Second-opinion pathologic review is a patient safety mechanism that helps reduce error and decrease waste.

PURPOSE: We have a crisis in health care delivery, originating from increasing health care costs and inconsistent quality-of-care measures. During the past several years, value-based health care delivery has gained increasing attention as an approach to control costs and improve quality. One proven way to control costs and improve the quality of health care is subspecialty pathologic review of patients with cancer before initiation of therapy. Our study examined the diagnostic error rate among patients with cancer treated at a tertiary care hospital and demonstrated the value of subspecialty pathologic review before initiation of treatment. METHODS: From September 1 to September 30, 2011, all patients seeking a clinical consultation had pathology submitted to and reviewed by a pathologist with subspecialty expertise and correlated in our pathology database. RESULTS: A total of 2,718 patient cases were reviewed during September 2011. There was agreement between the original pathologist and our departmental subspecialty pathologist in 75% of cases. In 25% of cases, there was a discrepancy between the original pathology report and the subspecialty final pathology report; 509 changes in diagnosis were minor discrepancies (18.7%), and in 6.2% of patients (169 reports), the change in diagnosis represented a major discrepancy that potentially affected patient care. CONCLUSION: Second review of a patient's outside pathology by a subspecialist pathologist demonstrates the value of multidisciplinary cancer care in a high-volume comprehensive cancer center. The second review improves clinical outcomes by providing patients with evidence-based treatment plans for their precise pathologic diagnoses.

Developing a system to track meaningful outcome measures in head and neck cancer treatment.

BACKGROUND: The health care industry, including consumers, providers, and payers of health care, recognize the importance of developing meaningful, patient-centered measures. This article describes our experience using an existing electronic medical record largely based on free text formats without structured documentation, in conjunction with tumor registry abstraction techniques, to obtain and analyze data for use in clinical improvement and public reporting. METHODS: We performed a retrospective analysis of 2467 previously untreated patients treated with curative intent who presented with laryngeal, pharyngeal, or oral cavity cancer in order to develop a system to monitor and report meaningful outcome metrics of head and neck cancer treatment. Patients treated between 1995 and 2006 were analyzed for the primary outcomes of survival at 1 and 2 years, the ability to speak at 1 year posttreatment, and the ability to swallow at 1 year posttreatment. RESULTS: We encountered significant limitations in clinical documentation because of the lack of standardization of meaningful measures, as well limitations with data abstraction using a retrospective approach to reporting measures. Almost 5000 person-hours were required for data abstraction, quality review, and reporting, at a cost of approximately $134,000. Our multidisciplinary teams document extensive patient information; however, data is not stored in easily accessible formats for measurement, comparison, and reporting. CONCLUSION: We recommend identifying measures meaningful to patients, providers, and payers to be documented throughout the patients' entire treatment cycle, and significant investment in the improvements to electronic medical records and tumor registry reporting in order to provide meaningful quality measures for the future.

Pretreatment patient comorbidity and tobacco use increase cost and risk of postoperative complications after esophagectomy at a high-volume cancer center.

PURPOSE: Understanding the mechanisms and drivers of cost is a key component of improving the value of cancer care at both the system and patient level. Previous research on the cost of esophagectomy has established important postoperative drivers of cost; however, no study has linked pretreatment patient characteristics with cost. We sought to identify pretreatment patient characteristics that increase inpatient cost, length of stay, and risk of anastomotic leak and major pulmonary event (MPE) after esophagectomy for locally advanced esophageal adenocarcinoma. METHODS: We identified 191 patients with locally advanced esophageal adenocarcinoma treated with trimodality therapy at our institution between January 2002 and December 2008. All patients underwent espophagectomy 6 to 8 weeks after completion of neoadjuvant therapy. Multiple linear regression models were used to identify pretreatment predictors of total cost and length of stay. Multivariable logistic regression was used to identify pretreatment factors associated with leak and MPE. RESULTS: Pretreatment comorbidity (ß=0.1215, P=.039) and history of tobacco use (ß=0.0022, P=.028) significantly increased cost of esophagectomy. A comorbid condition increased total cost by 12.9%. Comorbidity (ß=0.2597, P=.001) and poor performance status (ß=0.1514, P=.021) were also significantly associated with prolonged length of stay. Patients with a higher comorbidity score had an increased risk of anastomotic leak (odds ratio, 6.564; 95% CI, 1.676 to 25.716) and MPE (odds ratio, 2.732; 95% CI, 1.317 to 5.666). CONCLUSION: Pretreatment patient comorbidity and tobacco use increases cost and risk of postoperative complications after esophagectomy. Other institutions must examine the relationship between their own costs and outcomes as cancer care delivery and payment systems become integrated at a national level.

Measuring the value of process improvement initiatives in a preoperative assessment center using time-driven activity-based costing.

BACKGROUND: The value and impact of process improvement initiatives are difficult to quantify. We describe the use of time-driven activity-based costing (TDABC) in a clinical setting to quantify the value of process improvements in terms of cost, time and personnel resources. PROBLEM: Difficulty in identifying and measuring the cost savings of process improvement initiatives in a Preoperative Assessment Center (PAC). GOALS: Use TDABC to measure the value of process improvement initiatives that reduce the costs of performing a preoperative assessment while maintaining the quality of the assessment. STRATEGY: Apply the principles of TDABC in a PAC to measure the value, from baseline, of two phases of performance improvement initiatives and determine the impact of each implementation in terms of cost, time and efficiency. RESULTS: Through two rounds of performance improvements, we quantified an overall reduction in time spent by patient and personnel of 33% that resulted in a 46% reduction in the costs of providing care in the center. The performance improvements resulted in a 17% decrease in the total number of full time equivalents (FTE's) needed to staff the center and a 19% increase in the numbers of patients assessed in the center. Quality of care, as assessed by the rate of cancellations on the day of surgery, was not adversely impacted by the process improvements.

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America.

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.

The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery.

In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. This legislation attempts to address cost control and improve the quality of healthcare in the United States. Cancer is a major health problem in the United States and the leading cause of death for Americans under the age of 80. Therefore, cancer care providers need to be fully engaged in ongoing discussions regarding quality measurement and care delivery. With the optimum level of collaboration and support, the proposals in the legislation can be properly structured to deliver improved access to care via better delivery systems, as well as more appropriate reimbursement to advance the prevention and treatment of cancer.