Mind the gap: how vulnerable patients fall through the cracks of cancer quality metrics

In USA, cancer outcomes have steadily improved but considerable disparities in outcomes persist.1 There is continued evidence that vulnerable patients (ie, those who are socially or economically disadvantaged) are less likely to receive high-quality care and subsequently have poorer outcomes.2 Since the release of the Institute of Medicine’s report Ensuring Quality Cancer Care in 1999, increased attention has been paid to the importance of measuring cancer care quality, understanding its effects on outcomes and identifying effective strategies for ensuring that all patients have access to high-quality cancer care.3 Studies have demonstrated that patient survival varies by hospital type (eg, community vs academic cancer centre), even after risk adjustment for tumour characteristics and comorbidities, and that patients treated at hospitals that perform worse on some cancer quality metrics have inferior survival.4–10 Collectively, these findings suggest that variations in cancer care quality translate into decreased survival for thousands of patients every year, and vulnerable patients are at particular risk of poorer cancer outcomes. The intended goals of quality metrics are to allow hospitals to identify and improve on substandard care, thereby elevating individual and population level cancer care quality, while also enabling patients and payers to choose high-performing hospitals through public reporting. There has been close consideration of how best to measure quality that addresses social drivers of poor cancer outcomes, without punishing hospitals that treat large numbers of vulnerable patients. While quality metrics that focus on the outcomes that matter most to cancer patients—living longer (overall survival) and living better (quality of life)—would be preferred, this is very difficult in practice as these outcomes may indirectly hold hospitals accountable for extrinsic socioeconomic factors beyond their direct control.11 12 The limitations attached to using survival and quality of life outcomes as quality metrics mean that the substantial …