Journal of the National Cancer Institute Advance Access originally published online on January 8, 2008
JNCI Journal of the National Cancer Institute 2008 100(2):86-91; doi:10.1093/jnci/djm316
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© Oxford University Press 2008.
NEWS |
PRACTICE, PRACTICE, PRACTICE
Key to Finding Quality Cancer Hospitals and Surgeons Is Finding Out How Much They Practice
A person newly diagnosed with cancer has enough things to worry about without having to struggle to find the best care. Many just go to whomever their primary physician recommends. But people who want to make more informed choices have a hard time finding out who is the best.
In this age of answers a mouse click away, patients must do some old-fashioned phone calling and digging to get the facts they need to find the best doctor. And the facts they can get on the Internet or from organizations aren’t what they really need, although those resources might do a good enough job pointing out the better hospitals and surgeons until health care organizations get together and provide data that consumers can use. Those data might include the number of surgeries performed at a hospital, which tells you generally about the quality of care you might expect. But cancer research organizations are pushing for new systems that will better monitor how well hospitals and surgeons perform.
Experts are more aware than consumers of the shortcomings of the current system. Says surgeon John Birkmeyer, M.D., of the University of Michigan in Ann Arbor, "You want a Web site where you can punch in your ZIP code and get rates of survival, a Web site that would be reliable for profiling a hospital or surgeon. Those data are not available—not because anyone's hiding anything, but there's no large-scale database that includes it all."
No Easy Answers
Even Web sites that purport to give valuable information aren’t as useful as surgeons think they should be, says Lee Newcomer, M.D., senior vice president of United Health Care Oncology in Minneapolis. "There aren’t a whole lot of options" for patients or physicians, he says.
This might not be such a problem if health care were universally great. But a 2006 study in the Journal of Clinical Oncology that looked at the quality of cancer care found that patients received only about 78%–86% of the current recommended care for several different cancers. Another recent study revealed a wide disparity between the best and the worst cancer care. "The quality varies to a far greater extent than people think," says pulmonologist Peter Bach, M.D., of Memorial Sloan-Kettering Cancer Center in New York City.
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Consumer Web sites such as those of Healthgrades.com and WebMD, and even Medicare, do compile some data such as the complication rates of hospitals and how long people stay. For example, the Centers for Medicare and Medicaid Services tracks doctors with the Medicare Quality Monitoring System, but those reports are not something one could easily use to identify names and numbers. "There's no data on outcomes at all," Newcomer says. He questions the value of those databases for certain cancers. "When it comes to breast cancer and lumpectomies, there are hardly any complications."
Birkmeyer points out that the National Cancer Institute maintains a database called SEER (Surveillance, Epidemiology, and End Results), from which you can pull detailed information about the prognosis of cancer by type and by how far along it is. "But there hasn’t been a priority to give outcome data [for surgeons and hospitals]," he says, adding, "and it may be politically sensitive to do so."
Although the data on outcomes are not readily available, that doesn’t mean such data do not exist. "We do have very good information on outcomes in hospitals’ tumor registries," Newcomer says. But whether the hospitals allow people to access those data is entirely up to the hospital. For Newcomer's hospital system, Park Nicollet Health Services, their registry is open.
But even with open access, such registries aren’t easy for laypeople to use, and even cancer care Web sites such as WebMD require some background to understand the data. "The ease of use of the system has not reached the level of the data that argues for transparency," Bach says. "It's really hard for the patient." The National Comprehensive Cancer Network provides information on what a patient is to expect, but its guidelines don’t rate individual hospitals and doctors.
Some Help Available
Cancer patients should not turn away from surgery in despair. Birkmeyer says that indirect measures can provide at least a step in the right direction. He cites two variables that have been directly associated with outcomes: how many surgeries have been done at a hospital and whether the hospital has gotten a blessing from the National Cancer Institute.
"The biggest is the experience of that particular hospital with that particular cancer. That's an indication not only of outcome at time of surgery but also prospects for survival many years later," he says.
Many studies back up this assertion. For example, Birkmeyer published a study in Annals of Surgery that showed the odds for surviving throat cancer were 34% at hospitals that performed a high volume of procedures versus 17% at hospitals that did a low volume. "Volume is more important than other choices patients have to make, like whether to get chemotherapy and radiation," Birkmeyer says. "And it's not as toxic."
Bach found similar results for lung cancer. He reported in the New England Journal of Medicine in 2001 that after 5 years, 44% of patients at hospitals who performed between 67 and 200 operations a year were still alive. This finding compared with 33% of patients at hospitals that performed between one and eight procedures. The benefits didn’t stop at long-term outcomes. The highest-volume hospitals had half the rates of complications and 30-day mortality as the lowest-volume institutions.
Another indicator of quality is whether the hospital has been designated a "center of clinical or research excellence" by the NCI, Birkmeyer says. "They’ve invested in more than 50 hospitals," he says. A 2004 study in Cancer by Birkmeyer and his colleague Nancy Birkmeyer compared 51 of these centers of excellence to other hospitals of similar size and volume. In almost all outcomes, the designated cancer centers came out better. The big advantage didn’t hold up over time, though, he says. "The difference in the long run was quite small," he says.
Surgeons at the best hospitals are not necessarily the best doctors, and Birkmeyer says that it's also important for the individual surgeon to have a lot of experience. A study in August 2007 in JNCI (J Natl Cancer Inst 2007;99:1171–7) showed that patients whose doctors had done more than 250 prostate surgeries were 70% more likely to be cancer free in 5 years than were patients whose doctors had done fewer than 10. The authors of the study refer to this result as a "learning curve" and consider surgeons to be masters in prostate cancer surgery after about 250 operations. "Also, surgeons with higher volume tend to do better in terms of other complications that don’t kill you but make your life miserable," Birkmeyer says, citing incontinence after prostate cancer surgery as an example.
What counts as high volume for a surgeon isn’t the same for every cancer, Newcomer says. For example, esophageal cancer patients do better with surgeons who perform more than 15 operations a year, he says. The difference in performance numbers may be due to how common a cancer is and therefore how much opportunity surgeons have to practice. But so far, no one has determined the learning curves for the whole range of cancers.
Even if patients can’t find that information, they can find out if their doctor has specialized in their surgery of interest. "Independent of volume, patients getting surgery by a specialist do better than [those treated by] a generalist," Birkmeyer says. Specialists in thoracic surgery lose one-third fewer patients than do generalists performing the same procedure.
"For ovarian cancer, gynecological oncologists clearly do best. For rectal, surgeons who are specialists in colorectal cancer are better. Going to a subspecialist definitely makes a difference," Newcomer says.
Some experts think that consumers won’t ever have full access to data—and that surgeons and hospitals won’t keep track of it—until some sort of mandatory reporting system is put into place. Bach says surgeons are wary of being graded. "Doctors generally resist being portrayed in that way," he says. Surgeons argue that their performance might be due to factors beyond their control, such as the socioeconomic status of their patients or how their patients are monitored by other doctors, Newcomer says.
However, Bach said that mandatory reporting would benefit everyone. "Everyone would be pleased to get better information on quality. Surgeons would also get information on shortfalls, and this would give them incentives to improve," he says.
Until an easy-to-use system is in place, the experts say consumers are vulnerable if they don’t ask their surgeons about their experience and skills. "There's nothing protecting consumers from a surgeon who doesn’t tell the patient you’re his first case," Newcomer says. Sometimes surgeons will keep track of their own performance, but they aren’t required to and don’t always know how many operations they’ve done.
It's not easy to give advice to patients when even the surgeons themselves are in the dark. "We’re struggling with this. When do we tell patients that they should be going to see another surgeon?" Newcomer says. "If someone calls me from Dallas asking for a recommendation for an esophageal surgeon, I’m sure there's someone in Dallas who does more than 15 procedures a year, but I don’t know [that person]." Even so, Newcomer says that sometimes patients need to find an advocate to help them find the facts. "The best way is to find someone in the medical community who is going to be making some calls for you," he says.
Birkmeyer adds that some states have patient advocacy groups that could be helpful as well. And if the patient must choose between an experienced surgeon and a highly ranked hospital, he says it's better to go with the surgeon.
Even with the obvious need, the experts aren’t sure if outcome data for cancer surgery will ever become available. One could argue that better outcomes might save money over time—although the studies haven’t been done. Even so, "How do you count your costs?" Birkmeyer asks. Perhaps if patients—or maybe insurance companies, which pay for all those complications—start clamoring for open records, change might happen. "They should make the data from all the hospitals transparent. It's a great way to compete," Newcomer says.
| Web Sites to Help Patients Find Quality Care These consumer- and physician-oriented Web sites include various measures of care quality. HealthGrades: http://www.healthgrades.com Leapfrog hospital ratings: http://www.leapfroggroup.org/for_consumers NCI-designated cancer centers and comprehensive cancer centers: http://cancercenters.cancer.gov/cancer_centers/cancer-centers-names.html SEER program: http://seer.cancer.gov/statistics/ Medicare's Medical Quality Monitoring System: http://www.cms.hhs.gov/QualityInitiativesGenInfo/15_MQMS.asp WebMD's Cancer Health Center: http://www.webmd.com/cancer/default.htm American College of Surgeons Commission on Cancer: http://www.facs.org/cancer
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