In response to the Institute of Medicine having identified significant shortcomings and disparities regarding cancer care in the United States, professional organizations (e.g., American Society of Clinical Oncology, American Psychosocial Oncology Society), accrediting bodies (e.g., American College of Surgeons Commission on Cancer), and associations of cancer-treating programs (e.g., National Comprehensive Cancer Network) have developed standards and initiatives for improving the quality of oncology services. As a means of supporting such improvement strategies, AOSW created A Project to Assure Quality Cancer Care (APAQCC) – a national quality assurance/quality improvement project funded by Takeda Oncology.

The APAQCC study was conducted in 2014-2015 with the purpose of assessing the capacity of cancer programs to deliver comprehensive psychosocial services. The study was comprised of two phases during which two areas of interest and concern were examined:

1. Cancer care providers’ perceptions regarding the capacity of their institutions to provide quality psychosocial support services, and
2. The degree to which distress screening protocols are implemented across various cancer treatment programs. These areas of study represent a response to ongoing shifts in health care financing and the subsequent need for the integration of psychosocial, biomedical and behavioral health care as a means of improving patient outcomes, operational efficiencies and cost-offsets.

AOSW members employed by Commission on Cancer-accredited programs (including two Canadian institutions) comprised those eligible to participate in APAQCC. Of these individuals, 65 members were chosen. During Phase 1, the APAQCC participants recruited various providers in their cancer programs to complete the National Cancer Institute (NCI) Cancer Psychosocial Care Matrix (CPCM). This was a 10-item survey that assesses quality performance indicators such as patient-provider communication, patient needs assessment, care planning and coordination, provider training and education, evaluation of service delivery and patient outcomes, and quality improvement; 2,490 providers at 60 institutions completed the matrix.

During Phase II, each APAQCC participant completed a two-month retrospective review of patient medical records in his or her cancer program. The review sought documentation supporting that (1) distress screening had occurred for each patient, as per protocol, and (2) an appropriate response occurred when indicated by the screening. Participants also counted the number of missed appointments, Emergency Department visits and hospitalizations regarding each patient in a two-month window following the encounter when screening was to be completed. The purpose of the data analysis was to examine each cancer program’s rate of adherence to its own distress screening protocol, the extent to which providers responded to patient needs as indicated by the screens and whether rates of missed visits, Emergency Department visits and hospitalizations varied for patients who were screened versus those not screened. Ultimately, 9,781 patient records were reviewed at 57 participating institutions.

Key Findings

Phase I
The majority of providers (83%) reported that their institutions were operating with at least moderate capacity while delivering comprehensive psychosocial services. Perceptions of capacity to deliver care, however, differed among the various types of institutions. When compared to Academic Comprehensive Cancer Programs (ACAD), Comprehensive Community Cancer Programs (CCCP), and NCI-designated Comprehensive Cancer Programs (NCIP), Community Cancer Programs (CCP) reported the highest capacity to deliver psychosocial care. In contrast, NCIP providers most often reported the lowest capacity. As CCPs are smaller than CCCPs and ACADs (100-500 annual cancer diagnoses vs greater than 500 annual cancer diagnoses), and NCIPs are required by the National Cancer Institute to conduct cancer research, greater patient volume and research obligations may account for diminished perceptions of capacity to adhere to established protocols and deliver psychosocial services. An additional discrepancy was identified as minority institutions (those serving greater than 30% non-white patients) consistently reported lower perceptions of capacity when compared to non-minority institutions.

Phase II
The review of patient medical records revealed a 68% adherence rate to distress screening protocols, with a range of 12%-100% adherence across 57 cancer programs. As with the data regarding provider perceptions of the capacity to deliver psychosocial care, differences in adherence to distress screening protocols varied significantly among the various types of institutions. While CCPs reported the highest average adherence rate at 80%, CCCPs, ACADs and NCIPs reported 75%, 71% and 54% adherence rates respectively.

Of the 6,611 patients screened, 3,675 individuals (56%) required further assessment, attention or referral to additional services according to their facilities’ established protocols. When action was required, 87% of these individuals received appropriate action. Responsiveness rates did not differ among the various types of institutions. Given that 32% of patients were not screened as intended per protocol, however, the percentage of patients requiring further attention may be higher. In addition, we do not know whether programs could have retained a high level of responsiveness if these unscreened patients were to require further attention

Conclusion
While improvements in cancer care have been noted throughout the past 10 years, challenges to the integration of psychosocial services into routine care on a systems level persist. Further, achieving improved patient outcomes and significant cost-offsets require that cancer programs transcend racial disparities in the provision of care, monitor the quality of care on a system-wide level, and educate all professions on patient/provider communication and the provision of psychosocial care. As APAQCC has identified both barriers and facilitators to comprehensive psychosocial services at the patient, provider and systems level among cancer institutions, additional studies, monitoring and documentation are required to enhance quality care and ensure the presence of oncology social workers among cancer settings.