Measuring Outcomes that matter to patients in breast cancer assessment and treatment

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Measuring outcomes that matter to patients in breast cancer assessment and treatment

 

Giles S.L. Davies MB BS BSc. MD FRCS

Director The Breast Clinic Ltd.

 

Introduction

Doctors working in hospitals treating patients for breast cancer evaluate the quality of their care currently in 2 main areas.

Firstly structural evaluation. So what do I mean by this? I'm talking about the facilities they work in and the equipment and technology that they provide to their patients. In fact we are very good as doctors at evaluating structure in which we work And we are very good at informing patients about it. The size of our hospital services, the quality of the imaging equipment and more recently particularly in the area of radiotherapy, we compete with fellow institutions for patients based on owning the latest equipment (MRIdian Linac, intensity modulated radiotherapy (IMRT), stereotactic ablative radiotherapy (SABR), gamma knife radiosurgery etc). By showcasing the latest technology equipment and facilities we highlight to patients the difference between our service and our competitors. The average patient does not care about equipment, they care about being cured, not being damaged during treatment, and moving on to rebuild the life they had before their diagnosis. Their definition of success is very different from ours.

 

The second area in which doctors and hospitals spend much of their time assessing and evaluating is process. once again, we are very good doing this and telling our patients about it. We measure the time it takes from being referred from a GP to initiating treatment for cancer. We measure compliance and adherence to guidelines both local and national. we audit and record incidents, infections, and MRSA and VTE rates and have meetings to discuss these regularly. We hold morbidity and mortality meetings to highlight where things have gone wrong and where lessons can be learned. We spend a lot of time assessing risk and spend a lot of time evaluating whether we follow practices that reduce these risks. We measure variance in practice and use multidisciplinary team meetings to discuss and recommend what we feel is the best treatment for our patients. However, how much of this diligent and time consuming work is a measure of the quality of our care? One could argue that all this information is very important for running a safe and efficient hospital and conforming to regulations and clinical guidelines, but how much of this helps patients choose where to seek their care and therefore create competition based on results important to patients? In fact, very little of this structural and process evaluation and measurement actually assesses things that matter to patients. We have seen in recent times how measurements of “quality” such as a very low caesarean section rate provide no measure of quality at all and in some cases have led to significant harm to patients over many years.

 

Adopting a value-based healthcare model

 

Adopting a value-based healthcare model is a new paradigm focused on outcomes and results that matter most to patients. This creates an environment where patients can ask their doctors about meaningful outcomes and doctors can provide answers based on data. It is about creating a new definition of what success is in breast cancer treatment.

 

Value based Healthcare is a movement championed by Professor Michael E Porter from Harvard Business School (1) and this movement is based on a  solid framework has led to the development of the International Consortium on Health Outcomes Measurement (ICHOM), an international non-profit organisation whose mission is to unlock the potential of value-based healthcare by defining global standard sets of outcome measures that really matter to patients (2). So, what are the principles of value-based healthcare? They are as follows:

 

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Competition based on results

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Competition centred on medical conditions over a full care cycle

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Value assessed by provider experience

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Overall aim is that high quality care should be less costly

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Competition should be regional and national

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Results information to support value-based competition should be widely available

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Value needs to be measured at the level of the individual condition

 

In simple terms it is about redesigning your healthcare provision to be centred around the patient. In fact, I think of four key principles which underpin this process.

 

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Identify the patient need

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Put the pathway around the patient

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Integrate all practitioners irrespective of their individual department based on that patient’s condition

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Measure patient relevant outcomes

 

There is an additional core structural concept within a value-based healthcare system that is is important to understand and consider is the development of an integrated practice unit (IPU). This can be defined as a dedicated team involving nonclinical and clinical personnel who work together to provide the whole care cycle for a group of patients with the same medical condition. Worldwide there all good examples of this and in the UK this model is now starting to be considered (Schoen Clinic, Cleveland Clinic, One Welbeck are two such examples).

 

Developing a breast service based on a value-based healthcare model

 

Step one – structure

 

In defining the patient condition, it is not possible to separate breast cancer from women’s health and in fact the vast majority of patients seen in one stop breast clinics will not have breast cancer but will have symptoms and conditions related to women's health that may need support, treatment and tests. By collocating primary care doctors care doctors with special interests in gynaecology, family planning, cervical screening, and menopause, alongside specialists in gynaecology and breast surgery, it will allow integration of assessment and treatment pathways. This integrated women’s health unit may be better placed outside of a hospital and closer to the area of patient need. In fact, multiple such units may serve local communities. This integrated women's health unit may provide onsite mammography, ultrasound, biopsy facilities, colposcopy, physiotherapy, bone density assessment, psychological support and other services needed to provide a comprehensive integrated onsite service for the majority of health needs in this segmented patient population.

 

In contrast the centre of excellence, typically a hospital will provide more complex care including complex surgery, chemotherapy and radiotherapy. This means that for patients with breast cancer all the treatments required are available under a single roof.

 

Step 2 – Process

 

Having developed the structure based on the segmented population group it is vital to develop processes that allow the triage,  assessment and investigation of patients in the right place at the right time with the right people to hand. By developing effective screening and triaging processes, low risk patients can be seen in the integrated practice unit where the wrap around care provided can meet their care needs more effectively and at less cost that the centre. Conversely, patients referred at high risk of a cancer diagnosis should be seen in the centre allowing rapid and more complex assessment (for example rapid CT PET scanning) and the more sophisticated support and advocacy required (Clinical Nurse Specialists, information provision, psychological support). This develops a model of high volume low acuity work in the IPU and high acuity work occurring in the centre of excellence where patient will travel to to receive high quality care.

 

Step 3 – Measurement

 

In addition to routine outcome measurement and contribution to local and national databases around cancer metrics and hospital metrics (Length of stay, 31- and 62-day targets), it is important to develop mechanisms to accurately capture data points at the multidisciplinary meeting stage, contribute to the National Breast Implant registry and National Flap Audit. These items are a mandatory part of a specialist breast unit. Data points on stage, performance status and diagnosis form the core dataset, and it is important to develop a tracking process to allow snapshot evaluation of where patients are in the phases of treatment. A wider dataset recording decision making and a Cancer and Oncoplastic Multidisciplinary Team Meeting following defined Terms of Reference and guidelines are also vital. An overarching Cancer Board structure allows reporting and evaluation of the process metrics alongst with compliance against set key performance indicators and peer review. Setting the membership of the board to include representation from Surgery, Oncology, Radiology, Nursing, Pharmacy and Managerial representation is key to clear lines of communication and accountability.

 

 

 

 

What other outcomes measurements can be made?

 

Net Promotor Score is one such measurement commonly recorded. It is a good measure of patient experience and provides a good core measure of the overall quality of your service. It is also why be used across business sectors and is a leading indicator of customer experience particularly when coupled with other metrics and insights. Is it is also simple to apply and record and it is a good measure of the perception of your brand. Many individual clinicians use feedback tools such as Iwantgreatcare or Doctify and collecting individual patient feedback can be very useful for understanding gaps in a clinical service and reinforcing and marketing successful clinical pathways or services. however, it is PROMS (patient reported outcome measures) that form the key measure of patient experience and form an integral part of a ICHOM data set. These include:

 

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EORTC QLQ-C30

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EORTC-BR23 and Breast Q

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FACT-ES

 

By assessing a wider range of patient centred outcomes including body image, fatigue, depression, pain, sexual function, neuropathy (and more), it is possible to understand the impact of treatments on patients’ day to day lives. It also provides a platform for measurement of interventions such as:

 

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Clinical exercise

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Symptom tracking applications

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Prehabilitation programmes

 

These data can start to complement recording of outcomes readily available with wearable technology that are not only relevant but important to patients (e.g. quality of sleep, heart rate variability, energy).

 

Currently the private health information network (PHIN) provides the mainstay of information for patients publishing performance and fees information about private consultants and hospitals. The aim is to provide unbiased information to allow patients access to information to choose where to access care based on informed choice but in addition allows transparency, and the ability of hospitals and consultants to have data to improve the quality of their services. The information collected covers safety quality and cost. Hospitals that have the facilities, resources, and expertise to adopt an ICHOM dataset should do so as part of a value-based healthcare agenda.

 

Summary

 

Data on outcomes that matter to patients in Breast Cancer are poorly recorded and inconsistent in the UK currently. Transitioning to healthcare delivery based on a value-based healthcare model and agenda and measuring outcomes that matter to patients will improve the quality of care and lower costs.

 

References

 

1: Redefining Healthcare, creating value-based competition based on results. Michael E. Porter, Elizabeth Olmsted Teisberg. Harvard Business Review Press.

 

 

 

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Measuring outcomes that matter to patients in breast cancer assessment and treatment Giles S.L. Davies MB BS BSc. MD FRCSDirector The Breast...

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The Breast Clinic is a breast surgery specialist and Mr Giles Davies is a specialist breast cancer surgeon and Oncoplastic breast surgeon who can offer a range of Breast surgery treatments and breast reconstruction.

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