Quality assessment in oncology

Conducting a National RT-QI Project - Challenges and Opportunities

Over the past decade, there has been an increased interest in defining and monitoring quality indicators (QI) in the field of oncology including the field of radiation oncology. The comprehensive gathering and analysis of QIs on a multicentric scale offer valuable insights into identifying gaps in clinical practice and fostering continuous improvement. This article delineates the evolution and results of the Belgian national project dedicated to radiotherapy-specific QIs while also exploring the challenges and opportunities inherent in implementing such a multi-centric initiative.

Ninety-day mortality following curative intent radiotherapy for stage I-III lung cancer in the Netherlands

BACKGROUND AND PURPOSE

The 90-day mortality following lung cancer treatment is a common performance indicator. The aim of this study was to investigate 90-day mortality following (chemo)radiotherapy for stage I-III lung cancer to evaluate the applicability of this outcome indicator in this patient population.

MATERIALS AND METHODS

The Netherlands National Cancer Registry was queried for this retrospective population-based study. Early mortality rates from the start and end of radiotherapy are reported with 95% confidence intervals (CI). The association between clinical characteristics and 90-day mortality was evaluated with multivariable logistic regression analysis.

RESULTS

18,355 Patients treated between 2015 and 2020 were included. The 90-day mortality was 2.56% in stages I-II and 4.60% in stage III, was significantly higher in males, elderly patients and patients with a poor performance status and independent of facility volume. In stage I-II, 90-day mortality was lower after stereotactic versus conventional radiotherapy (2.0% versus 5.25%, OR 0.5 (95%CI 0.4-0.7)). In stage III, mortality decreased from 5.26% in 2015-2016 to 3.73% in 2019-2020 (OR 0.7 (95% CI 0.5-0.9)) and was lower after concurrent versus sequential chemoradiotherapy (3.4% versus 5.9%, OR 1.5 (95%CI 1.2-1.9)). Early mortality increased to 3.20% in stages I-II and 6.70% in stage III when calculated from the end of radiotherapy.

CONCLUSION

Short-term mortality rates following curative intent radiotherapy for lung cancer in the Netherlands are low and independent of facility volume. It was demonstrated that 90-day mortality is an arguable indicator to monitor radiotherapy quality and that standardization of definitions and relevant case-mix factors is warranted.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators

AIM

To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs).

METHODS

The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance.

RESULTS

A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level.

CONCLUSION

This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

Consensus Quality Measures and Dose Constraints for Lung Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and ASTRO Expert Panel

PURPOSE

For patients with lung cancer, it is critical to provide evidence-based radiation therapy to ensure high-quality care. The US Department of Veterans Affairs (VA) National Radiation Oncology Program partnered with the American Society for Radiation Oncology (ASTRO) as part of the VA Radiation Oncology Quality Surveillance to develop lung cancer quality metrics and assess quality of care as a pilot program in 2016. This article presents recently updated consensus quality measures and dose-volume histogram (DVH) constraints.

METHODS AND MATERIALS

A series of measures and performance standards were reviewed and developed by a Blue-Ribbon Panel of lung cancer experts in conjunction with ASTRO in 2022. As part of this initiative, quality, surveillance, and aspirational metrics were developed for (1) initial consultation and workup; (2) simulation, treatment planning, and treatment delivery; and (3) follow-up. The DVH metrics for target and organ-at-risk treatment planning dose constraints were also reviewed and defined.

RESULTS

Altogether, a total of 19 lung cancer quality metrics were developed. There were 121 DVH constraints developed for various fractionation regimens, including ultrahypofractionated (1, 3, 4, or 5 fractions), hypofractionated (10 and 15 fractionations), and conventional fractionation (30-35 fractions).

CONCLUSIONS

The devised measures will be implemented for quality surveillance for veterans both inside and outside of the VA system and will provide a resource for lung cancer-specific quality metrics. The recommended DVH constraints serve as a unique, comprehensive resource for evidence- and expert consensus-based constraints across multiple fractionation schemas.

Synoptic operative reporting in cancer surgery: A scoping review

BACKGROUND

Narrative operative reports (NOR) are important for cancer management but often lack key information. This review investigated the efficacy of synoptic operative reports (SORs) for cancer operations compared to NORs.

METHODS

A database search included published studies up to October 31, 2021. Overall report completeness and reporting frequencies of cancer elements were descriptively compared between NORs and SORs.

RESULTS

Among 4353 studies, 32 were included. 47% of studies compared NORs to SORs. Overall completeness favored SORs (80 ± 19%) over NORs (47 ± 18%, p < 0.001). Essential cancer operative report elements including tumor location (NOR: 51 ± 28%, SOR: 89 ± 11%, p < 0.001), presence of metastases (NOR: 36 ± 33%, SOR: 96 ± 5%, p < 0.001), and final resection margins (NOR: 39 ± 30%, SOR: 87 ± 17%, p < 0.001) demonstrated higher mean reporting frequencies in SORs.

CONCLUSION

Overall completeness and reporting of cancer elements were superior in SORs. Although standardization of SORs requires further research, transition from NORs to SORs may improve the quality of postoperative cancer care.

Establishing quality indicators to comprehensively assess quality assurance and patient safety in radiotherapy and their relationship with an institution's background

BACKGROUND AND PURPOSE

Quality indicators (QIs) for radiotherapy have been proposed by several groups, but no study has been conducted to correlate the implementation of indicators specific to patient safety over the course of the clinical process with an institution's background. An initial large-scale survey was conducted to understand the implementation status of QIs established for quality assurance and patient safety in radiotherapy and the relationship between implementation status and an institutions' background.

MATERIALS AND METHOD

Overall, 68 QIs that were established by this research team after a pilot survey were used to assess structures and processes for quality assurance and patient safety. Data on the implementation of QIs and the institutions' backgrounds were obtained from designated cancer care hospitals in Japan.

RESULTS

Overall, 284 institutions (72 %) responded and had a median QI achievement rate of 60.8 %. QIs with low implementation rates, such as the implementation of an error reporting system and establishment of a quality assurance department, were identified. The QI achievement rate and scale of the institution were positively correlated, and the achievement rate of all QIs was significantly higher (p < 0.001) in institutions capable of advanced treatments, such as intensity-modulated radiotherapy, and those with a quality assurance department.

CONCLUSION

A large-scale survey on QIs revealed their implementation and relationship with a facility's background. QIs that require improvement were identified, and that these QIs might be effective in providing advanced medical care to many patients.

Between-hospital variations in 3-year survival among patients with newly diagnosed gastric, colorectal, and lung cancer

Due to increases in cancer survivability, quality assessments of cancer care must include long-term outcomes. This multicenter retrospective cohort study evaluated between-hospital variations in the 3-year survival rates of patients with gastric, colorectal, and lung cancer irrespective of treatment modality. We linked cancer registry data and administrative data from patients aged 18–99 years who were diagnosed with gastric, colorectal, or lung cancer between 2013 and 2015 in Osaka Prefecture, Japan. The 3-year survival rates were adjusted for potential prognostic factors using multilevel logistic regression models. Between-hospital variations were visually evaluated using funnel plots. We analyzed 10,296 gastric cancer patients from 30 hospitals, 9276 colorectal cancer patients from 30 hospitals, and 7978 lung cancer patients from 28 hospitals. The 3-year survival rate was 70.2%, 75.2%, and 45.0% for gastric, colorectal, and lung cancer, respectively. In the funnel plots, the adjusted survival rates of gastric and colorectal cancer for all hospitals lay between the lower and upper control limits of two standard deviations of the average survival rates. However, the adjusted survival rates of lung cancer for four hospitals lay below the lower limit while that for two hospitals lay above the upper limit. Older age, men, advanced cancer stage, comorbidities, functional disability, emergency admission, current/ex-smokers, and underweight were independently associated with poorer survival. In conclusion, there were between-hospital variations in 3-year survival for lung cancer even after adjusting for case mix. Quality improvement initiatives may be needed to raise the consistency of care.

Quality indicators for radiation oncology

Quality Indicators, based on clinical practice guidelines, have been used in medicine and within oncology to measure quality of care for over twenty years. However, radiation oncology quality indicators are sparse. This article describes the background to the development of current national and international, general and tumour site‐specific radiation oncology quality indicators in use. We explore challenges and opportunities to expand their routine prospective collection and feedback to help drive improvements in the quality of care received by people undergoing radiation therapy.

The radiotherapy quality assurance gap among phase III cancer clinical trials

PURPOSE

Quality assurance (QA) practices improve the quality level of oncology trials by ensuring that the protocol is followed and the results are valid and reproducible. This study investigated the utilization of QA among randomized controlled trials that involve radiotherapy (RT).

METHODS AND MATERIALS

We searched ClinicalTrials.gov in February 2020 for all phase III oncology randomized clinical trials (RCTs). These trials were screened for RT-specific RCTs that had published primary trial results. Information regarding QA in each trial was collected from the study publications and trial protocol if available. Two individuals independently performed trial screening and data collection. Pearson's Chi-square tests analyses were used to assess factors that were associated with QA inclusion in RT trials.

RESULTS

Forty-two RCTs with RT as the primary intervention or as a mandatory component of the protocol were analyzed; the earliest was started in 1994 and one trial was still active though not recruiting. Twenty-nine (69%) trials mandated RT quality assurance (RTQA) practices as part of the trial protocol, with 19 (45%) trials requiring institutional credentialing. Twenty-one (50%) trials published protocol deviation outcomes. Clinical trials involving advanced radiation techniques (IMRT, VMAT, SRS, SBRT) did not include more RTQA than trials without these advanced techniques (73% vs. 65%, p = 0.55). Trials that reported protocol deviation outcomes were associated with mandating RTQA in their protocols as compared to trials that did not report these outcomes (100% vs. 38%, p < 0.001).

CONCLUSIONS

There is a lack of RTQA utilization and transparency in RT clinical trials. It is imperative for RT trials to include increased QA for safe, consistent, and high-quality RT planning and delivery.

Use of quality indicators in neuroblastoma treatment: A feasibility assessment

BACKGROUND

Quality indicators (QIs) may be used to monitor the quality of neuroblastoma (NBL) care during treatment, in addition to survival and treatment toxicity, which can only be evaluated in the years after treatment. The present study aimed to assess the feasibility of a new set of indicators for the quality of NBL therapy.

PROCEDURE

Seven QIs have been proposed based on literature and consensus of experts: (a) duration of complete diagnostic work-up, (b) prescription of thyroid prophylaxis before metaiodobenzylguanidine imaging, (c) treatment intensity, (d) use of tumor board meetings, (e) number of outpatient visits and sedation procedures during follow-up, (f) protocolled follow-up, and (g) required apheresis sessions. A retrospective data analysis from October 2014 to November 2017 including all patients with NBL in the centralized Princess Máxima Center in the Netherlands was performed to assess these parameters and determine practicality of measurement.

RESULTS

A total number of 72 patients (aged between 2 weeks and 15 years) were analyzed. Adherence to all QIs could be determined for all eligible patients using their electronic medical records. Three indicators were compared over time, and an increase in adherence was observed.

CONCLUSIONS

Assessment of QIs in neuroblastoma treatment is feasible. Seven new QIs were found to be feasible to measure and showed improvement over time for three indicators. Monitoring of these QIs during treatment may provide tools for quality improvement activities and comparisons of treatment quality over time or between centers. Further study is required to investigate their association with long-term outcomes.

Quality indicators for breast cancer care: A systematic review

Objectives

We evaluated breast cancer (BC) care quality indicators (QIs) in clinical pathways and integrated health care processes.

Methods

Following protocol registration (Prospero n^o: CRD42021228867), relevant documents were identified, without language restrictions, through a systematic search of bibliographic databases (EMBASE, Scopus, Web of Science, MEDLINE), health care valuable representatives and the World Wide Web in April 2021. Data concerning QIs, measurement tools and compliance standards were extracted from European and North American sources in duplicate with 98% reviewer agreement.

Results

There were 89 QIs found from 22 selected documents (QI per document mean 13.5 with standard deviation 11.9). The Belgian (38 QIs) and the EUSOMA (European Society of Breast Cancer Specialists) (34 QIs) documents were the ones that best reported the QIs. No identical QI was identified in all the documents analysed. There were 67/89 QIs covering processes (75.3%) and 11/89 (12.4%) for each structure and outcomes QIs. There were 21/89 QIs for diagnosis (30.3%), 43/89 for treatment (48.3%), and 19/89 for staging, counselling, follow-up and rehabilitation (21.4%). Of 67 process QIs and 11 outcome QIs, 20/78 (26%) did not report a minimum standard of care. Shared decision making was only included as a QI in the Italian document.

Conclusion

More than half of countries have not established a national clinical pathway or integrated breast cancer care process to achieve the excellence of BC care. There was heterogeneity in QIs for the evaluation of BC care quality. Over two-thirds of the clinical pathways and integrated health care processes did not provide a minimum auditable standard of care for compliance, leaving open the definition of best practice. There is a need for harmonisation of BC care QIs.

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The quality of breast cancer care has become a preference for health systems.

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There was no established set of quality indicators to harmonise BC quality management’s evaluation. A consensus is needed.

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Most of the integrated breast cancer care processes or clinical pathways did not indicate any standard for care compliance.

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No quality indicators specifically related to patient satisfaction or Primary care were found in our study.

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Shared decision making was only included as a QI in the Italian document.

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There is a vast space for improvement, and future studies should pay attention to this issue.

Breast Cancer Care Quality Indicators in Spain: A Systematic Review

Breast cancer (BC) management care requires an increment in quality. An initiative to improve the BC quality care is registered, and quality indicators (QIs) are studied. We appraised the appearance of QIs and their standards systematically in Spain. A prospective systematic search (Prospero no: CRD42021228867) for clinical pathways and integrated breast cancer care processes was conducted through databases and the World Wide Web in February 2021. Duplicate data extraction was performed with 98% reviewer agreement. Seventy-four QIs (QI per document mean: 11; standard deviation: 10.59) were found in 15 documents. The Catalonian document had the highest number of QIs (n = 30). No QI appeared in all the documents. There were 9/74 QIs covering structure (12.16%), 53/74 covering process (71.62%), and 12/74 covering outcome (16.22%). A total of 22/66 (33.33%) process and outcome QIs did not set a minimum standard of care. QIs related to primary care, patient satisfaction, and shared decision making were deficient. Most of the documents established a BC QI standard for compliance, but the high variability hinders the comparison of outcomes. Establishing a consensus-based set of QIs needs urgent attention.

Quality indicators for hyperthermia treatment: Italian survey analysis

AIM

Nowadays, no Quality Indicators (QI) have been proposed for Hyperthermia treatments. Starting from radiotherapy experience, the aim of this work is to adapt radiotherapy indicators to Hyperthermia and to propose a new specific set of QI in Hyperthermia field.

MATERIAL AND METHODS

At first, radiotherapy quality indicators published in literature have been adapted to hyperthermia setting. Moreover, new specific indicators for the treatment of hyperthermia have been defined. To obtain the standard reference values of quality indicators, a questionnaire was sent to 7 Italian hyperthermia Institutes with a list of questions on physical and clinical hyperthermia treatment in order to highlight the different therapeutic approaches.

RESULTS

Three structure, five process and two outcome QI were selected. It has been possible to adapt seven indicators from radiotherapy, while three indicators have been defined as new specific indicators for hyperthermia. Average values used as standard reference values have been obtained and proposed.

CONCLUSION

The survey performed on 7 Italian centres allowed to derive the standard reference value for each indicator. The proposed indicators are available to be investigated and applied by a larger number of Institutes in which hyperthermia treatment is performed in order to monitor the operational procedures and to confirm or modify the reference standard value derived for each indicator.

Cancer of the head and neck: a set of indicators based on register and administrative data

SUMMARY

Head and neck (H&N) tumours are a heterogeneous group of neoplasms with 5-year relative survival ranging from about 25% for the hypopharynx to 60% for the larynx in Europe. To improve survival rates, along with therapeutic improvements, it is important to standardise and optimise care received by patients with H&N tumours across different healthcare providers. To reach this goal, it is necessary to evaluate adherence to standards of received care at a population level. Published guidelines can serve as the basis to develop indicators, which can be computed from administrative health databases, measuring the adherence to specific recommendations at the individual level in unselected H&N cancer patients, identified from a population cancer register. We developed a set of indicators and calculated them in a cohort of 2007-2012 incident cases of H&N tumours in the cancer register of the Milan province (n = 1441 cases). The study cohort was mainly composed of men (77%) and patients older than 50 years (89%). Surgery was the most frequently employed treatment (66%). Ten percent of patients had no recorded treatment. Timing between cyto-histological assessment and first therapy for those having a recorded microscopic verification procedure was ≤ 60 days for 90.4% of patients undergoing surgery, 86.3% of those undergoing radiotherapy, and 90.7% of patients receiving chemotherapy. Eighty-three percent of patients underwent cyto-histological assessment in the 180 days before the first treatment. Evaluation by a pain therapist, opioid therapy or hospitalisation for palliative therapy in the 90 days before death was performed in 51% of patients who eventually died of cancer. This is the first Italian study defining and calculating quality indicators to monitor adherence to standards of care received by H&N cancer patients at a population level.

Development of quality indicators to monitor radiotherapy care for men with prostate cancer: A modified Delphi method

BACKGROUND AND PURPOSE

Quality indicators (QIs) have been developed for many aspects of prostate cancer care, but are under-developed with regard to radiotherapy treatment. We aimed to develop a valid, relevant and feasible set of core QIs to measure quality of radiotherapy care in men with prostate cancer.

MATERIALS AND METHODS

We used a RAND-modified Delphi process to select QIs that were regarded as both important and feasible measures of quality radiotherapy care. This involved two phases: (1) a literature review to identify a list of proposed QIs; and (2) a QI selection process by an expert panel (n = 12) conducted in a series of three rounds: two online questionnaires' and one face-to-face meeting. The RAND criterion identified variation in ratings and determined the level of agreement after each round of voting.

RESULTS

A total of 144 candidate QIs, which included measures from pre-treatment to post-treatment and survivorship care were identified. After three rounds of voting, the panel approved a comprehensive set of 17 QIs, with most assessing a process of care (n = 16, 94.1%) and the remaining assessing a health outcome.

CONCLUSION

This study developed a core set of 17 QIs which will be used to report from the Prostate Cancer Outcomes Registry-Australia & New Zealand, to monitor the quality of radiotherapy care prostate cancer patients receive.

Improving the quality of radiation oncology: 10years' experience of QUATRO audits in the IAEA Europe Region

BACKGROUND AND PURPOSE

The IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region.

MATERIALS AND METHODS

The 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations).

RESULTS

Overall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO.

CONCLUSIONS

This analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.

Assessment of performance indicators of a radiotherapy department using an electronic medical record system

AIM

To retrospectively assess the performance indicators of our radiotherapy department and their temporal trends, using a commercially available electronic-medical-record (EMR) system.

BACKGROUND

A recent trend in healthcare quality is to define and evaluate performance indicators of the service provided.

MATERIALS AND METHODS

Patient and external-beam-radiotherapy-treatments data were retrieved using the Mosaiq EMR system from 1-January-2012 till 31-December-2015. Annual performance indicators were evaluated as: productivity (number of new cases/year and diagnosis distribution); complexity (ratio of Volumetric-Modulated-Arc-Therapy (VMAT) courses, average number of imaging procedures/patient); and quality (average, median and 90th percentile waiting times from admission to first treatment). The temporal trends of all performance indicators were assessed by linear regression.

RESULTS

Productivity: the number of new cases/year increased with an average rate of 4%. Diagnosis distribution showed that breast is the main pathology treated, followed by gastro-intestinal and head-and-neck. Complexity: the ratio of VMAT courses increased from 13% to 35%, with an average rate of 7% per year. The average number of imaging procedures/patient increased from 8 to 11. Quality: the waiting times from admission to treatment remained stable over time (R² ≤ 0.1), with average, median and 90th percentile values around 20, 15, and 31 days, respectively.

CONCLUSIONS

An EMR system can be used to: monitor the performance indicators of a radiotherapy department, identify workflow processes needing attention and improvement, estimate future demands of resources. Temporal analysis of our data showed an increasing trend in productivity and complexity paired with constant waiting times.

Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda

PURPOSE

As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer center.

PATIENTS AND METHODS

We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis.

RESULTS

Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor-positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up.

CONCLUSION

Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.

Quality indicators in the management of bladder cancer: A modified Delphi study

BACKGROUND

Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement.

OBJECTIVE

To produce an evidence- and consensus-based list of QIs for the management of bladder cancer.

METHODS

A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed.

RESULTS

A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed.

CONCLUSIONS

This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.

Quality indicators for thyroid cancer surgery: current perspective

INTRODUCTION

While the disease specific mortality of differentiated thyroid cancer has remained low with current treatments, its incidence has been steadily rising over the past several decades, and cancer related recurrence and morbidity have remained a significant problem. Quality indicators currently employed are relevant to the surgical intervention, but do not necessarily reflect oncological outcomes. Therefore, thyroid cancer specific surgical quality indicators, that offer insight into risk of cancer related morbidity and mortality are needed.

AREAS COVERED

This review aims to discuss the role of measuring quality in thyroid surgical oncology and carry out a comprehensive review of potential quality indicators for thyroid cancer operations. The three quality indicators reviewed here are the postoperative radioactive iodine update by remnant thyroid tissue, the proportion of resected lymph nodes with evidence of metastases, and the post-operative serum thyroglobulin level. Expert commentary: Together, these quality indicators may be utilized to guide improvement of the quality of surgical care for this unique patient population. A critical future step in establishing the role of quality indicators for thyroid cancer surgery is the determination of cutoff values of each indicator in an evidence-based manner.

Indicators based on registers and administrative data for breast cancer: routine evaluation of oncologic care pathway can be implemented

RATIONALE, AIMS AND OBJECTIVES

Assuring the best standards of care - in a sustainable way - in chronic diseases as breast cancer is nowadays an important challenge for any health system. The aim of this study was to present the methodology used to define a set of quality indicators, computable from administrative data for the pathway of care of breast cancer, and its application at a population level.

METHOD

The cohort of 2007-2009 incident cases of breast cancer was identified through a network of six cancer registers in Northern Italy. Cases of sarcoma and lymphoma, patients with multiple primary cancers and those metastatic at diagnosis were excluded; 9614 women were retained for the analysis. For each indicator, the sub-cohort of women eligible for the diagnostic/therapeutic procedures was identified and calculations were performed through record linkage between the cohort and sources of health information. Data on potential available confounders or prognostic factors were also collected.

RESULTS

For a few indicators, such as cyto-histological assessment before surgery (62%) and intensive follow-up (79%), deviation from recommendations was evident. Younger patients (≤50 years) more frequently needed a short term re-intervention, while older patients less frequently underwent reconstructive surgery and received palliative care. Several indicators had a great variability across hospitals. In some cases, this heterogeneity appeared to be related to the hospital size, with high-volume hospitals being more compliant to guidelines.

CONCLUSION

It is possible to evaluate the quality of cancer care delivered in clinical practice in recent years, in order to implement interventions aimed to improve adherence to international standards of care.

Quality indicators for prostate radiotherapy: are patients disadvantaged by receiving treatment in a 'generalist' centre?

INTRODUCTION

The purpose of this retrospective review was to evaluate concordance with evidence-based quality indicator guidelines for prostate cancer patients treated radically in a 'generalist' (as distinct from 'sub-specialist') centre. We were concerned that the quality of treatment may be lower in a generalist centre. If so, the findings could have relevance for many radiotherapy departments that treat prostate cancer.

METHODS

Two hundred fifteen consecutive patients received external beam radiotherapy (EBRT) and/or brachytherapy between 1.10.11 and 30.9.12. Treatment was deemed to be in line with evidence-based guidelines if the dose was: (i) 73.8-81 Gy at 1.8-2.0 Gy/fraction for EBRT alone (eviQ guidelines); (ii) 40-50 Gy (EBRT) for EBRT plus high-dose rate (HDR) brachytherapy boost (National Comprehensive Cancer Network (NCCN) guidelines); and (iii) 145 Gy for low dose rate (LDR) I-125 monotherapy (NCCN). Additionally, EBRT beam energy should be ≥6 MV using three-dimensional conformal RT (3D-CRT) or intensity-modulated RT (IMRT), and high-risk patients should receive neo-adjuvant androgen-deprivation therapy (ADT) (eviQ/NCCN). Treatment of pelvic nodes was also assessed.

RESULTS

One hundred four high-risk, 84 intermediate-risk and 27 low-risk patients (NCCN criteria) were managed by eight of nine radiation oncologists. Concordance with guideline doses was confirmed in: (i) 125 of 136 patients (92%) treated with EBRT alone; (ii) 32 of 34 patients (94%) treated with EBRT + HDR BRT boost; and (iii) 45 of 45 patients (100%) treated with LDR BRT alone. All EBRT patients were treated with ≥6 MV beams using 3D-CRT (78%) or IMRT (22%). 84%, 21% and 0% of high-risk, intermediate-risk and low-risk patients received ADT, respectively. Overall treatment modality choice (including ADT use and duration where assessable) was concordant with guidelines for 176/207 (85%) of patients.

CONCLUSION

The vast majority of patients were treated concordant with evidence-based guidelines suggesting that, within the limits of the selected criteria, prostate cancer patients are unlikely to be disadvantaged by receiving radiotherapy in this 'generalist' centre.

[Quality assurance in head and neck medical oncology]

In medical oncology, how can we be sure that the right drug is being administered to the right patient at the right time? The implementation of quality assurance criteria is important in medical oncology, in order to ensure that the patient receives the best treatment safely. There is very little literature about quality assurance in medical oncology, as opposed to radiotherapy or cancer surgery. Quality assurance must cover the entire patient care process, from the diagnosis, to the therapeutic decision and drug distribution, including its selection, its preparation and its delivery to the patient (administration and dosage), and finally the potential side effects and their management. The dose-intensity respect is crucial, and its reduction can negatively affect overall survival rates, as shown in breast and testis cancers for example. In head and neck medical oncology, it is essential to respect the few well-standardized recommendations and the dose-intensity, in a population with numerous comorbidities. We will first review quality assurance criteria for the general medical oncology organization and then focus on head and neck medical oncology. We will then describe administration specificities of head and neck treatments (chemoradiation, radiation plus cetuximab, postoperative chemoradiation, induction and palliative chemotherapy) as well as their follow-up. Lastly, we will offer some recommendations to improve quality assurance in head and neck medical oncology.

American Society for Radiation Oncology's Performance Assessment for the Advancement of Radiation Oncology Treatment: A practical approach for informing practice improvement

PURPOSE

Performance Assessment for the Advancement of Radiation Oncology Treatment (PAAROT) is a practice quality improvement program. This study seeks to determine baseline performance rates and practice variation from PAAROT data.

METHODS AND MATERIALS

The cohort includes all physicians from academic, hospital, and free-standing settings who completed at least 10 consecutive self-audited medical records in the PAAROT program (version 2.5) from 2010 to 2011 (n = 519 medical records). Mean performance rates were analyzed at the physician and medical record levels and, where appropriate, were stratified by the physician's practice setting.

RESULTS

Forty-nine physicians were included in the study; 22 (45%), 17 (35%), and 10 (20%) physicians practiced in a hospital, academic, or a free-standing setting, respectively. The measures with a high adoption rate (more than 80%) include the following: documentation of history and physical; review of physics and dosimetry plan by radiation oncologist; patient informed risks of therapy; evaluation of acute symptoms during therapy; pathology in consultation note; communication of treatment summary within 30 days of treatment completion; documentation of intent of treatment, use of clinical guidelines or published data; and documentation of American Joint Committee on Cancer staging. Lower rates of adoption were noted (mean, 65%; range, 0-100%) when these measures were converted to a composite measure. Low adherence was noted for screening of a pain using a standard scale (mean, 58%; range, 0-100%). Physicians from an academic setting scored higher on the composite measure (40%) compared with those from a hospital setting (36%) and from a free-standing setting (24%); (P < .001). Physicians from a hospital setting scored higher on the quality indicator of screening for pain (54%) compared with physicians from an academic setting (35%) and free-standing setting (11%) (P < .001).

CONCLUSIONS

This first assessment of PAAROT (version 2.5) data provides an initial snapshot on the use of quality indicators and practice patterns for radiation oncology. Self-reported practice data and the use of quality indicators will become important for the purpose of continuous, prospective evidence-based learning on an individual basis. Despite the small sample size, the data from this study will help address potential improvement opportunities for the next iteration of the PAAROT program.

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.

Quality standards in radiation medicine

PURPOSE

Identifying and conducting "best practice" medicine is arguably the ubiquitous goal of practitioners. However, to distill the many available quality standards, guidelines, recommendations, and indicators down to a best practice set requires a logical schema to group standards addressing similar quality issues and, from manageable lists of related standards, to extract the essential dimensions of quality. The purpose of this study was to explore a method of collating publicly available quality standards, in this case in radiation therapy, using a 2-step decision tree approach with statistical analysis. Successful grouping into manageable lists, addressing related quality issues, informs the ongoing development of quality indicators that are one expression of "best practice."

METHODS AND MATERIALS

A comprehensive literature search was used to identify quality standards currently in use and publicly available. Using 2 decision trees, 5 evaluators assigned each standard to Donabedian's structure, process, or outcome and also to the target of the standard: patients, staff, equipment or clinical process, or organization for a total of 3 × 4 = 12 primary categories.

RESULTS

A total of 454 radiation medicine program quality standards spread across 8 national and international documents was identified. Agreement between the 5 evaluators, using the free marginal kappa statistic, ranged from fair to almost perfect. In all but 2% of 5 × 454 evaluations were the evaluators able to assign a statement to categories in the decision trees suggesting that these trees are appropriate to the task. In only 3/454 was a majority (≥ 3/5) decision not reached on the assignment to structure, process, or outcome. Sixty-four percent of the standards were identified with structure, 26% with process and 10% with outcome.

CONCLUSIONS

Donabedian's model constitutes a reliable method of managing quality standards. The 2-step decision tree framework can be applied to inform the further development of national and international quality standards.

Quality indicators in radiation oncology

Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, the field of radiation oncology has a long history of organized quality assessment efforts and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. This report provides a comprehensive review of the current state of quality assessment in radiation oncology. Specifically, this report highlights implications of the healthcare quality movement for radiation oncology and reviews existing efforts to define and measure quality in the field, with focus on dimensions of quality specific to radiation oncology within the "big picture" of oncologic quality assessment efforts.