JNCI J Natl Cancer Inst (2015) 107(3): dju438 doi: 10.1093/jnci/dju438 First published online January 24, 2015 Editorial
editorial Patient Satisfaction, Outcomes, and the Need for Cancer-Specific Quality Metrics Sanjay Mohanty, Christine V. Kinnier, Karl Y. Bilimoria Affiliations of authors: Surgical Outcomes and Quality Improvement Center, Department of Surgery (SM, CVK, KYB) and Northwestern Institute for Comparative Effectiveness Research in Oncology (SM, CVK, KYB), Chicago, IL; Department of Surgery, Henry Ford Hospital (SM), Detroit, MI; Department of Surgery, Massachusetts General Hospital (CVK), Boston, MA. Correspondence to: Karl Bilimoria, MD, MS, Surgical Outcomes and Quality Improvement Center Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N. St. Clair Street, Suite 6–650, Chicago, IL 60611 (e-mail: [email protected]).
In this issue of the Journal, Wright and colleagues highlight the relationship between patient satisfaction and thirty-day oncologic outcomes (1). The authors demonstrate that current publicly reported measures of quality and patient satisfaction are poorly correlated with thirty-day morbidity and mortality in patients undergoing solid tumor resections. The measures of patient satisfaction from Hospital Compare are for hospitalwide performance, not just oncology patients, so the findings are not particularly surprising. However, this study does highlight the need to: 1) examine whether patient experience and satisfaction really need to correlate with traditional measures of clinical quality (eg, outcomes), 2) discuss how patients seeking provider performance data are unable to access oncology-specific information from public reporting programs, and 3) discuss how cancer quality improvement efforts would benefit from both patient experience and traditional quality measures that are cancer specific. An increasing emphasis has been placed on patient experience measures as they carry considerable weight in Centers for Medicare & Medicaid Services (CMS) pay-for-performance programs. A number of studies have sought to assess whether these patient experience measures are associated with outcomes. Some have demonstrated that hospitals with higher patient satisfaction scores often perform better on traditional measures of quality (2), while others, like Wright et al., have found that current measures of the patient experience do not correlate with traditional quality measures like morbidity (3). The studies that do not find a correlation then frequently criticize patient experience measures and suggest they may not be important. However, we would argue that the lack of an association with traditional outcomes is actually beneficial because it means that patient experience measures highlight a different aspect of quality and offer new opportunities for improvement efforts. Patient satisfaction represents many facets of the patient experience, most of which are not captured by existing
data, clinical outcomes, or other quality metrics. In addition to the obviously important metrics of survival and recurrence rates, patients undoubtedly care about how their physicians explain things to them, how well they explain post-discharge care and expectations, and whether their pain was adequately controlled. Therefore, demonstrating correlations between patient experience measures and traditional outcomes is not really required and should not necessarily lessen the value of patient experience measures. However, when patients seek information on providers’ patient satisfaction performance, they are only able to access a hospital-wide score, which comes from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey from Hospital Compare. Thus, this is less informative, as it is not specific to cancer care, a discipline of cancer care (eg, surgical oncology), or a particular oncology physician. Cancer patients may have very different needs and priorities than other patients, and cancer patients want to know how their specific providers perform with respect to cancer care. As Wright et al. and other authors have noted, this is a problem that extends to most publicly reported measures, not patient-experience measures (4,5). Similarly, it is important to ensure that providers have access to comparative cancer-specific patient satisfaction scores in order to identify areas of poor performance and effectively implement change. Traditional quality metrics (eg, process and outcome measures) that are cancer specific have been generally lacking from publicly reporting programs, so patients cannot get information on which to base their decisions about where to go for care. The National Quality Forum (NQF), the clearinghouse for quality measure development and endorsement, has endorsed nearly fifty measures pertaining to cancer care from a variety of stewards such as the American College of Surgeons, Commission on Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network (6). These measures
Received: December 8, 2014; Accepted: December 10, 2014 © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
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primarily address processes unique to cancer care, such as the timely administration of adjuvant therapy and appropriate lymph node examination. Some measures also address processes related to palliative care but of interest to cancer patients, like symptom control and the use of hospice services. However, few if any of these measures have been incorporated into public reporting initiatives. Moving forward, requiring reporting of some of these measures may help expand the utility of public reporting specific for cancer patients, caregivers, and referring providers attempting to identify a good hospital for cancer care. One small group of hospitals will begin reporting cancerspecific metrics publicly based on a mandate in the Affordable Care Act. Cancer hospitals that were previously exempt from Medicare’s prospective payment system (PPS) and public reporting requirements, so called PPS-Exempt Cancer Hospitals, are required to submit three cancer-specific NQF-endorsed quality measures for public reporting beginning with the Fiscal Year 2014 payment determination year (7). These measures include the timely administration or consideration of adjuvant chemotherapy in patients with Stage III colon cancer, appropriate and timely combination chemotherapy for American Joint Committee on Cancer (AJCC) T1c or Stage II/III hormone receptor negative breast cancer, and appropriate and timely adjuvant hormonal therapy in AJCC T1c or Stage III hormone receptor positive breast cancer. While an important move toward transparency, only eleven hospitals in the country will be included. Public reporting initiatives need to include cancer quality metrics for all hospitals in the United States. As Wright and colleagues emphasize, substantial work is still needed in developing and publishing cancer-specific patient satisfaction measures and traditional quality metrics. The ideal future is one in which publicly reported measures will be appropriately risk adjusted, reliably collected and reported,
varied enough to cover the entire breadth of a patient’s care from appropriateness to outcomes and satisfaction, and granular enough to be meaningful. This information would allow for a more comprehensive picture of hospital performance than is currently available and would both incentivize and guide quality improvement more effectively.
Note The authors have no conflicts of interest to declare.
References 1. Wright J, Tergas A, Ananth C, et al. Relationship Between Surgical Oncologic Outcomes and Publically Reported Quality and Satisfaction Measures. J Natl Cancer Inst. 2014;107(3):dju409 doi:10.1093/jnci/dju409. 2. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ Perception of Hospital Care in the United States. N Engl J Med. 2008;359(18):1921–1931. 3. Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg. 2014;260(4):592–598; discussion 598–600. 4. Spinks TE, Walters R, Feeley TW, et al. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood). 2011;30(4):664–672. 5. Merkow RP, Chung JW, Paruch JL, Bentrem DJ, Bilimoria KY. Relationship between cancer center accreditation and performance on publicly reported quality measures. Ann Surg. 2014;259(6):1091–1097. 6. National Quality Forum. NQF-Endorsed Standards. http:// www.qualityforum.org/QPS/. Accessed November 26, 2014. 7. Patient Protection and Affordable Care Act, 124 Stat. 119, §3005 (2010).
Copyright of JNCI: Journal of the National Cancer Institute is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
editorial Patient Satisfaction, Outcomes, and the Need for Cancer-Specific Quality Metrics Sanjay Mohanty, Christine V. Kinnier, Karl Y. Bilimoria Affiliations of authors: Surgical Outcomes and Quality Improvement Center, Department of Surgery (SM, CVK, KYB) and Northwestern Institute for Comparative Effectiveness Research in Oncology (SM, CVK, KYB), Chicago, IL; Department of Surgery, Henry Ford Hospital (SM), Detroit, MI; Department of Surgery, Massachusetts General Hospital (CVK), Boston, MA. Correspondence to: Karl Bilimoria, MD, MS, Surgical Outcomes and Quality Improvement Center Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N. St. Clair Street, Suite 6–650, Chicago, IL 60611 (e-mail: [email protected]).
In this issue of the Journal, Wright and colleagues highlight the relationship between patient satisfaction and thirty-day oncologic outcomes (1). The authors demonstrate that current publicly reported measures of quality and patient satisfaction are poorly correlated with thirty-day morbidity and mortality in patients undergoing solid tumor resections. The measures of patient satisfaction from Hospital Compare are for hospitalwide performance, not just oncology patients, so the findings are not particularly surprising. However, this study does highlight the need to: 1) examine whether patient experience and satisfaction really need to correlate with traditional measures of clinical quality (eg, outcomes), 2) discuss how patients seeking provider performance data are unable to access oncology-specific information from public reporting programs, and 3) discuss how cancer quality improvement efforts would benefit from both patient experience and traditional quality measures that are cancer specific. An increasing emphasis has been placed on patient experience measures as they carry considerable weight in Centers for Medicare & Medicaid Services (CMS) pay-for-performance programs. A number of studies have sought to assess whether these patient experience measures are associated with outcomes. Some have demonstrated that hospitals with higher patient satisfaction scores often perform better on traditional measures of quality (2), while others, like Wright et al., have found that current measures of the patient experience do not correlate with traditional quality measures like morbidity (3). The studies that do not find a correlation then frequently criticize patient experience measures and suggest they may not be important. However, we would argue that the lack of an association with traditional outcomes is actually beneficial because it means that patient experience measures highlight a different aspect of quality and offer new opportunities for improvement efforts. Patient satisfaction represents many facets of the patient experience, most of which are not captured by existing
data, clinical outcomes, or other quality metrics. In addition to the obviously important metrics of survival and recurrence rates, patients undoubtedly care about how their physicians explain things to them, how well they explain post-discharge care and expectations, and whether their pain was adequately controlled. Therefore, demonstrating correlations between patient experience measures and traditional outcomes is not really required and should not necessarily lessen the value of patient experience measures. However, when patients seek information on providers’ patient satisfaction performance, they are only able to access a hospital-wide score, which comes from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey from Hospital Compare. Thus, this is less informative, as it is not specific to cancer care, a discipline of cancer care (eg, surgical oncology), or a particular oncology physician. Cancer patients may have very different needs and priorities than other patients, and cancer patients want to know how their specific providers perform with respect to cancer care. As Wright et al. and other authors have noted, this is a problem that extends to most publicly reported measures, not patient-experience measures (4,5). Similarly, it is important to ensure that providers have access to comparative cancer-specific patient satisfaction scores in order to identify areas of poor performance and effectively implement change. Traditional quality metrics (eg, process and outcome measures) that are cancer specific have been generally lacking from publicly reporting programs, so patients cannot get information on which to base their decisions about where to go for care. The National Quality Forum (NQF), the clearinghouse for quality measure development and endorsement, has endorsed nearly fifty measures pertaining to cancer care from a variety of stewards such as the American College of Surgeons, Commission on Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network (6). These measures
Received: December 8, 2014; Accepted: December 10, 2014 © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
1 of 2
Mohanty et al. | 2 of 2
primarily address processes unique to cancer care, such as the timely administration of adjuvant therapy and appropriate lymph node examination. Some measures also address processes related to palliative care but of interest to cancer patients, like symptom control and the use of hospice services. However, few if any of these measures have been incorporated into public reporting initiatives. Moving forward, requiring reporting of some of these measures may help expand the utility of public reporting specific for cancer patients, caregivers, and referring providers attempting to identify a good hospital for cancer care. One small group of hospitals will begin reporting cancerspecific metrics publicly based on a mandate in the Affordable Care Act. Cancer hospitals that were previously exempt from Medicare’s prospective payment system (PPS) and public reporting requirements, so called PPS-Exempt Cancer Hospitals, are required to submit three cancer-specific NQF-endorsed quality measures for public reporting beginning with the Fiscal Year 2014 payment determination year (7). These measures include the timely administration or consideration of adjuvant chemotherapy in patients with Stage III colon cancer, appropriate and timely combination chemotherapy for American Joint Committee on Cancer (AJCC) T1c or Stage II/III hormone receptor negative breast cancer, and appropriate and timely adjuvant hormonal therapy in AJCC T1c or Stage III hormone receptor positive breast cancer. While an important move toward transparency, only eleven hospitals in the country will be included. Public reporting initiatives need to include cancer quality metrics for all hospitals in the United States. As Wright and colleagues emphasize, substantial work is still needed in developing and publishing cancer-specific patient satisfaction measures and traditional quality metrics. The ideal future is one in which publicly reported measures will be appropriately risk adjusted, reliably collected and reported,
varied enough to cover the entire breadth of a patient’s care from appropriateness to outcomes and satisfaction, and granular enough to be meaningful. This information would allow for a more comprehensive picture of hospital performance than is currently available and would both incentivize and guide quality improvement more effectively.
Note The authors have no conflicts of interest to declare.
References 1. Wright J, Tergas A, Ananth C, et al. Relationship Between Surgical Oncologic Outcomes and Publically Reported Quality and Satisfaction Measures. J Natl Cancer Inst. 2014;107(3):dju409 doi:10.1093/jnci/dju409. 2. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ Perception of Hospital Care in the United States. N Engl J Med. 2008;359(18):1921–1931. 3. Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg. 2014;260(4):592–598; discussion 598–600. 4. Spinks TE, Walters R, Feeley TW, et al. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood). 2011;30(4):664–672. 5. Merkow RP, Chung JW, Paruch JL, Bentrem DJ, Bilimoria KY. Relationship between cancer center accreditation and performance on publicly reported quality measures. Ann Surg. 2014;259(6):1091–1097. 6. National Quality Forum. NQF-Endorsed Standards. http:// www.qualityforum.org/QPS/. Accessed November 26, 2014. 7. Patient Protection and Affordable Care Act, 124 Stat. 119, §3005 (2010).
Copyright of JNCI: Journal of the National Cancer Institute is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
