Quality Measures, Clinical Practice, NCCN, and McAllen, Texas

Author: Harold J. Burstein MD, PhD
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The most important recent publication on health care in the United States can be found in the June 1 The New Yorker magazine, in an article by Dr. Atul Gawande of Brigham & Women's Hospital (available at: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrail). Dr. Gawande spoke with locals about health care in McAllen, Texas—a town notable for spending more per capita on health care than the average resident earns in a year. He made a quick diagnosis: health care costs are high in McAllen because of the most expensive piece of medical equipment—the doctor's pen!That is, expenses are high because clinicians order and deliver a lot of health care services, many of which may not be needed. The result is not necessarily better health but simply higher costs. The White House is reportedly paying close attention to Dr. Gawande's article as the administration embarks on health care reform.Doctors may have several reasons for over-ordering medical services, including insecurity in medical judgment, misunderstanding proper care algorithms, patient demand, the desire to “do right” by patients, excess supply of available medical services, and personal financial gain.In light of this article, data in the paper by Foster et al. in this issue of JNCCN (page 712) are illuminating. The authors created a series of hypothetical case management questions and asked oncologists to state the next treatment or evaluation. The study reports that oncologists often made guideline-consistent choices but also suggests that these same oncologists frequently order unnecessary tests (such as staging PET, chest imaging, and...

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Harold J. Burstein, MD, PhD, editor-in-chief of JNCCN, is an Associate Professor of Medicine at Harvard Medical School and a medical oncologist at Dana-Farber Cancer Institute and Brigham & Women's Hospital. He is a clinician and clinical investigator specializing in breast cancer.

Dr. Burstein attended Harvard College and earned his MD at Harvard Medical School, where he also earned a PhD in immunology. He trained in internal medicine at Massachusetts General Hospital and was a fellow in medical oncology at Dana-Farber before joining the staff.

Dr. Burstein's clinical research interests include novel treatments for early- and advanced-stage breast cancer and studies of quality of life and health behavior among women with breast cancer. He has written widely on breast cancer in both traditional medical journals and on the web, including New England Journal of Medicine and Journal of Clinical Oncology. International committees focusing on cancer treatments that he has or continues to participate in include the NCCN Clinical Practice Guidelines Breast Cancer Panel, St. Gallen Breast Cancer Panel, CALGB Breast Cancer Committee, ASCO Health Services Research and Clinical Research Committees, the National Quality Forum Breast Cancer Technical Panel, and other ASCO expert panels.

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