BACKGROUND/RATIONALE:
Noting the need to reduce the time from positive screening test to diagnosis and increase the use of guideline concordant care, the VA Colorectal Cancer Quality Enhancement Research Initiative (QUERI), VA Office of Quality and Performance, and VA Advanced Clinic Access (ACA) Initiative partnered to conduct the Colorectal Cancer Care Collaborative (C4), and Veterans Integrated Service Network (VISN) 1. The project also involved collaboration with the VA Offices of Patient Care Services, Undersecretary of Health for Operations and Management, and the Office of Research and Development (ORD). C4 includes at least one team from each of the 21 VISNs (total of 28). Successful strategies for quality improvement developed by the teams were disseminated VA-wide. In addition, a Cancer Care Quality Measurement System (CCQMS) was developed with the goal of increasing the ability to map/describe the process of delivering cancer care, identifying potential targets for quality improvement, and monitoring the effects of cancer care quality improvement initiatives.

OBJECTIVE(S):
As part of the C4 project, the Durham HSR&D Center of Excellence collaborated with other C4 partners to develop a Cancer Care Quality Measurement System that will provide data on the quality of colorectal cancer care in the VA. Using established National Comprehensive Cancer Network (NCCN) guidelines and the VA Directive on Cancer Care as benchmarks for the standard of care, we developed a quality measurement template that was completed by each of the 28 facilities in the C4 collaborative. The template included data elements that, when aggregated, formed measures for evaluating the quality of colorectal cancer care in VHA. These NCCN-based measures: a) identify facility level gaps in care to patients; b) identify facility level deviations from established standards of patient care; c) identify system-wide gaps in care to patients; and d) identify system-wide deviations from established standards of patient care.

METHODS:
The Colorectal Cancer Care Quality Measurement System collected data on patients from 28 VA facilities participating in C4 identified using a screening protocol using data from the Computerized Patient Record System (CPRS). This was the first component of the quality measurement system.

The project team in Durham, in cooperation with various VA constituencies (e.g. Oncology Field Advisory Committee), developed quality measures. A data collection tool was developed in Durham that enabled data from the multiple sources to be aggregated to create a report of the key quality indicators for colorectal cancer treatment. Given the variability of coding practices across sites, each site was provided with a blank data reporting tool, standardized coding conventions, and detailed instructions for populating the tool with fields required for determination of quality indicators. Once populated, the data were processed and quality performance reports were generated in conjunction with the sites and distributed. The quality measurement system has a modular design that will facilitate extension of the system to include additional quality indicators as needed.

Data was collected for patients diagnosed with colorectal cancer from January 1, 2004-December 31, 2007.

FINDINGS/RESULTS:
Data on approximately 1,400 veterans with colorectal cancer were entered into the Cancer Care Quality Measurement System. We found an even distribution of patients in each stage of CRC (I- 359, II- 385, III- 362, and IV- 269). At 98.7%, one of the highest scoring quality measures was the proportion of patients with non-metastatic node-positive colon cancer referred to medical oncologist who then received 5-FU based therapy. Medical centers also offered additional therapy (surgery, chemotherapy, or hospice) or documented a reason for not offering such treatment to 95.1% of colon cancer patients with metastases. 66.4% of patients with resected colon cancer had 12 lymph nodes examined by pathology per NCCN guidelines. At the other end of the spectrum, only 12.3% of stage II and III colon cancer patients with a preoperative obstructing lesion received a complete colonoscopy within 3-6 months of surgery or had a documented reason for not receiving procedure. It is important to note that these data were gathered at VA medical centers that participated in the Collaborative and may not be representative of the performance of VA as a whole.

IMPACT:
This effort supported the VA's goal of improving cancer diagnosis and care for our nation's veterans. Specifically, the project established a Cancer Care Quality Measurement System that can be disseminated throughout the VA healthcare system. The CCQMS improved VA's ability to specifically target and monitor cancer care quality improvement with the goal of optimizing care of veterans. While the initial focus was on colorectal cancer treatment within the VA, the system is also being expanded to for use in additional healthcare organizations. In the future, VA may be able to increase use of CCQMS for additional cancer types.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Partin MR, Powell AA, Nugent S, Ordin DL. Colorectal cancer diagnosis improvement project evaluation demonstrates the importance of using multiple measures to track progress toward timeliness goals. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2013 May 1; 35(3):41-8. [view]
2. Jackson GL, Powell AA, Ordin DL, Schlosser JE, Murawsky J, Hersh J, Ponte G, Zullig LL, Erb F, Parlier R, Haggstrom DA, Koets N, Mills PD, Francis J, Kelley MJ, Davies ML, Provenzale D, VA Colorectal Cancer Care Planning Committee Members. Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:38-43. [view]
3. Chao HH, Schwartz AR, Hersh J, Hunnibell L, Jackson GL, Provenzale DT, Schlosser J, Stapleton LM, Zullig LL, Rose MG. Improving colorectal cancer screening and care in the Veterans Affairs Healthcare system. Clinical Colorectal Cancer. 2009 Jan 1; 8(1):22-8. [view]
4. Phelan SM, Griffin JM, Jackson GL, Zafar SY, Hellerstedt W, Stahre M, Nelson D, Zullig LL, Burgess DJ, van Ryn M. Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer. Psycho-oncology. 2013 Jan 1; 22(1):65-73. [view]

Journal Other

1. Provenzale D, Jackson GL, Zullig LL. The Colorectal Cancer Quality Measurement System (CCQMS). [Abstract]. Gastroenterology. 2009 Mar 1; 136(suppl 1):M1035. [view]

Conference Presentations

1. Jackson G, Ordin D, Parlier R, Murawsky J, Kochevar L, Provenzale D. Building Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
2. Conner L, Jackson GL, Provenzale DT. Colorectal Cancer Care Collaborative: Cancer Care Quality Measurement System. Paper presented at: Association of VA Hematology/Oncology Annual Meeting; 2007 Aug 15; Alexandria, VA. [view]
3. Provenzale DT, Jackson GL. Colorectal Cancer Care Collaborative: Cancer Care Quality Measurement System. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2007 Apr 15; San Antonio, TX. [view]
4. Provenzale, Jackson, Zullig, Paynter. Colorectal Cancer Care Collaborative: Cancer Care Quality Measurement System. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2007 Oct 15; Las Vegas, NV. [view]
5. Jackson GL, Conner L, Powell AA, Provenzale DT. Colorectal Cancer Care Collaborative: Role of Research Partners. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2007 Apr 15; San Antonio, TX. [view]
6. Schlosser, Ordin, Provenzale, Jackson. Colorectal Cancer Care Improvement. Paper presented at: VA Oncology Field Advisory Committee Meeting; 2008 Jul 10; Washington, DC. [view]
7. Provenzale D, Jackson GL. Colorectal Cancer Diagnosis. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2005 Sep 1; Las Vegas, NV. [view]
8. Provenzale. CRC Treatment Improvement Collaborative: Cancer Care Quality Measurement System. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2007 Oct 15; Las Vegas, NV. [view]
9. Jackson GL, Zullig LL, Provenzale D, Powell AA. Developing and Sustaining Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative. Presented at: VA QUERI National Meeting; 2008 Dec 1; Phoenix, AZ. [view]
10. Jackson GL, Ordin DL, Zullig LL, Khwaja R, Powell AA, van Ryn M, Clauser SV, Provenzale D. Development and utilization of colorectal cancer care quality measures in an integrated delivery system. Poster session presented at: National Cancer Institute Multilevel Interventions in Health Care: Building the Foundation for Future Research Goals Conference; 2011 Mar 5; Las Vegas, NV. [view]
11. Jackson GL, Khwaja R, Paynter B, Zafar SY, Powell AA, Ordin DL, Garrett M, Gellad Z, Newlin CB, Conner L, Czarnecki T, Provenzale DT. Development of a Cancer Care Quality Measurement System: A VA Research-Operations Partnership. Paper presented at: Duke University Comprehensive Cancer Center Annual Meeting; 2007 Mar 20; Durham, NC. [view]
12. Conner LZ, Jackson GL, Paynter B, Khwaja R, Powell AA, Ordin DL, Gellad ZF, Zafar Y, Hamilton NS, Newlin CB, Provenzale DT. Development of a cancer care quality measurement system: a VA research-operations partnership. Presented at: Association of VA Hematology/Oncology Annual Meeting; 2008 Sep 7; Nashville, TN. [view]
13. Provenzale D. Focus on Colon Cancer: Colorectal Cancer Improvement Initiatives. Paper presented at: VA VISN 8 Cancer Annual Symposium; 2009 Aug 15; Washington, DC. [view]
14. Ordin, Hersh, Davies, Jackson. Improving Colorectal Cancer Care: Past, Present, Future. Paper presented at: VA Office of Quality and Performance Annual Quality Conference; 2008 Aug 1; Washington, DC. [view]
15. Jackson GL, Khwaja R, Paynter B, Powell AA, Bloomfield HE, Erb F, Hellings T, Koets N, Levesque O, Mills PD, Murawsky J, Nelson RA, Ordin DL, Parlier R, Schlosser J, Provenzale D. Linking measurement and Quality Improvement Across Primary and Specialty Care: Development of a Cancer Care Quality Measurement System. Paper presented at: VA Primary Care and Preventive Medicine Conference; 2006 Jul 1; Arlington, VA. [view]
16. Jackson GL, Zullig LL, Paynter B, Khwaja R, Powell AA, Ordin DL, Zafar SY, Gellad ZF, Newlin CB, Hamilton NS, Provenzale DT. Measuring the Quality of Colorectal Cancer Care in the Veterans Health Administration. Paper presented at: Association of VA Hematology/Oncology Annual Meeting; 2008 Sep 10; Nashville, TN. [view]
17. Powell AA, Ordin DL, Provenzale DT, Jackson GL, Bloomfield HE. Process Evaluation of the VA Colorectal Cancer Care Collaborative (C4) Pilot Project. Presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]
18. Provenzale D, Jackson GL, Zullig LL. The Colorectal Cancer Quality Measurement System (CCQMS). Paper presented at: Digestive Disease Week Annual Meeting; 2009 Jun 1; Chicago, IL. [view]
19. Zullig LL, Jackson GL, Provenzale D, Griffin J, Phelan S, van Ryn M. Transportation - A Vehicle or Roadblock to Cancer Care for VA Colorectal Cancer Patients? Presented at: University of North Carolina Chapel Hill Cecil G. Sheps Center Annual Seminar; 2012 Mar 12; Chapel Hill, NC. [view]
20. Jackson. Using Data Reports for Non-abstractors. Paper presented at: VA Colorectal Cancer Care Treatment Collaborative (C4) Biannual Learning Session; 2007 Oct 15; Las Vegas, NV. [view]
21. Provenzale D, Jackson GL, van Ryn M, Zullig LL, Ordin DL, Clauser SB. VA Cancer Quality Improvement Initiatives-Research Infrastructure. Poster session presented at: National Cancer Institute Multilevel Interventions in Health Care: Building the Foundation for Future Research Goals Conference; 2011 Mar 5; Las Vegas, NV. [view]
22. Gellad ZF, Provenzale D, Jackson GL, Garrett M, Zafar SY, Khwaja R, Paynter B, Powell AA. Variability of Access to Quality Colorectal Cancer Care in the VA Healthcare System. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 15; Arlington, VA. [view]

DRA: none
DRE: none
Keywords: Cancer, Quality assessment, Quality assurance, improvement
MeSH Terms: none