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The ACOS, QA, and the Burden of Cancer

Dorothy Darcy, AS, CTR, Frank Schaberg, Jr., MD, and John P. Fulton, PhD

Published in: Medicine and Health/Rhode Island , 1997;80(4) 130-131

Dorothy Darcy, AS, CTR, is Director, Cancer Information System, Hospital Association of Rhode Island. Frank Schaberg, Jr., MD, is Surgeon-in-Chief, Memorial Hospital of Rhode Island, and Assistant Clinical Professor of Surgery, Brown University School of Medicine. John P. Fulton, PhD, is Acting Associate Director, Division of Disease Prevention and Control, Rhode Island Department of Health, and Clinical Associate Professor, Brown University School of Medicine.

Reducing Cancer Mortality with State-of-the-Art Cancer Therapy

In 1986, the National Cancer Institute (NCI) published Cancer Control Objectives for the Nation: 1985-2000. (1) The NCI made a convincing case for the widespread adoption of state-of-the-art cancer therapy, arguing that doing so would reduce the overall cancer mortality rate in the U.S. by 26 percent. In comparison, it was estimated that universal adoption of proven cancer screening tests, including the mammogram, clinical breast exam, and the Pap test, would reduce the overall cancer mortality rate in the U.S. by only 3 percent.

Two Approaches

The NCI suggested a variety of strategies to promote state-of-the-art cancer therapy. Two key strategies were adapted and incorporated into Rhode Island’s official cancer control plan, published in 1989. (2) First, the plan recommended enrollment of eligible patients in approved clinical trials, reasoning that all of the major advances in the treatment of cancer in the last two decades have been the result of randomized prospective controlled studies. The population of Rhode Island has benefited greatly from these studies. Second, the plan recommended voluntary adoption of American College of Surgeons’ (ACOS) approved cancer programs at all acute care hospitals in the State, reasoning that a coordinated collaborative approach to clinical cancer care with multidisciplinary input prior to the initiation of care would optimize treatment for our cancer patients. Although both strategies are important, the second has greater significance for reducing the burden of cancer, because it has universal impact on the thousands of cancer patients in Rhode Island. The first affects only a few hundred patients who may be eligible for clinical trials at any one time.

Progress since 1989

In the intervening years, both recommendations have guided the development of cancer control policy in Rhode Island. At the request of a state senator and a group of concerned constituents, the Rhode Island General Assembly established a commission to study the reimbursement of experimental cancer treatment programs by third party health insurers. Eventually, the work of the commission resulted in a 1993 law which guaranteed health insurance coverage for experimental cancer treatment as part of phase III and phase IV clinical trials. More recently, a number of acute care hospitals have moved to establish ACOS approved cancer programs. In 1989, when the cancer control plan was published, six of 11 private, acute care hospitals in the State (excluding the VA Hospital and the Naval Hospital) had approved cancer programs. Currently, the remaining five are positioning themselves for approval. It is key for the quality of cancer therapy in Rhode Island that this process continues until all private, acute care hospitals in the State achieve ACOS approval.

The ACOS and QA

The purpose of an ACOS approved cancer program is to assure "that the atmosphere and organization exist within the institution to offer optimal care to the patient with cancer." The essence of an ACOS approved cancer program is active quality assurance, based on four program components, a multidisciplinary cancer committee, multidisciplinary cancer conferences, patient care studies, and a cancer registry. Each of these components has a unique role to play in assuring the quality of cancer therapy in an institution.

• The multidisciplinary cancer committee provides leadership to the overall program. They maintain the vision of "optimal care to the patient with cancer," advocating for improved cancer care through quality assurance (including assessment, intervention, and evaluation).

• Multidisciplinary cancer conferences are held weekly or monthly, depending on caseload, to remove barriers to coordinated care. Physicians, nurses, social workers, the hospital tumor registrar, and other professionals attend the conferences, examining approaches to cancer therapy for those cancers seen in the institution, and discussing individual cases.

• Two patient care evaluations are performed annually, to assess approaches to cancer therapy in the institution, and to recommend improvements. Topics for evaluation are selected by the cancer committee, based upon the quality-of-care priorities it has identified. A cancer program may elect to participate in national cancer studies run by the Commission on Cancer, an organization established by the American College of Surgeons and expanded to include members from more than 30 professional associations in the United States.

• A tumor registry is established and maintained to track all cases of cancer diagnosed or treated in the institution. The registry provides quantitative information on disease, patient demographics, components of therapy, and survival.

The Tumor Registry: Key QA Tool

The tumor registry is the key quality assurance tool used by the cancer committee to perform quantitative evaluations of cancer diagnosis and therapy. Its purpose is to track all tumors from the date of diagnosis to the date of death (from any cause). Data from the tumor registry may be used to describe caseload, disease type and severity, the selection and coordination of therapies, patient status, and survival. The tumor registry may also be used to track patients, assuring that follow-up treatments and examinations are performed on schedule, and that overall continuity of care is preserved.

Maintaining a tumor registry is a labor intensive task, even when modern computers are used to input, aggregate, and analyze data, and comprises the main cost of ACOS approval. Establishing an effective tumor registry is usually the main stumbling block to implementing an approved cancer program.

Statewide Registry Support

Realizing the importance of tumor registries in hospital cancer program approval, the Hospital Association of Rhode Island (HARI) offers basic support for hospital tumor registries. Currently, 9 of 11 private, acute care hospitals in the State are enrolled in HARI’s Cancer Information System (CIS), from which they receive:

• Ongoing training and consultation for tumor registrars,

• Assistance with the complete, accurate collection of all data elements,

• Assistance with patient follow-up,

• Computerized death certificate searches, crucial to the efficient maintenance of adequate patient follow-up rates,

• Regional data aggregates against which a hospital’s data may be compared, and

• Consultation on computerized registry operations.

The Rhode Island Department of Health, in close collaboration with HARI’s CIS, also supports hospital tumor registries through a statewide cancer registry established by the Rhode Island General Assembly in 1985. The Rhode Island Cancer Registry (RICR) performs regular evaluations of the completeness and accuracy of hospital tumor registry data, provides tumor registry software to all acute care hospitals in Rhode Island, and produces official cancer incidence and mortality rates for the State.

Physician Support

Physician support is key to the existence of voluntary ACOS approved cancer programs. Programs begin with physician concern for the quality of cancer therapy. Physician advocacy drives program development and maintenance. Physicians specializing in cancer therapy form the nucleus of the cancer committee. Their belief in a multidisciplinary approach to cancer therapy is essential to the success of multidisciplinary cancer conferences. Physicians from all disciplines are asked to report periodic information on patient status to the tumor registry.

Physicians in Rhode Island are urged to support the development and maintenance of approved cancer programs at their hospitals. The ACOS approach to optimizing the quality of cancer therapy is voluntary, practical, and effective. It was developed by physicians and is respectful of their traditional and fundamental role in cancer therapy, while promoting a useful, widely accepted multidisciplinary approach to cancer therapy, its assessment, and improvement.

Physicians are not alone in this endeavor. The Hospital Association has developed effective support for tumor registries and stands ready to advise cancer committees on the collection and use of effective quality assurance data. The Hospital Association has also developed a successful collaboration with the Department of Health on the Rhode Island Cancer Registry, thereby creating effective linkages to additional technical resources. Assuring state-of-the-art cancer therapy for all cancer patients in Rhode Island is achieveable. Let’s do it.

References

1. National Cancer Institute. Cancer control objectives for the nation: 1985-2000. NCI Monographs. Number 2. Bethesda, Maryland: National Cancer Institute, 1986.

2. Rhode Island Department of Health. Cancer control Rhode Island. Plan for 1990-1992. Providence, Rhode Island: Rhode Island Department of Health, 1989.