Beyond mammograms: Outcomes project raises the bar on cancer care
Centers measure needle biopsies, breast-conserving surgery
If you provide mammograms to more women who need them, then you will increase the rates of early detection of breast cancer, saving money and lives. That is the premise behind making mammograms an indicator of clinical performance.
But what happens to those breast cancer patients after they are diagnosed? Are they receiving breast-conserving surgery? Are they living longer?
While many medical groups are struggling just to track their mammography rates, Sutter Health in Sacramento, CA, is proving that more detailed outcomes measurement can shape clinical practice. Sutter is tracking data on patient satisfaction and functioning as well as six clinical indicators, including stage at diagnosis, breast conserving surgery, five-year disease-free survival, and needle biopsy rate.
"We have markedly improved care for women and saved dollars," says Gale Katterhagen, MD, medical director of the Mills Peninsula Medical Center Cancer Program and Breast Center in San Mateo, CA, and Sutter's medical director for quality. "Our motto is that quality costs less."
For example, treating breast cancer in Stage 0 or I costs an estimated $18,900 to $23,200, vs. $60,500 at Stage III, notes Katterhagen. Almost three-quarters of breast cancer cases diagnosed at the Mills Peninsula center in the first half of 1997 were Stage 0 or I, and only 4% were Stage III or IV.
Moving beyond mammograms requires a strong commitment to outcomes measurement and quality improvement. But the task is made easier by cancer registries that exist, by law, around the country. Hospitals often maintain these registries, which include the patient name, treating physician, stage of cancer, and other clinical information.
Sutter used the cancer registries to gain much of the data for the Breast Project, which was based on the breast cancer measurement set of the Foundation for Accountability in Portland, OR.
"We started out just looking at mammography rates, as many others have for HEDIS [Health Plan Employer Data and Information Set - the National Committee for Quality Assurance's effectiveness of care measures], but that told us just one piece of information," says Krystin Gregory, RN, director of clinical integration. "The whole purpose of screening mammograms is to catch cancer early so it's the most treatable and the most curable," she says. "That's the outcome we want to achieve for our patients."
Docs felt uneasy with benchmarks
Being a pioneer in performance measurement isn't easy. Beyond the technical headaches of defining the indicators and collecting the data, Katterhagen faced some friction from physicians about the project itself.
Some physicians felt threatened by the measurement. "Some of our benchmarks were [created] on the basis of taking our performance last year and raising the bar," he says. "This was very traumatic for many of our physicians. Physicians or health professionals are not used to quantifying targets or outcomes."
Concerns have diminished as physicians see that the measurement is a step toward quality improvement. "They realize [the outcomes project] is one of the unique strengths of our program," Katterhagen says.
As the eight centers compare their quarterly results from 1996 and 1997, differences in treatment become immediately apparent.
For example, the project prompted discussion about the wide variation in axillary dissection rates for ductal carcinoma-in-situ in which lymph nodes are removed. Katterhagen, a medical oncologist, notes that axillary dissection isn't medically necessary or appropriate for those early stage cancers. Yet the rates at Sutter's eight breast cancer centers have ranged from 0% to 50%.
By following needle biopsy rates, Katterhagen discovered that four of the breast centers didn't have the stereotactic equipment to perform the procedure. After raising the issue with Sutter's senior management, the health system purchased four new stereotactic tables.
Such simple solutions are rare. "The performance of the eight hospitals is proportionate to the strength and capability of the local medical leaders," he says.
"If your physician leadership is weak, your program will be weak. If your physician leadership strong, your program will be strong."
Few guideposts for expected performance
What is Sutter's expected level of performance? That question has been one of the thorniest issues in the outcomes project.
Since established benchmarks didn't exist for many measures, project leaders set them based on medical literature, past performance, and established clinical guidelines. The ultimate goal was to push the physicians and centers toward improvement, while understanding that factors such as patients' treatment preferences might influence rates.
"It took us months to work out what we really want to know," says Gregory. "Are we catching the cancer early by mammography? We can tell that by the stage at diagnosis."
Sutter set targets related to cancer stage. For example, one target states that at least 35% of Class I tumors - those cases originating in the Sutter system - should be 1 cm or less. In the first half of 1997, the actual rate was 28%. (For more information on targets, see graphs, p. 68.)
In 1991, a consensus conference of the National Cancer Institute in Bethesda, MD, stated that the majority of women with early stage breast cancer should have breast conserving surgery - a lumpectomy with radiation therapy. Sutter set its target at 65% of Stage I and II cancers that were 5 cm or smaller.
"We knew from the previous year that our system record was 60% to 61%," says Katterhagen. "We raised the bar a few percentage points."
Yet the selection of a precise number raised debate. Why not 68%? Or 63%? Sutter's Clinical Leadership Council, comprised of medical directors from the system's 13 medical groups, eventually approved the benchmarks.
In 1996 and the first half of 1997, the centers overall met the 65% target. One had a rate as high as 75%; the lowest rate was 46%.
"My argument is not that the breast conservation rate should be 68% or 65%. The woman should be involved in the decision," says Katterhagen.
Some will opt out of radiation
He notes that some women will prefer not to undergo radiation therapy, required after the lumpectomy. Rates also may vary among communities based on cultural factors. But Katterhagen adds, "If women of all ages understand their options, the majority will opt for breast conservation."
The breast project gave Sutter a wealth of knowledge about how its centers care for patients and where there is room for improvement. But it hasn't diminished the focus on screening mammograms.
Numbers alone reveal the importance of screening. In California - about one in six women are diagnosed with breast cancer.
"The most important thing is for the primary care physician to order the mammogram," says Katterhagen.
Sutter recently entered into a partnership with Merck Pharmaceutical to provide laminated cards to physicians. One side provides the screening guidelines. The other shows the survival rate of breast cancer from Stage 0 to Stage IV over a 10-year period.
"The message is that mammography influences stage, and stage dictates survival. In other words, mammography dictates survival," says Katterhagen. "All these other things don't happen unless the woman gets a mammogram."
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