to Success
Two keys to the success among the Florida practices, he said, is that money was provided for chart abstraction, which helped promote cooperation, and strict anonymity of the sites built trust and collaboration. These practices now meet annually to discuss quality care and “many centers are eager to learn from other practices on how to do better,” he said.
With growing recognition of the importance of psychosocial care, it will be increasingly important to incorporate this into standards of cancer care, Dr. Jacobsen said. The good news on this front is that the recently issued ASCO/ONS guidelines for standards for safe chemotherapy administration include an assessment of psychosocial concerns and need for support for those about to begin chemotherapy.
“We also have to consider raising the bar in terms of how we measure psychosocial indicators. It's important to see to what extent physicians are using validated screening instruments to assess distress. Simply asking whether patients are in distress or depressed is likely to lead to underestimates,” he said, pointing out that 17% of patients in the Florida practices were identified as having emotional problems while epidemiologic surveys suggest the actual percentage of patients is closer to 25% to 30%.
“I think we can make improvements by giving practices feedback, but for many practices it will take more than that. We need to assist practices that are seeking to improve the quality of psychosocial care. This is trickier with actions to be taken, particularly in centers where there are no mental health professionals on staff,” he said.
Resources need to be developed for community-based practices, linking them with providers in the community and web-based resources that can provide psychosocial care.
Most importantly, “we need to determine whether what we're seeing on performance indicators is reflected in outcomes—that is, are increases in the percentage of patients assessed and receiving care for emotional well-being reflected in patients' actual well-being in quality-of-life measures,” he said.
The Discussant for the study, Steven Katz, MD, Professor of Medicine and Health Management and Policy at the University of Michigan, noted in his remarks that quality improvement has three aims: improve the individual experience of care, improve the health of populations, and reduce the per capita costs of care.
“Barriers to achieving these aims are the lack of accountability, not enough push on clinicians and the system, and the lack of an ‘integrator’ able to focus and coordinate services,” Dr. Katz said, adding that he admits, though, that as a clinician, he often doesn't push as hard as he can on quality improvement.
Dr. Jacobsen's presentation highlighted a successful model for incorporating performance measures into practice change, Dr. Katz said. The model set out to attain quality improvement in emotional well-being, to evaluate changes in outcomes over time and across institutions, and to improve screening and intervene earlier in higher risk patients. “This was a win, win, win in terms of quality improvement. I was impressed with the feedback and the context for quality improvement, as well as the description of the hard work put in to get the Florida practice partnership going.”