Defining Cancer Care Quality or Delivering Quality Cancer Care

Many in the oncology world see as accepted that quality and value are difficult to define and that no specialty-wide consensus is likely to be reached in the short term about how to measure and report success at improving either. Others find the definition just beyond their grasp and suggest that, like pornography, they know it when they see it. Large organizations, publications, conferences, and processes have sprung up around the concept, and various attempts have been made to develop “measures of quality” that can characterize a practice or physician in this area. This work includes ongoing efforts within and among the National Quality Forum, NCCN, ASCO, The US Oncology Network (The Network), the Community Oncology Alliance, and Ontario Cancer Care to identify quality measures—many of which focus on surrogate processes or activities that should lead to quality. Instead, however, we believe this effort and investment should focus on outcomebased measures, and we offer a paradigm for measuring interventions: •� Quality is the efficient delivery of evidence-based care by trained clinicians in an accessible setting. •� In this context, value is providing higher quality care at the same cost, or the same quality at a lower cost. We believe these concepts are at the core of cancer care delivery, whether in the community or academic setting and across specialties, including medical oncology, radiation oncology, gynecologic oncology, urology, and surgery. Achieving quality will require integrated, coordinated care with clinical teams spanning these professionals and settings. It requires not only coordination among clinicians of different specialties but also investment in infrastructure resources to facilitate the integration of process development and clinical decision support tools that support evidence-based practices that optimize practice efficiency and care delivery. If the right investments have been made and communications highways created, these definitions are measurable, reportable, and comparable (without significant manual effort). Just as important, these definitions allow quality and value to evolve over time as the evidence evolves. Consequently, the highest-quality treatment pathways, and even the best modalities of treatment, may be vastly different in the future. For example, advance care planning and palliative care services would likely not have been included in the concept of evidence-based care 10 years ago. Today, however, the data suggest that palliative care concurrent with disease-directed care can improve outcomes and patient experiences while reducing costs. This view is also supported by a decade of hypothesis, consensus-building, technology investment, data collection, and analysis by physicians and supporting clinicians and staff of The Network, who we believe pioneered the concepts of narrowly drawn, evidence-based pathways for care in oncology. Nearly a decade ago, physicians in The Network decided to develop Level I Pathways, evidence-based guidelines that redirect the wide range of treatments in oncology care into more precise, clinically proven treatment options. (More information is available at http://www.usoncology.com/cancercareadvocates/ AdvancingCancerCare/DeliverHigh-QualityCare/LevelIPathways.) The Level I Pathways program helps physicians eliminate disparities in care by refining potential