Adherence to quality indicators and survival in patients with breast cancer

Quality-of-care indicators for children with sickle cell disease

OBJECTIVE

To develop a set of quality-of-care indicators for the management of children with sickle cell disease (SCD) who are cared for in a variety of settings by addressing the broad spectrum of complications relevant to their illness.

METHODS

We used the Rand/University of California Los Angeles appropriateness method, a modified Delphi method, to develop the indicators. The process included a comprehensive literature review with ratings of the evidence and 2 rounds of anonymous ratings by an expert panel (nominated by leaders of various US academic societies and the National Heart, Lung, and Blood Institute). The panelists met face-to-face to discuss each indicator in between the 2 rounds.

RESULTS

The panel recommended 41 indicators that cover 18 topics; 17 indicators described routine health care maintenance, 15 described acute or subacute care, and 9 described chronic care. The panel identified 8 indicators most likely to have a large positive effect on improving quality of life and/or health outcomes for children with SCD, which covered 6 topics: timely assessment and treatment of pain and fever; comprehensive planning; penicillin prophylaxis; transfusion; and the transition to adult care.

CONCLUSIONS

Children with SCD are at risk for serious morbidities and early mortality, yet efforts to assess and improve the quality of their care have been limited compared with other chronic childhood conditions. This set of 41 indicators can be used to assess quality of care and provide a starting point for quality-improvement efforts.

Translating scientific advances to improved outcomes for children with sickle cell disease: a timely opportunity

Despite the recent advances made in the care of children with sickle cell disease (SCD), premature mortality, especially among older children and young adults, remains a hallmark of this disease. The lack of survival gains highlights the translational gap of implementing innovations found efficacious in the controlled trial setting into routine clinical practice. Health services research (HSR) examines the most effective ways to finance, organize, and deliver high quality care in an equitable manner. To date, HSR has been underutilized as a means to improve the outcomes for children with SCD. Emerging national priorities in health care delivery, new sources of funding, and evolving electronic data collection systems for patients with SCD have provided a unique opportunity to overcome the translational gap in pediatric SCD. The purpose of this article is to provide a comprehensive HSR agenda to create patient-specific evidence of clinical effectiveness for interventions used in the routine care setting, understand the barriers faced by clinicians to providing high quality care, assess and improve the interactions of patients with the health care system, and measure the quality of care delivered to increase survival for all children and young adults with SCD.

Development and measurement of guideline-based indicators for patients with non-Hodgkin's lymphoma

PURPOSE

Patients with cancer are not always treated according to available guidelines. Factors such as age and comorbidities are frequently used as arguments for nonadherence. The aim of this study was to measure guideline adherence with guideline-based indicators for patients with non-Hodgkin's lymphoma (NHL) and to examine the need for improvement, considering relevant arguments.

METHODS

A RAND-modified Delphi procedure was used to systematically develop NHL indicators. We evaluated their improvement potential (defined as < 90% score) in a random sample of patients with NHL (N = 431) diagnosed in 2006-2007 in 22 hospitals in the Netherlands with data from medical records. Multilevel logistic regression analyses were used to estimate the relationship between indicator scores and factors: comorbidity index (combined with age), stage, patient's objections, and lymphoma type. Scores were adjusted for significant factors.

RESULTS

Of the 20 indicators developed, 16 had improvement potential. Scores were lowest for assessment of International Prognostic Index, 21%; imaging of neck, thorax, and abdomen and bone marrow examination during the diagnostic process, 23%, and after chemotherapy, 37%; adequate pathology reporting, 11%; and multidisciplinary discussion of patients, 21%. Scores for eight indicators were better for patients with a low Charlson index, stage III or IV disease, no objections to care, and aggressive lymphoma. After adjustments, adherence to all but one indicator (administration of the combination of rituximab and cyclophosphamide-doxorubicin-vincristine-prednisone) remained < 90%.

CONCLUSION

In the Netherlands, almost all indicators for NHL needed improvement. This should be evaluated in other countries as well. International efforts should be undertaken to improve the quality of care of this often curable malignancy.

Radiation therapy after breast-conserving surgery: does hospital surgical volume matter? A population-based study in Taiwan

PURPOSE

To examine the association between hospital surgical volume and the use of radiation therapy (RT) after breast-conserving surgery (BCS) in Taiwan.

METHODS AND MATERIALS

We used claims data from the National Health Insurance program in Taiwan (1997-2005) in this retrospective population-based study. We identified patients with breast cancer, receipt of BCS, use of radiation, and the factors that could potentially associated with the use of RT from enrollment records, and the ICD-9 and billing codes in claims. We conducted logistic regression to examine factors associated with RT use after BCS, and performed subgroup analyses to examine whether the association differs by medical center status or hospital volumes.

RESULTS

Among 5,094 patients with newly diagnosed invasive breast cancer who underwent BCS, the rate of RT was significantly lower in low-volume hospitals (74% vs. 82%, p < 0.01). Patients treated in low-volume hospitals were less likely to receive RT after BCS (odds ratio = 0.72, 95% confidence interval = 0.62-0.83). In addition, patients treated after the implementation of the voluntary pay-for-performance policy in 2001 were more likely to receive RT (odds ratio = 1.23; 95% confidence interval = 1.05-1.45). Subgroup analyses indicated that the high-volume effect was limited to hospitals accredited as non-medical centers, and that the effect of the pay-for-performance policy was most pronounced among low-volume hospitals.

CONCLUSIONS

Using population-based data from Taiwan, our study concluded that hospital surgical volume and pay-for-performance policy are positively associated with RT use after BCS.

Adherence to the National Quality Forum (NQF) breast cancer measures within cancer clinical trials: a review from ACOSOG Z0010

BACKGROUND

In 2007, the National Quality Forum (NQF) released four performance measures for the treatment of breast cancer. We proposed to study the degree of adherence with these measures among participating institutions in a multi-institutional trial.

METHODS

American College of Surgeons Oncology Group (ACOSOG) Z0010 enrolled breast cancer patients onto a phase II trial studying the prognostic significance of bone marrow and sentinel node micrometastases. The current study used chi(2) analyses to determine the degree of adherence with four NQF measures among three institution types: academic, community, and teaching affiliate.

RESULTS

The study revealed small but important differences in two measures. Ninety-five percent of patients from teaching affiliated institutions received whole-breast radiation compared to 92% at academic and 91% at community hospitals. Among patients who were underinsured or uninsured, a marked decrease in radiation use was noted in comparison to patients with insurance-85 versus 93%, respectively. The study also revealed a difference among institutional types in patients undergoing excisional biopsy for diagnosis. In teaching-affiliated hospitals, 28.6% underwent excisional biopsy as compared to 36.8 and 37.4% in academic and community hospitals, respectively. There was no statistically significant difference between adherence rates with the remaining two measures. Adjuvant chemotherapy was administered to patients with hormone receptor negative tumors > or =1 cm in size in 79-85% of institutions. Tamoxifen was administered to 79-82% of those patients with hormone receptor-positive cancers.

CONCLUSIONS

Among breast cancer patients enrolled onto a multi-institutional clinical trial, we found a high degree of adherence with current consensus standards for adjuvant treatment, despite varied practice environments.

Secular trends in breast cancer mortality in five East Asian populations: Hong Kong, Japan, Korea, Singapore and Taiwan

Breast cancer risk is increasing in most Asian female populations, but little is known about the long-term mortality trend of the disease among these populations. We extracted data for Hong Kong (1979-2005), Japan (1963-2006), Korea (1985-2006), and Singapore (1963-2006) from the World Health Organization (WHO) mortality database and for Taiwan (1964-2007) from the Taiwan cancer registry. The annual age-standardized, truncated (to > or =20 years) breast cancer death rates for 11 age groups were estimated and joinpoint regression was applied to detect significant changes in breast cancer mortality. We also compared age-specific mortality rates for three calendar periods (1975-1984, 1985-1994, and 1995-2006). After 1990, breast cancer mortality tended to decrease slightly in Hong Kong and Singapore except for women aged 70+. In Taiwan and Japan, in contrast, breast cancer death rates increased throughout the entire study period. Before the 1990s, breast cancer death rates were almost the same in Taiwan and Japan; thereafter, up to 1996, they rose more steeply in Taiwan and then they began rising more rapidly in Japan than in Taiwan after 1996. The most rapid increases in breast cancer mortality, and for all age groups, were in Korea. Breast cancer mortality trends are expected to maintain the secular trend for the next decade mainly as the prevalence of risk factors changes and population ages in Japan, Korea, and Taiwan. Early detection and treatment improvement will continue to reduce the mortality rates in Hong Kong and Singapore as observed in Western countries.

Quality indicators and quality assessment in child health

Quality indicators are systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services and outcomes. In this review, the range and type of indicators that have been developed for children in the UK and USA by prominent governmental agencies and private organisations are highlighted. These indicators are classified in an effort to identify areas of child health that may lack quality measures. The current state of health information technology in both countries is reviewed, since these systems are vital to quality efforts. Finally, several recommendations are proposed to advance the quality indicator development agenda for children. The convergence of quality measurement and indicator development, a growing scientific evidence base and integrated information systems in healthcare may lead to substantial improvements for child health in the 21st century.