Since its inception a decade ago, the Quality Oncology Performance Initiative (QOPI) has grown to become a tool in a wide range of quality-improvement efforts and an opportunity for oncology practices to differentiate themselves to payers. And if the American Society of Clinical Oncology has its way, QOPI will become a government-designated system for measuring the quality of care that oncology practices provide.
“We hope it will be the one quality measurement tool that practices are allowed to use to demonstrate their commitment to quality care,” said Michael N. Neuss, MD, Chief Medical Officer of Vanderbilt-Ingram Cancer Center. “We simply can't do something different for every organization and payer, and we can't leave this measurement up to third parties who may have motivations other than excellence in patient care.”
More than 500 practices have submitted performance data to QOPI in at least one data-collection period. That translates into an estimated 15 percent of oncologists participating in QOPI at some level. Neuss said he is impressed with that level of participation in light of the fact that, in most cases, payers are not yet paying QOPI participants more than they do other oncologists.
“The fact that doctors take the trouble to participate in this self-examination, and do it repeatedly, is an impressive endorsement of the program and would seem to indicate that it has value,” he said.
QOPI was piloted by seven oncology practices across the country starting in 2003; three years later, it became available to all ASCO members who wished to participate.
Since then, QOPI has expanded to include more than 100 measures of quality of cancer care. At ASCO's first Quality Care Symposium, held late last year, Neuss presented an analysis of about 50 measures that were used throughout the initiative's first five years—from 2006 to 2010. Data were analyzed from 156 practices that completed at least two rounds of data collection during that period and reported on at least 30 patients per round.
Overall, the mean quality adherence scores of those 156 practices improved from 71 to 85 percent during the five years, he reported. The measures can be organized into three categories:
- Measures that have shown considerable improvement over time. These are primarily measures of the adoption of new clinical practices, such as obtaining genetic testing to predict response to treatment in patients with metastatic colorectal cancer, based on new guidelines or clinical evidence.
- Measures for which average scores are too high to show improvement over time. Most QOPI participants have consistently reported high rates of adherence to guidelines for adjuvant chemotherapy so there is little room for improvement.
- Measures that have not shown improvement despite consistently low scores. In particular, QOPI practices as a group have low rates of smoking-cessation counseling and discussions of infertility risks and fertility preservation options, and overall they have not improved performance over time. Neuss said he was not surprised by those findings: “I suspect they feel like I do, that telling a patient with a terminal disease to stop smoking is just adding insult to injury,” he said. “And I suspect they feel that providing fertility preservation to potentially child-parenting men above a certain age or women with certain diagnoses isn't really helpful.”
QOPI's original purpose was to allow participating practices to benchmark their performance against that of others. For example, as reported in a poster study at the symposium, the 14-bed Molokai General Hospital on an isolated Hawaiian island is using QOPI to assess the quality of its outpatient oncology program, which is delivered through a telemedicine program partnership with Queen's Medical Center in Honolulu. William S. Loui, MD, Chief of Oncology there, said that QOPI allows Molokai to understand the strengths and weaknesses of its cancer care program even though the hospital lacks staff and resources for a full-time quality improvement program.
Being able to benchmark performance is the first step to understanding where performance improvement is needed. When the twice-yearly QOPI reports arrive in her office, Carolyn B. Hendricks, a solo practitioner at the Center for Breast Health in Bethesda, Md., looks for trouble spots. “Any time we score less than 90 percent, the staff and I sit down and devise relatively simple projects to improve our scores,” she said.
At St. Luke's Mountain States Tumor Institute in Boise, Iowa, the performance improvement team uses that same approach, according to a poster presentation by Shelby Darland, RN, MSN, and colleagues. In July 2011, the team embedded alerts and reminders in MSTI's electronic health record system to help with three QOPI measures: signed chemotherapy consent, smoking cessation counseling, and assessment of emotional well-being.
In 2012, MSTI scored 100 percent on the signed chemotherapy consent measure, up from 10 percent in its initial QOPI report in 2007. The other two measures also scored above 90 percent.
Similarly, leaders at Palmetto Hematology Oncology in Spantanburg, S.C., were dissatisfied to learn from the Fall 2010 QOPI report that only 71 percent of their patients had signed chemotherapy consents, a percentage lower than the QOPI aggregate score of 86 percent.
Another poster study, presented by Patricia Hegedus, RN, OCN, MBA, Director of Oncology Clinical Performance, and colleagues reported that the QOPI data inspired a revision of the chemotherapy administration policy. The policy now includes a “hard stop,” meaning that chemotherapy cannot be administered if the signed consent is not available. In the Spring 2012 QOPI reporting period, the practice achieved a 100 percent score on the consent measure.
In addition to benchmarking their performance against QOPI averages, oncology practices are finding many ways to use QOPI for strategic initiatives. For example, poster studies at the Symposium: identified the following:
- More than 40 practices participating in the NCI Community Cancer Centers Program (NCCCP) use QOPI to inform quality improvement efforts. In a webinar after every QOPI reporting period, the practices review how their performance stacks up against the NCCCP national average on certain indicators. High-performers share their tips for success, and the NCCCP quality of care subcommittee selects quality improvement projects to pursue.
- Baystate Medical Practices, a large physician group in Springfield, Mass., is using QOPI to support the pay-for-performance initiative for its nine-member oncology division.
- The University of Texas MD Anderson Cancer Center is using the QOPI process to monitor compliance among seven survivorship clinics with its policy that cancer survivors should receive an electronic cancer survivorship care plan (CSCP). The analysis found that compliance ranged from 64.5 to 94.7 percent.
- An ASCO state affiliate, the Northern New England Oncology Society, established a collaborative improvement network (CIN) in which QOPI practices mentored oncology practices that had no experience with the system. Members of the network also benchmarked their QOPI results against one another and shared best practices—including a one-page chemotherapy treatment summary and a “chair-side” smoking cessation program—so that care could improve among all participants.
QOPI could become important to oncologists in another way if the government deems QOPI to be an alternative to oncologists' participation in the Physician Quality Reporting System (PQRS)—and the first step in that process has already occurred.
The so-called “fiscal cliff” legislation signed by President Obama on Jan. 2 sets the stage for physicians to submit data on quality measures via a “qualified clinical data registry” in lieu of participating in PQRS, beginning in 2014.
Many details about what exactly constitutes a “qualified clinical data registry” remain to be worked out. The law assigns the Department of Health and Human Services to establish requirements for the registries.
ASCO leaders have been discussing this idea with officials at the Centers for Medicare & Medicaid Services and Congress for several months, said W. Charles Penley, MD, FASCO, Chair of ASCO's Governmental Relations Committee, who practices at Tennessee Oncology.
“We are hoping that we can continue the conversation and move QOPI forward as a legitimate representation of quality measurement in oncology practice.”
If QOPI meets the requirements to be a qualified registry, it would mean that oncologists could satisfy the federal government's quality reporting requirements through QOPI.
Oncologists have been unhappy with PQRS since it was introduced as a pilot program (then called Physician Quality Reporting Initiative) six years ago, saying that the government's measures were mostly irrelevant to cancer care and that submitting data was more trouble than it was worth. Most oncologists have not submitted quality data to PQRS, choosing to forego financial bonuses offered by the government.
Opting out of PQRS, however, is about to become a more difficult financial decision. Beginning this year, physicians who do not successfully submit data to PQRS will receive a 1.5 percent decrease in their Medicare pay in 2015.
In testimony before the U.S. Senate Committee on Finance Roundtable last July, Barbara McAneny, MD, Chief Executive Officer of New Mexico Oncology Hematology Consultants, urged Congress to allow QOPI to be the data-reporting vehicle for oncologists who participate in the government's e-Prescribing Program and other reporting programs.
“While ASCO strongly supports the goals of these initiatives, we have shared with CMS that these programs are often duplicative and subject to unrealistic timelines,” she said. “The use of QOPI could serve as a central program to replace or streamline most of the existing CMS reporting requirements, save significant resources and provide much more granular and meaningful information beyond what can be achieved with CMS-directed programs.”
The “fiscal cliff” legislation identifies the following elements that might be required for a qualified clinical data registry:
- Provides for transparency of data elements and specifications, risk models, and measures.
- Requires submission of data from participants with respect to multiple payers.
- Provides timely performance reports to participants at the individual participant level.
- Supports quality improvement initiatives.
The law instructs the Government Accountability Office to conduct a study on the potential of clinical data registries to improve the quality and efficiency of care in the Medicare program including through payment incentives. The report is due by Nov. 15.