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:

None at this time.

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