Journal Article
. 2017 Nov;4(2).
doi: 10.1001/jamaoncol.2017.3803.

Critical Lessons From High-Value Oncology Practices

Douglas W Blayney 1 Melora K Simon 2 Beatrice Podtschaske 2 Scott Ramsey 3 Margaret Shyu 2 Craig Lindquist 2 Arnold Milstein 2 
  • PMID: 29145584
  •     24 References
  •     4 citations


Importance: Cancer care is expensive. Cancer care provided by practice organizations varies in total spending incurred by patients and payers during treatment episodes and in quality of care, and this unnecessary variation contributes to the high cost.

Objective: To use the variation in total spending and quality of care to assess oncology practice attributes distinguishing "high value" that may be tested and adopted by others to produce similar results.

Design, Setting, And Participants: "Positive deviance" was used in this exploratory mixed-methods (quantitative and qualitative) analysis of interview results. To quantify value, oncology practices located near the US Pacific Northwest and Midwest with low mean insurer-allowed spending were identified. Among those, practices with high quality were selected. A team then conducted site visits to interview practice personnel from June 2, 2015, through October 3, 2015, and to probe for attributes of high-value care. A qualitative analysis of their interview results was performed, and a panel of experienced oncologists was convened to review attributes occurring uniquely or frequently in low-spending practices for their contribution to value improvement and ease of implementation. Four positive deviant (ie, low-spending) oncology practices and 3 oncology practices that ranked near the middle of the spending distribution were studied.

Main Outcomes And Measures: Thematic saturation in a qualitative analysis of high-value care attributes.

Results: From the 7 oncology practices studied, 13 attributes within the following 5 themes emerged: treatment planning and goal setting, services supporting the patient journey, technical support and physical layout, care team organization and function, and external context. Five attributes (ie, conservative use of imaging, early discussion of treatment limitations and consequences, single point of contact, maximal use of registered nurses for interventions, and a multicomponent health care system) most sharply distinguished the high-value practice sites. The expert oncologist panel judged 3 attributes (ie, early and normalized palliative care, ambulatory rapid response, and early discussion of treatment limitations and consequences) to carry the highest immediate potential for lowering spending without compromising the quality of care.

Conclusions And Relevance: Oncology practice attributes warranting further testing were identified that may lower total spending for high-quality oncology care.

The growing power of some providers to win steep payment increases from insurers suggests policy remedies may be needed.
Robert A Berenson, Paul B Ginsburg, Jon B Christianson, Tracy Yee.
Health Aff (Millwood), 2012 May 09; 31(5). PMID: 22566436
American medical home runs.
Arnold Milstein, Elizabeth Gilbertson.
Health Aff (Millwood), 2009 Sep 10; 28(5). PMID: 19738247
In search of joy in practice: a report of 23 high-functioning primary care practices.
Christine A Sinsky, Rachel Willard-Grace, +3 authors, Thomas Bodenheimer.
Ann Fam Med, 2013 May 22; 11(3). PMID: 23690328    Free PMC article.
Highly Cited.
Baseline Estimates of Adherence to American Society of Clinical Oncology/American Board of Internal Medicine Choosing Wisely Initiative Among Patients With Cancer Enrolled With a Large Regional Commercial Health Insurer.
Scott D Ramsey, Catherine Fedorenko, +4 authors, Aasthaa Bansal.
J Oncol Pract, 2015 Jun 11; 11(4). PMID: 26060225
Quality oncology practice initiative certification program: overview, measure scoring methodology, and site assessment standards.
Kristen K McNiff, Katherine R Bonelli, Joseph O Jacobson.
J Oncol Pract, 2009 Nov 01; 5(6). PMID: 21479069    Free PMC article.
Development and future of the American Society of Clinical Oncology's Quality Oncology Practice Initiative.
Douglas W Blayney, Kristen McNiff, +6 authors, Joseph Simone.
J Clin Oncol, 2014 Sep 17; 32(35). PMID: 25225418
A process for measuring the quality of cancer care: the Quality Oncology Practice Initiative.
Michael N Neuss, Christopher E Desch, +8 authors, Joseph V Simone.
J Clin Oncol, 2005 Aug 10; 23(25). PMID: 16087948
Qualitative research in health care. Analysing qualitative data.
C Pope, S Ziebland, N Mays.
BMJ, 2000 Jan 22; 320(7227). PMID: 10625273    Free PMC article.
Highly Cited. Review.
Perceived quality of interprofessional interactions between physicians and nurses in oncology outpatient clinics.
Charlotte T Lee, Diane M Doran, Ann E Tourangeau, Neil E Fleshner.
Eur J Oncol Nurs, 2014 Jul 19; 18(6). PMID: 25035193
The cost-quality trade-off: need for data quality standards for studies that impact clinical practice and health policy.
Jennifer L Malin, Nancy L Keating.
J Clin Oncol, 2005 Apr 27; 23(21). PMID: 15851767
Underutilization of gene expression profiling for early-stage breast cancer in California.
Rosemary D Cress, Yingjia S Chen, +2 authors, Kenneth W Kizer.
Cancer Causes Control, 2016 Apr 22; 27(6). PMID: 27097910    Free PMC article.
What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study.
Leslie A Curry, Erica Spatz, +6 authors, Elizabeth H Bradley.
Ann Intern Med, 2011 Mar 16; 154(6). PMID: 21403074    Free PMC article.
Highly Cited.
What is value in health care?
Michael E Porter.
N Engl J Med, 2010 Dec 15; 363(26). PMID: 21142528
Highly Cited.
Episode Treatment Groups (ETGs): a patient classification system for measuring outcomes performance by episode of illness.
M T Forthman, H G Dove, L D Wooster.
Top Health Inf Manage, 2001 Jan 06; 21(2). PMID: 11143280
Potential for cancer related health services research using a linked Medicare-tumor registry database.
A L Potosky, G F Riley, +2 authors, L G Kessler.
Med Care, 1993 Aug 01; 31(8). PMID: 8336512
Highly Cited.
Implementation of the Quality Oncology Practice Initiative at a university comprehensive cancer center.
Douglas W Blayney, Kristen McNiff, +3 authors, Michael Neuss.
J Clin Oncol, 2009 Jun 03; 27(23). PMID: 19487377
What is an adequate sample size? Operationalising data saturation for theory-based interview studies.
Jill J Francis, Marie Johnston, +4 authors, Jeremy M Grimshaw.
Psychol Health, 2010 Mar 06; 25(10). PMID: 20204937
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Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer.
Gabrielle B Rocque, Maria Pisu, +13 authors, Patient Care Connect Group.
JAMA Oncol, 2017 Jan 27; 3(6). PMID: 28125760    Free PMC article.
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Cost Containment and the Tale of Care Coordination.
J Michael McWilliams.
N Engl J Med, 2016 Dec 14; 375(23). PMID: 27959672    Free PMC article.
National Health Spending In 2014: Faster Growth Driven By Coverage Expansion And Prescription Drug Spending.
Anne B Martin, Micah Hartman, +2 authors, National Health Expenditure Accounts Team.
Health Aff (Millwood), 2015 Dec 04; 35(1). PMID: 26631494
American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology.
Lowell E Schnipper, Thomas J Smith, +4 authors, Dana S Wollins.
J Clin Oncol, 2012 Apr 12; 30(14). PMID: 22493340
Highly Cited. Review.
Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels.
Jessica Greene, Judith H Hibbard, Carmen Alvarez, Valerie Overton.
Ann Fam Med, 2016 Mar 10; 14(2). PMID: 26951590    Free PMC article.
Adding Value by Talking More.
Robert S Kaplan, Derek A Haas, Jonathan Warsh.
N Engl J Med, 2016 Dec 14; 375(20). PMID: 27959597
Research in action: using positive deviance to improve quality of health care.
Elizabeth H Bradley, Leslie A Curry, +3 authors, Harlan M Krumholz.
Implement Sci, 2009 May 12; 4. PMID: 19426507    Free PMC article.
Highly Cited.
Improving Nonclinical and Clinical-Support Services: Lessons From Oncology.
Leonard L Berry, Katie A Deming, Tracey S Danaher.
Mayo Clin Proc Innov Qual Outcomes, 2018 Sep 19; 2(3). PMID: 30225452    Free PMC article.
Early Accountable Care Organization Results in End-of-Life Spending Among Cancer Patients.
Miranda B Lam, Jie Zheng, E John Orav, Ashish K Jha.
J Natl Cancer Inst, 2019 Mar 13; 111(12). PMID: 30859226    Free PMC article.
Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value.
Brian M Brady, Meera V Ragavan, +2 authors, Arnold Milstein.
J Am Soc Nephrol, 2019 Nov 16; 30(12). PMID: 31727849    Free PMC article.
Understanding quality and equity: patient experiences with care in older adults diagnosed with hematologic malignancies.
Alex Fauer, Sung Won Choi, +2 authors, Christopher R Friese.
Cancer Causes Control, 2021 Feb 11; 32(4). PMID: 33566250    Free PMC article.