1. Butcher, Lola

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In recognition of the fast-changing medical practice environment, the American Society of Hematology has established both a quality committee and a new department assigned to bolster the organization's quality initiatives.

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Rob Plovnick, MD, former Director of Quality Improvement for the American Psychiatric Association, joined ASH as Director of the Department of Quality Improvement Programs in November, and additional staff with expertise in guideline development and other aspects of quality improvement will be recruited to join him, the Society notes.


The moves reflect the growing emphasis on delivering evidence-based care at a time when medical knowledge is exploding.


"Physicians, appropriately so, are going to be held to a standard for defining and measuring the quality of care that they deliver, and we feel that it's important to be proactive," ASH President Linda J. Burns, MD, Professor in the Division of Hematology, Oncology, and Transplantation at the University of Minnesota, said in an interview.


Mark Crowther, MD, Professor in the Department of Medicine, Hematology and Thromboembolism and Pathology and Molecular Medicine at McMaster University, chairs the new Committee on Quality, which is the successor to an earlier subcommittee that focused on quality issues.


Elevating quality to its own committee will help ASH represent hematologists in policy discussions, Burns explained.


"ASH realizes that providing excellent quality of care to patients is something that hematologists have always tried to do, but it needs to be formalized, both to make it measurable and to reflect the realities of the changing environment in U.S. health care," Crowther said. "Hematologists are going to end up having to practice within the context of measurement and quality assessment and payment based on the quality of their outcomes, and ASH should take a lead in developing how that happens."



Health care is quickly moving to value-based payment systems in which public and private payers reward physicians who deliver high-quality care at the lowest cost. For example, ASH's clinical practice guideline on the evaluation and management of immune thrombocytopenia (ITP), released in 2011, says that many patients with ITP should have a splenectomy in preference to being treated with rituximab. Although many hematologists avoid splenectomies and thus rituximab is widely used in this setting, the pay-for-value movement will eventually catch up to them, he said.


"If you have a practice where every patient who came in with a new diagnosis of ITP routinely gets rituximab, which is a very expensive intervention, and none of the practice's patients were assessed for splenectomy, I think payers would start to look at that practice and say 'why is this happening?'"


Value-based payment systems require a consensus on what high-quality care means for a given medical situation, and that is not always clear.


"There's ongoing friction between the evidence that's accrued from research and the opinion of experts," Crowther continued. "In some cases, those two things line up, and in many cases they do not. As a result, there is a perception that evidence is not easy to apply in practice, so people tend to do what they have always done, exclusively guiding their practice based on their prior experiences or the experiences of colleagues."


For hematologic malignancies, many physicians have incorporated guidelines produced by the American Society of Clinical Oncology, Cancer Care Ontario, and other organizations into their practice, but there are no guidelines for many benign hematological conditions.


"For many diseases, no guidelines exist, and current practice is based entirely on what people learned in medical school and what they hear talked about when they go to meetings," he said.


That situation makes it impossible for hematologists to document that they are providing high-quality care, let alone evidence-based care, which is what payers are asking them to do.


"When hematologists care for patients who have rare or unusual diseases, for which there may not be a lot of evidence about the best practice, it is very difficult to make optimal therapeutic decisions," Burns said.


The quality committee has reviewed existing guidelines that apply to hematology practice and identified a list of guidelines that would be most helpful to ASH members, she said. Committee members will determine how to integrate standard practice, expert opinion, and other information when published evidence is not available.


Beyond Guidelines

In addition to guideline development, the ASH quality initiative includes creating toolkits that help hematology practices implement the guidelines. The toolkits will include pocket guides, mobile apps, webinars, and quality measures that could be used in pay-for-performance reporting.


Further, ASH recently joined the "Choosing Wisely" campaign initiated by the American Board of Internal Medicine (ABIM) Foundation to identify common tests, treatments and procedures that hematologists and their patients should question before proceeding. In December, ASH released its "Top Five" list of evidence-based recommendations as part of the campaign (OT1/10/14 issue).


ASH also encourages members to use its practice-improvement modules for non-Hodgkin lymphoma and myelodysplastic syndromes. The modules allow hematology practices to collect data on certain quality measures, create and implement a quality improvement project, and collect data on the same measures to see if performance has improved. Participants can also compare their own performance with that of other ASH members who have participated in the same module.


Additionally, Burns said, the ASH quality committee may look at the development of registries to support its quality initiatives. Data collected for registries could be used to answer specific research questions or to identify variations in practice and outcomes.