Improving outcomes starts with lots and lots of data
Look for long-term results
Measuring clinical outcomes is becoming a necessity for today’s physician, asserts Marilyn Haas, PhD, RN, ANP-C, nurse practitioner/outcomes analyst for Mountain Radiation Oncology in Asheville, NC.
"With managed care, we need to be demonstrating high-quality medical care and controlling the costs at the same time," says Haas, who embarked on a long-term outcomes measuring project three years ago.
The practice started the project to meet consumer and managed care plans’ demands for outcomes information as a way to get a handle on costs, and because of accreditation requirements for performance measures and documentation of outcomes, Haas says.
"We knew we needed to be collecting our own clinical outcomes and measuring patient satisfaction and quality of life — what we hadn’t monitored beyond morbidity and mortality. We were interested in monitoring what had happened to patients and what the treatment was doing to improve the patients’ quality of life," she adds.
It’s a long-term process, she adds. After three years, she is just beginning to compile enough data to analyze.
"An outcomes program is encompassing. It goes beyond just demographic information. It should contain clinical data, short- and long-term complications, patient satisfaction, quality of life, and financial costs," Haas says.
The oncology practice chose to evaluate data for patients who are being treated for 10 common cancer areas: brain, breast, cervix, esophagus, palliative, lung, prostate, rectum, uterus, and vocal cord.
To develop the outcomes measuring program, Haas started by working with the physicians to set up broad clinical guidelines for treating each of the 10 areas.
Haas and the physicians reviewed literature and national treatment guidelines, which they combined with the physicians’ treatment management protocols. They came up with practice guidelines that have four components: standard workup, intervention, follow-up frequency, and outcomes monitoring.
"It was a long process. We had to get consensus as to how they were going to treat that disease. We did it in a broad range and tried to encompass everyone’s training, education, and background," Haas says.
The practice tried to look at variances in treatment between physicians to find common ground, Haas says. However, Haas anticipates possibly being able to identify more effective types of treatment when she has five years of data.
"We have two physicians who treat breast cancer differently. It will be interesting to see the five-year follow-up data," she says.
The practice monitors patients prior to treatment, and at one month, six months, and annually after treatment for five years.
The next step was to develop a survey for the information that would be entered into the outcomes monitoring database. Components include demographic and risk characteristics, interventions, patient-reported outcomes, and direct clinical outcomes. They are linked to Relative Value Units billing and other financial information.
The survey form extrapolated information from the practice guidelines. For instance, components of the standard workup are in the survey in a check-off format.
Haas developed a questionnaire that could be scanned to save personnel time. Physicians, nurses, billing personnel, and patients collect the data. Most of the information is contained in check boxes. Patients are asked to fill out the Medical Outcomes Short Form 36 which rates their perception of their health, functional measures, quality of life, and pain scales.
Over time, Haas expects more than 1,200 items in each patient record.
Among the outcomes the practice monitors are skin reaction to radiation treatment, how the patients tolerate the treatment, and if they are getting better or worse after treatment.
"We tried to keep it very broad," Haas says.
One aim of the outcomes studies is to see if there is a way to lower cost while keeping the quality of care high.
"With the three years of data we’re now analyzing, I can’t say that there has been cost savings. It has given us some understanding of quality of life and patient satisfactions. We have changed the way we do some things based on satisfaction levels and their areas of improvement," she says.
| Outcomes Database Components | |
| Standard workup | Pathology, operative report, laboratory studies, imaging studies, significant history and physical findings, staging information. |
| Treatment | Equipment used, treatment prescription, radiation guidelines, re-simulations, immobilization aids. |
| Outcomes measures | Patient demographics, risk assessment, functional status, pain perception, cost profile, patient satisfaction. |
| Clinical outcomes | Short- and long-term complications, quality of life, employment status, medical and surgical interventions, hospitalization, treatment interruptions. |
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