A Quality Improvement Initiative Advancing CLL Care Practices across Four US Health Systems

Background: National initiatives for quality improvement (QI) are intended to promote safe, effective, coordinated, and affordable healthcare practices, yet reports of QI programs involving hematologic malignancies are lacking. To address quality-related gaps and needs of hematology-oncology teams in US health systems, we conducted a QI study that focused on clinical assessment practices, patient counseling, and care coordination for patients with chronic lymphocytic leukemia (CLL).

Methods: Participants in the IRB-approved study were 20 hematologists-oncologists and their clinical teams of nurses, nurse practitioners, physician assistants, and case managers at 20 centers. The teams practiced in 4 health systems in different US regions: a large corporate system (n = 5 teams), 2 private regional hematology-oncology centers (n = 9 teams), and a large public health system (n = 6 teams). At baseline, 10 consecutive charts of patients with a confirmed diagnosis of CLL were retrospectively reviewed per provider for documentation of diagnostic and prognostic assessments, patient counseling, and care coordination. The chart variables align with national clinical practice guidelines, quality measures for CLL-specific and patient-centered care, and requirements of healthcare reform programs including the Oncology Care Model and the Medicare Access and CHIP Reauthorization Act.

After the baseline charts were reviewed, chart audit feedback was presented to the physicians and their teams by external independent CLL experts. The audit-feedback webinar intervention focused on improving the CLL clinical assessment, patient-centered care, and care coordination practices that were central to the QI program, and was designed according to principles of plan-do-study-act (PDSA) models, engaging participants in identifying gaps in care quality and developing written targeted action plans for improvement. Six months after the interventions, consecutive randomized charts were reviewed according to the methods of the baseline review. Chi-square tests were conducted to assess the reliability of baseline and post-intervention differences in rates of documentation for the chart variables. A P-value less than .05 was considered significant.

Results: We reviewed 200 baseline charts and 200 post-intervention charts. The baseline and post-intervention samples were similar in age, years since CLL diagnosis, gender, and Rai stage 0/1 and 3/4 (Table). A significantly greater proportion of patients in the post-intervention sample was at Rai stage 2 (+10%) and had received CLL treatment (+13%). Rates of chart documentation were significantly higher in the post-intervention versus baseline samples for Rai staging (+23%), flow cytometry (+22%), FISH testing for genetic abnormalities (+26%), and assessment of functional status using the Eastern Cooperative Oncology Group (ECOG) scale (+10%). A significantly greater proportion of charts in the post-intervention sample were documented for care coordination (+17%) and for patient counseling on CLL treatment options (+20%) and treatment risks and benefits (+18%). The teams' written action plans included strategies for adjusting electronic medical records to facilitate performance and documentation of key quality measures, initiating periodic review of QI-related data, incorporating new workflow processes to obtain and utilize prognostic marker testing results in decision-making for uniform care delivery, and involving team members for care coordination and patient counseling.

Conclusion: This study demonstrates positive outcomes of a team-based QI program on clinical assessment practices, patient counseling, and care coordination for patients with CLL across 4 oncology group settings. The study methods and findings are especially relevant in the context of national initiatives for improving clinical and patient-centered care practices. Moreover, the findings reflect process improvements that are essential for accurately diagnosing CLL, making appropriate guideline-directed treatment decisions that account for genetic status, and promoting patient engagement in CLL care. Persistent gaps were noted in communication with patients about their preferences and treatment goals and counseling about side effects, highlighting the need for continuing education.

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