Mass General Assists Veterans Affairs in Selecting Quality Measures for Palliative and End-of-Life Cancer Care

Over the past decade, the U.S. Department of Veterans Affairs (VA) has fostered widespread access to palliative and end-of-life cancer care. However, like many other health care systems, the VA does not routinely track quality measures for the processes involved in this care—evidence-based measures of timely information provision, care planning and symptom management.

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The VA has now embarked on a project called Improving Palliative Measurement Application with Computer-Assisted Abstraction (ImPACS). In the first stage, it asked a panel of national experts to identify a shortlist of concepts for quality measures that will be presented to VA cancer patients and family caregivers to seek their input.

Christine Seel Ritchie, MD, MSPH, director of research in the Division of Palliative Care and Geriatric Medicine and director of the Mongan Institute Center for Aging and Serious Illness at Massachusetts General Hospital, moderated the panel. Anne M. Walling, MD, PhD, of UCLA Health, served as an advisor to the project and is the senior author of the report in the Journal of Palliative Medicine that lists the top-rated concepts.

The Panel's Procedure

Selecting Preliminary Measures

VA- and non-VA–affiliated physicians identified 226 potential process measures from 23 sources, then synthesized them into 64 concepts in 12 groups (topics). The largest groups were advanced care planning (11 concepts), pain (seven), dyspnea (nine), other specific symptoms (17) and palliative care–specific issues (six).

Pre-meeting Work

An interprofessional panel rated each concept from 1 (not important) to 9 (very important) on two attributes: (a) importance to patient- and family-centered care, and (b) potential to address gaps in care, align with current initiatives and be implemented. Each panelist also indicated the five concepts they considered most important for each attribute.

Panel Meeting

Ten panel members (seven physicians, two nurses and one social worker) met in person in September 2019 in Washington, DC. The moderator guided discussion on each concept, emphasizing those that had disparate pre-meeting ratings. The panelists then again rated each concept on the two attributes and chose their top five concepts for each attribute.

Concepts were placed on a shortlist if, for at least one attribute, the concept was nominated in the top five by at least one expert and had a median rating ≥7.

The Shortlist of Quality Measure Concepts

20 of the 64 concepts, which fell into nine groups, fulfilled the criteria for the shortlist:

• Advanced care planning—documentation of contact information for surrogate decision-maker, advanced directive in medical record, documentation of goals of care discussion, discussion of the prognosis within 72 hours of ICU admission, care preferences communicated to next setting of care, patient's treatment preferences being followed, documentation of timely physician communication with the family and assessment of patient's decisional capacity
• Pain—timely assessment of patients in pain, documentation of pain management plan when indicated, improvement in pain, consideration of single-fraction radiation therapy for painful bone metastases
• Dyspnea—assessment of all patients, management plan when indicated
• Palliative care–specific issue—whole-spine MRI or myelography as soon as possible, and within 24 hours, for a cancer patient with signs/symptoms of spinal cord compression, or documentation of why imaging was inappropriate
• Comprehensive assessment
• General symptom assessment
• Hospice/palliative care discussion/referral
• Treatment plan for patients with depression
• Professional interpreters or translators for deaf or non–English-speaking patients

The excluded groups related to specific symptoms other than pain and dyspnea, spiritual care and information provision.

Looking Ahead

Once the ImPACS project collects feedback from cancer patients and their families, it will incorporate selected quality measures into artificial intelligence systems that can review unstructured data such as clinical notes. The end goal is to promote the use of these measures in palliative and end-of-life cancer care at VA hospitals and non-VA health care systems.

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