	Quality Oncology Practice Initiative (QOPI) is an oncologist-created quality improvement program developed and maintained by ASCO. It is important to be able to objectively review the care that is given in your institution in order to improve the quality of care that is ultimately delivered. The QOPI program creates a uniform measurement of the quality of care delivered by an oncologist; this affords self-examination and directed improvement of practices. QOPI enables self-assessment through twice-yearly retrospective medical chart reviews that are designed to be used in the outpatient hematology/oncology setting. The collection of data from medical records applies identified universal quality measures that have been defined and developed by practicing medical oncologists based on established consensus guidelines. QOPI is designed to objectively measure parameters reflective of quality care that are managed by the medical oncologist. The results of each chart audit allow participants to compare their findings against other participating groups, enabling them to direct their efforts of quality improvement by identifying areas of deficiency.

	There are many benefits to QOPI. At its most basic level, QOPI places an emphasis on documentation. In medicine, we have all been told, “If it is not documented, it didn’t happen.” QOPI also focuses our attention on specifically what is important to include in an oncology patient’s medical record, which is paramount in a fellow’s education. For example, we may know that a particular chemotherapy in a certain case is for palliative intent and we may have discussed it with the patient, but it should be explicitly documented. QOPI also exposes us to continual practice-based quality improvement, which is one of the ACGME core competencies for fellowship. Participation in QOPI satisfies the practice-based improvement component of the ACGME requirements.

What type of information do you obtain from the charts?

	QOPI includes a variety of modules from which to choose. Some modules are universal (Core Measures, End-of-Life Care, and Symptom/ Toxicity Management), and others are disease specific (Breast Cancer, Colorectal Cancer, and NHL). Our fellowship program plans to participate in the Core Measures and Symptom/Toxicity Management modules for the spring 2012 audit. (There are 2 audits each year, in the spring and fall.) These 2 modules contain 34 total data points (25 Core Measures and 9 Symptom/ Toxicity Management measures) to be collected from patient charts. An example of the Core Measures data includes identifying chart documentation of pain assessment: Was the patient’s pain documented and quantified by the second visit? Was a plan documented for the treatment of moderate/ severe pain? If narcotics were prescribed, was the effectiveness documented at the next visit, and was constipation addressed? These questions address 5 of the 25 core measures.

	One or several modules are chosen, and charts are sequestered for audit. It takes approximately 30 to 45 minutes to audit each chart. After the data are collected, they are entered into a Web-based program that is maintained by ASCO. The data (expressed as percent compliance for each measure) can then be reported in a variety of ways. Percent compliance for each measure can be reported by overall practice or broken down to report each individual physician/fellow. The results can then be compared with the overall database results. This allows each program to compare its compliance with results from previous audits in order to gauge its overall improvement, as well as to judge overall performance in comparison with other programs.

How does your program incorporate QOPI for the fellows?

	The Allegheny General Hospital has been using QOPI on the attending level since 2006, and it is being initiated on the fellow level in spring 2012. To prepare for the addition of the program, we have been asked to keep track of at least 10 patients from our continuity clinic to submit for the spring 2012 audit. We were asked to choose our patients based on the following criteria, which are established by ASCO QOPI guidelines: patients must be diagnosed with an invasive malignancy in the past 2 years and must have had 2 office visits in a 6-month-period. Additionally, we were asked to choose patients whom we were involved with directly in development of the treatment plan and its documentation. In spring 2012, we plan to submit our 10 patients for review by another fellow in the program. Charts will not be self-analyzed in an attempt to prevent bias in regard to interpretation of the documentation.

	In preparation of initiation of QOPI, the fellows were involved in auditing charts for the attending-level spring 2011 audit. At that time, each fellow was asked to review 2 charts that had been previously audited by a third party. We were instructed not to interpret the documentation and to record data based directly on what was documented. For quality control, our individual audits were compared with audits previously performed on the same charts by a third party to determine reproducibility of results. When compared, the results were within 2%, which indicated that we were auditing the charts appropriately.

How will we use the results of the audit?

	We plan to meet after the spring 2012 audit to review our results and formulate a plan for improvement based on our discovered deficiencies. We are excited to participate in the spring 2012 audit, and we are interested to see how our fellowship compares with the practice as a whole and to other fellowships regarding these measures of quality. We were left wondering, however, if QOPI truly measures quality of care, or if it simply measures the quality of documentation. Either way, we believe it is a good tool to utilize in fellowship to help prepare us for our careers in hematology oncology.

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The QOPI program creates a uniform measurement of the quality of care delivered by an oncologist; this affords self-examination and directed improvement of practices. 

Using QOPI to Improve Quality Within Your Fellowship Program

	In this country, an estimated 46 million people—20.6% of all adults&mdash;smoke cigarettes. Cigarette smoking also happens to be the leading cause of preventable death in the United States, accounting for approximately 443,000 deaths, or 1 of every 5 deaths each year. Approximately 40% of these deaths are from cancer, of which lung cancer is the most prevalent.

	In addition to the disastrous impact that tobacco use has on our collective health as a nation, it wreaks havoc on our economy. Cigarette smoking is estimated to be responsible for $193 billion in annual health-related economic losses in the United States—that’s $96 billion in direct medical costs and approximately $97 billion in lost productivity. Cigarette smoking results in 5.1 million years of potential life lost in the United States annually.

	It is estimated that 70% of smokers want to quit completely and that 45% of smokers have tried to quit. Yet we realize from our interactions with patients that this is often a losing battle. Patients, even those with lung cancer, at some point in time will return to smoking. Compared with the billions of dollars that cigarette companies pour into marketing their products, the healthcare system is ill-equipped to respond. Smokers who want to quit often have limited resources available to them. As fellows and residents, we often know how important it is to counsel, yet have limited time with each patient to do so.

	There are many smoking cessation interventions available, group sessions being one of them. As effective as they are, they are often an option only for those who can pay for them. As fellows and residents, we not only have a responsibility to help fight this major public health hazard, but we are also in an excellent position to do so. Most training programs are affiliated with community health centers. Approximately 20 million Americans are served by such centers, with 40% of these affiliated with residency programs. The majority of patients that visit such centers are poor—the very people who smoke the most and who therefore need the most help. In the following sections, we provide an overview of how fellows/ residents can set up and successfully run a smoking cessation clinic.

	Planning is of paramount importance. You will need to speak with the health center director and ensure that resources are available to run such a clinic, which is held in a group meeting format in 2-hour-long sessions once a week for 4 weeks. The following are needed:

		A large conference room that can hold 10 to 15 people and that is available for a 2-hour slot on a specified day every week for 4 consecutive weeks

		A nurse and a medical assistant (MA) who are available each week for that 2-hour time period

		An attending physician who can be available for 30 minutes per session

		A whiteboard and pens and paper for the patients

	Once you have selected a day and a 2-hour time slot, begin by advertising the clinic. Print out flyers, hang them up in the clinic, and give them out to patients. Have a system in place where the MAs ask each patient coming through the clinic about his or her smoking status. If the patients smoke, at checkout have the staff off er to enroll them in your free smoking cessation clinic. Many will take you up on the off er. Once you have 10 to 15 patients enrolled, you are ready to start your very own smoking cessation clinic!

	Next, we will describe how you should conduct each of the 4 sessions. Note that the group sessions will last for approximately 1 hour, with the remaining 1 hour used for individual patient counseling in exam rooms. This counseling allows the clinic to bill for the sessions.

	Start off by congratulating the patients for joining. Introduce them to the notion of smoking cessation through behavior modification and group therapy along with pharmacotherapy, if necessary. Stress the importance of follow-up through subsequent sessions. Hand out printed smoking cessation material, if available.

	Next, talk about the harmful effects of smoking. Involve the group and ask them how much they know about the dangers associated with smoking. Discuss the heightened risk of cancer and chronic obstructive pulmonary disease (COPD). A useful exercise is to give out straws and ask the patients to pinch their noses and only breathe through the straws in their mouths; explain that if they do not stop smoking, this is how it will feel when they have emphysema.

	Discuss in detail the benefits of quitting smoking. Specifically mention the health benefits, such as having more energy and a reduced risk of cancer and heart and lung diseases. Emphasize the psychological benefits, such as increased self-esteem and self-respect and a sense of accomplishment in quitting. Next, talk about the financial benefits, such as reduced insurance premiums, decreased future healthcare costs, and an almost $2000 savings per year from not buying cigarettes.

	Wrap up by preparing patients for session 2. Prior to the next session, ask patients to think about what triggers their smoking. They should consider the reasons why they smoke as well as their desire to quit. Have them reflect on their past attempts to quit and why they failed and to start thinking about a quit date. Answer any questions that they may have. At the end of this and each subsequent session will be individualized patient sessions. (These are described at the end of the article.)

	This session will help patients understand the psychological aspects of smoking. It is designed to explore in detail the patients’ reasons for smoking and why they want to quit, and to reflect on past experiences with quit attempts.

	Start off by asking patients to discuss the reasons they smoke. Write them down on the whiteboard. Ask them if they think smoking is a psychological need or truly a physical addiction to nicotine. Ask them when they have their first cigarette in the morning. Then ask each patient why he or she likes or dislikes smoking. This exercise will start a discussion among the participants and help them realize the reasons they smoke so that they can plan to gradually eliminate those reasons.

	Discuss the circumstances in which they smoke each cigarette. Are they happy, sad, angry, frustrated, nervous, or something else? Make a list on the whiteboard of all the triggers for the different patients. They will soon realize that everyone has fairly similar triggers.

	Next, talk about the true desire of the patient to quit. Discuss why it is so important to do so. Make sure they understand that they may have to undergo many months—if not years&mdash;of self-reflection and attempts at quitting before finally being successful.

	Now, discuss in more detail the patients’ past quit attempts. Discuss the methods used. Ask them how long their quit periods lasted and whether the attempts were successful. Talk about the reasons why the patients feel that specific past interventions did not work.

	A useful exercise is to give out straws and ask the patients to pinch their noses and only breathe through the straws in their mouths; explain that if they do not stop smoking, this is how it will feel when they have emphysema. ”

	Toward the end of this session, you will discuss some strategies to cope with urges to smoke. Ask them to remember the “4 Ds” when they feel the need to smoke: delay, deep breath, drink water, and do something else. Ask each patient to come up with 3 situations that made him or her really want to smoke again. Write those on the whiteboard. Then ask them what they could do instead.

	Session 3: Arming Patients With the Tools to Quit

	Hopefully, by now the patients will have a clear idea of what makes them smoke and what strategies they can use to quit. This session is about dealing with recovery symptoms (ie, nicotine withdrawal) and the correct use and side effects of different smoking cessation products. At the end of this session the product of choice should be prescribed, if appropriate for the patient.

	It is important to teach patients how to deal with withdrawal. Explain that after quitting smoking, the body experiences both physical and psychological “recovery symptoms.” These symptoms decrease after the first few days and usually pass within 2 to 4 weeks. Specific interventions that can help are taking fluids for a dry mouth, sipping warm water for a cough, and having low-calorie snacks to combat hunger pangs. Other symptoms that are expected are insomnia, fatigue, headache, irritability, and constipation.

	Next, you will review products that can be used for smoking cessation. These include nicotine replacement (eg, patch, gum, lozenge, inhaler), bupropion, and varenicline (Chantix). Based on patient preference, any product or combination can be chosen. If nicotine replacement is chosen, it is best to prescribe the patch plus a short-acting nicotine product (eg, gum, lozenge) to deal with the cravings.

	You will need to describe in detail how to correctly use each product, their advantages and disadvantages, and their side effects. This sort of material is easily found on Web sites such as Uptodate.com.

	At this point, you hope that the patients have quit smoking and are perhaps also on a smoking cessation aid. This is the last session of the series and will mainly focus on relapse prevention and answering any questions that the patients might have about the program and the previous sessions.

	First off , discuss relapse-prevention techniques. Relapse prevention requires that patients develop a program that suits them and that they will follow if they begin to slip back to smoking. Talk about avoiding situations that serve as triggers to smoke. Exercising and taking up new hobbies often help. At the end, provide a short recap of all the sessions. If patients are using any of the smoking cessation aids, ensure that they are using them correctly. Answer any questions. Also be sure that you book follow-up visits with the patient’s primary care provider specifically for smoking cessation consultation.

	These sessions are required for billing purposes. The patients would already have had their vital signs taken by an MA when they registered for the course. The staff will bring them to the exam rooms and each meeting with the fellow or resident should not take more than 3 minutes. Briefly go over the specific reasons that the patient should quit. If the patient has a disease, such as coronary heart disease, the physician should tailor the smoking cessation plan accordingly. Briefly document your discussion and then precept with an attending physician. If needed, other patient complaints or concerns should be addressed on a separate visit. This meeting is only for smoking cessation.

	This program serves as a basic outline and can be tailored to your own specific needs and patient population. If you would like more details about running a smoking cessation clinic, please contact Dr Khan at 

Cyrus Khan, MD, is a second-year hematology/oncology fellow at the Western Pennsylvania and Allegheny General Hospital in Pittsburgh. Realizing that the lack of smoking cessation services was a major drawback to the efforts of patients who wanted to quit smoking, he helped start his community health center’s very first smoking cessation program.

	Alice Ulhoa-Cintra, MD, is a second-year hematology/oncology fellow at the Western Pennsylvania and Allegheny General Hospital in Pittsburgh. Her primary interests encompass all aspects of solid tumor oncology, including cancer-preventive strategies with the potential for a significant public health impact, such as smoking cessation initiatives.

Cigarette smoking is the leading cause of preventable death in the United States, accounting for approximately 443,000 deaths, or 1 of every 5 deaths each year.

Alice Ulhoa-Cintra, MD

Articles

Using QOPI to Improve Quality Within Your Fellowship Program

How Fellows Can Establish a Smoking Cessation Clinic