Robert “Bo” Gamble
Director, Strategic Practice Initiatives, Community Oncology Alliance in Washington, DC
Two of my favorite activities are running and salt-water fishing. Both are very precise and numbers-oriented activities. Running is about time, pace, distance, calorie burn rates, and heart rate zones, among other factors. When talking with runners, it does not take long for the conversation to come around to the essential questions: “What is your PR (personal record) for a half (or full) marathon?” or “What is your average weekly miles?” Both of these questions reflect standard benchmarks of the level of accomplishment in the sport.
Fishing, or as we say in the South, “fishin’,” has its own set of standards. Before we graduate to the point of hoping the fish do not bother us, we are watchful of length, weight, creel limit, and also making sure the catch falls within season. Measurement is serious business, to the point that the fishing industry has its own “Golden Rule”—an official calibrated tool to measure the length of a fish. Woe to the person who is caught with a fish under or over the size requirements. The fisherman strives to have the best answer to the routine question, “Did you catch anything?” If that is answered in the affirmative, the next question will hopefully be answered with a boast: “Any size?”
Both of these activities have finite and very specific criteria of what is considered “good” or “excellent.” Why is it we struggle with the similar concepts in healthcare, and particularly cancer care? It is interesting that healthcare accounted for 15.2% of GDP in 2008.1
Fishing (even when included in the category of agriculture, hunting, forestry, and fishing) is only 1.1% of GDP.2
The running industry is not even high enough to score a 1/100 of a percent. If healthcare consumes so much of our world, why is it then that we focus so little attention on the specifics of quality or value or outcomes in healthcare?
Defining Quality, Value, and Outcome Measures
The lack of attention in systematically measuring quality and value in cancer care became particularly obvious when working with the Oncology Medical Home (OMH) Steering Committee on its objective of defining 16 quality, value, and outcome measures for cancer care. This cross-section and balanced approach to defining key determinants to patient care, resource utilization, survivorship, and end-of-life care may prove challenging, but its time is past due. For example, as an outdoor enthusiast, my hope is that I will be called home while running, fishing, or simply walking on a trail. For a cancer patient, the hope is that he or she may leave this earth among family or friends and surrounded by a known and friendly environment—peacefully and quietly. Dying at home would seem to be the choice for all, if we had a choice. And there is no better indicator of the quality of life, at end of life, than the place of death. However, it seems that the national death registry does not record a “place” of death. The standard death certificate includes the following choices for place of death: “Hospital inpatient, ER/Outpatient or DOA; Nursing home, Residence or Other (Specify).” It would seem that it would be beneficial to include these data in the national death registry and to recognize same as a quality and value indicator for all of healthcare, not just cancer care. This seems to be an easy fix.