Trends in Gynecologic Cancer Care in North America

Screening log: Challenges in community patient recruitment for gynecologic oncology clinical trials

Background

Clinical trial participation can improve overall survival and mitigate healthcare disparities for gynecologic cancer patients in low-volume community centers. This study aimed to assess the effectiveness of a centrally regulated but administratively decentralized electronic screening log system to identify eligible patients across a large catchment area for a National Cancer Institute (NCI)-designated cancer center's open clinical trials.

Methods

Electronic screening log data collected between 2014 and 2021 from ten community partner sites in a single NCI-designated cancer center's catchment area were reviewed retrospectively. Clinical factors assessed included cancer site, primary versus recurrent disease status, and histology. Identification efficiency (the ratio of patients screened identified with an available trial) was calculated. Identification inefficiencies (failures to identify patients with a potentially relevant trial) were assessed, and etiologies were characterized.

Results

Across ten community partner sites, 492 gynecologic cancer patients were screened for seven open clinical trials during the study period. This included 170 (34.5 %) ovarian cancer patients, 156 (31.7 %) endometrial cancer patients, and 119 (24.2 %) cervical cancer patients. Over 40 % had advanced stage disease, and 10.6 % had recurrent disease. Only three patients were identified as having a relevant open trial; none ultimately enrolled due to not meeting trial eligibility criteria. An additional 2-52 patients were retrospectively found to have a relevant trial available despite not being identified as such within the electronic screening log system. Up to 14.4 % of patients had one or more missing minimum data elements that hindered full evaluation of clinical trial availability. Re-screening patients when new trials open may identify 12-15 additional patients per recurrent disease trial.

Conclusions

An electronic screening log system can increase awareness of gynecologic oncology clinical trials at a NCI-designated cancer center's community partner sites. However, it is inadequate as a single intervention to increase clinical trial enrollment. Providing adequate support staff, documenting clinical factors consistently, re-screening patients at relevant intervals, and coordinating with central study personnel may increase its utility.

Postoperative venous thromboembolism risk in patients with vulvar carcinoma: An analysis of the National surgical Quality Improvement Program (NSQIP) database

Objectives

Due to low incidence of vulvar cancer (VC), incidence and predictors for development of venous thromboembolism (VTE) are poorly understood. We examined incidence and risk factors associated with VTE in patients undergoing surgery for VC.

Methods

We included patients who underwent surgery for VC from the National Surgical Quality Improvement Program database. VTE within the 30-day postoperative period was captured with Current Procedural Terminology codes. Baseline demographics and clinical characteristics were compared between patients with and without VTE. Univariable and multivariable-adjusted exact logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and VTE.

Results

We identified 1414 patients undergoing procedures for VC from the NSQIP database. Overall, 11 (0.8 %) patients developed VTE. Univariable predictors of VTE included surgery type [compared with simple vulvectomy: radical vulvectomy only (OR = 7.97, 95 % CI = 1.44, infinity) and radical vulvectomy plus unilateral IFN (OR = 15.98, 95 % CI = 2.70, infinity)], unplanned readmission (OR = 11.56, 95 % CI = 2.74, 46.38), deep surgical site infection (OR = 16.05, 95 % CI = 1.59-85.50), and preoperative thrombocytosis (OR = 6.53, 95 % CI = 0.00, 34.86). In a multivariable-adjusted model, longer operative time (≥72 min OR = 11.33, 95 % CI = 1.58-499.03) and preoperative functional status [compared with complete independence: total dependence (OR = 53.88, 95 % CI = 0.85, infinity) and partial dependence (OR = 53.88, 95 % CI = 0.85, infinity)] were associated with VTE.

Conclusion

In this cohort of patients with VC undergoing radical vulvectomy, VTE incidence was low. Surgery type, longer operative time, dependent functional status, and wound disruption were identified as risk factors. Our findings highlight opportunities for prophylactic intervention in certain patients.

Pre-pandemic geographic access to hospital-based telehealth for cancer care in the United States

IMPORTANCE

Little is known about US hospitals' capacity to ensure equitable provision of cancer care through telehealth.

OBJECTIVE

To conduct a national analysis of hospitals' provision of telehealth and oncologic services prior to the SARS-CoV-2 pandemic, along with geographic and sociodemographic correlates of access.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional analysis with Geographic Information Systems mapping of 1) 2019 American Hospital Association (AHA) Annual Hospital Survey and IT Supplement, 2) 2013 Urban Influence Codes (UIC) from the United States Department of Agriculture, 3) 2018 Area Health Resources Files from the Health Services and Resources Administration (HRSA).

INTERVENTIONS

Hospitals were categorized by telehealth and oncology services availability. Counties were classified as low-, moderate-, or high-access based on availability of hospital-based oncology and telehealth within their boundaries.

MAIN OUTCOMES AND MEASURES

Geospatial mapping of access to hospital-based telehealth for cancer care. Generalized logistic mixed effects models identified associations between sociodemographic factors and county- and hospital-level access to telehealth and oncology care.

RESULTS

2,054 out of 4,540 hospitals (45.2%) reported both telehealth and oncology services. 272 hospitals (6.0%) offered oncology without telehealth, 1,369 (30.2%) offered telehealth without oncology, and 845 (18.6%) hospitals offered neither. 1,288 out of 3,152 counties with 26.6 million residents across 41 states had no hospital-based access to either oncology or telehealth. After adjustment, rural hospitals were less likely than urban hospitals to offer telehealth alongside existing oncology care (OR 0.27; 95% CI 0.14-0.55; p < .001). No county-level factors were significantly associated with telehealth availability among hospitals with oncology.

CONCLUSIONS AND RELEVANCE

Hospital-based cancer care and telehealth are widely available across the US; however, 8.4% of patients are at risk for geographic barriers to cancer care. Advocacy for adoption of telehealth is critical to ensuring equitable access to high-quality cancer care, ultimately reducing place-based outcomes disparities. Detailed, prospective, data collection on telehealth utilization for cancer care is also needed to ensure improvement in geographic access inequities.

Patterns of First-Line Systemic Therapy Delivery and Outcomes in Advanced Epithelial Ovarian Cancer in Ontario

Background: First-line treatment of epithelial ovarian cancer (EOC) consists of a combination of cytoreductive surgery and platinum-based chemotherapy. Recently, targeted therapies such as bevacizumab have been shown to improve oncologic outcomes in a subset of a high-risk population. The objective of this study is to evaluate the patterns of practice and outcomes of first-line systemic treatment of advanced EOC, focusing on the adoption of bevacizumab. Methods: A population cohort study was conducted using administrative data in Ontario, Canada. Patients diagnosed with advanced stage non-mucinous EOC between 2014 and 2018 were identified. Datasets were linked to obtaining information on first-line treatment including surgery, systemic therapy, providers of care, systemic therapy facilities, and acute care utilization (emergency department (ED) visits and hospitalizations) during systemic treatment. Multivariate logistic regression was used to determine factors associated with systemic therapy utilization. Results: Among 3726 patients with advanced EOC, 2838 (76%) received chemotherapy: 1316 (47%) received neoadjuvant chemotherapy, 1060 (37%) underwent primary cytoreductive surgery followed by chemotherapy, and 462 (16%) received chemotherapy only. The median age was 67 (range: 20–100). Most chemotherapies were prescribed by gynecologic oncologists (60%) and in level 1 academic cancer centres (58%). Only 54 patients (3.1%) received bevacizumab in the first-line setting after its approval in Ontario in 2016. Bevacizumab was more likely to be administered by medical oncologists compared to gynecologic oncologists (OR 3.95, 95% CI 2.11–7.14). In total, 1561 (55%) and 1594 (56%) patients had at least one ED visit and/or hospitalization during systemic treatment, respectively. The most common reasons for ED visits were fever and bowel obstruction. Conclusion: Patterns of care for EOC in Ontario differed between care providers. The uptake of bevacizumab for first-line treatment of EOC was low. Acute care utilization related to EOC was high.

Effect of Digital Care Platforms on Quality of Care for Oncological Patients and Barriers and Facilitators for Their Implementation: Systematic Review

BACKGROUND

Oncological health care services are challenged by the increasing number of cancer survivors, long-term follow-up care, and fragmentation of care. Digital care platforms are potential tools to deliver affordable, patient-centered oncological care. Previous reviews evaluated only one feature of a digital care platform or did not evaluate the effect on enhancement of information, self-efficacy, continuity of care, or patient- and health care provider-reported experiences. Additionally, they have not focused on the barriers and facilitators for implementation of a digital care platform in oncological care.

OBJECTIVE

The aim of this systematic review was to collect the best available evidence of the effect of a digital care platform on quality of care parameters such as enhancement of available information, self-efficacy, continuity of care, and patient- and health care provider-reported experiences. Additionally, barriers and facilitators for implementation of digital care platforms were analyzed.

METHODS

The PubMed (Medline), Embase, CINAHL, and Cochrane Library databases were searched for the period from January 2000 to May 2020 for studies assessing the effect of a digital care platform on the predefined outcome parameters in oncological patients and studies describing barriers and facilitators for implementation. Synthesis of the results was performed qualitatively. Barriers and facilitators were categorized according to the framework of Grol and Wensing. The Mixed Methods Appraisal Tool was used for critical appraisal of the studies.

RESULTS

Seventeen studies were included for final analysis, comprising 8 clinical studies on the effectiveness of the digital care platform and 13 studies describing barriers and facilitators. Usage of a digital care platform appeared to enhance the availability of information and self-efficacy. There were no data available on the effect of a digital care platform on the continuity of care. However, based on focus group interviews, digital care platforms could potentially improve continuity of care by optimizing the exchange of patient information across institutes. Patient-reported experiences such as satisfaction with the platform were considerably positive. Most barriers for implementation were identified at the professional level, such as the concern for increased workload and unattended release of medical information to patients. Most facilitators were found at the patient and innovation levels, such as improved patient-doctor communication and patient empowerment. There were few barriers and facilitators mentioned at the economic and political levels.

CONCLUSIONS

The use of digital care platforms is associated with better quality of care through enhancement of availability of information and increased self-efficacy for oncological patients. The numerous facilitators identified at the patient level illustrate that patients are positive toward a digital care platform. However, despite these favorable results, robust evidence concerning the effectiveness of digital care platforms, especially from high-quality studies, is still lacking. Future studies should therefore aim to further investigate the effectiveness of digital care platforms, and the barriers and facilitators to their implementation at the economic and political levels.

Uterine Cancer Mortality in White and African American Females in Southeastern North Carolina

The residents of southeastern North Carolina (NC) are exposed to multiple socioeconomic and environmental risk factors and have higher mortality rates for a number of diseases. Uterine cancer mortality is known to vary dramatically by race, so we analyzed uterine cancer mortality in populations defined by zip codes in this area to investigate the contributions of various environmental risk factors to race-specific disease patterns. Methods. Zip code specific mortality and hospital admissions for uterine cancer from 2007 to 2013 were analyzed using the NC State Center for Health Statistics data and the Inpatient Database of the Healthcare Cost and Utilization Project datafiles, respectively. Results were adjusted for age, income, education, health insurance coverage, prevalence of current smokers, and density of primary care providers. Results. Uterine cancer mortality rates were generally higher in African American (32.5/100,000, 95% CI = 18.9–46.1) compared to White (19.6/100,000, 95% CI = 12.3–26.9) females. Odds ratios (ORs) of uterine cancer death were higher in White females (OR = 2.27, p < 0.0001) residing within zip codes with hog concentrated animal feeding operations (CAFOs) (hog density >215 hogs/km²) than in White females residing in non-CAFO communities. African American females living near CAFOs had less pronounced increase of uterine cancer death (OR = 1.08, p=0.7657). Conclusion. White females living in adjacent to hog CAFOs areas of southeastern NC have lower rates of mortality from uterine cancer than African American females, but they have higher odds of death compared to their counterparts living in other NC areas. African American females living near CAFOs also have modest increases from their high baseline mortality. While the observed associations do not prove a causation, improving access to screening and medical care is important to mitigate this health issues in southeastern NC.

Telemedicine and Gynecologic Cancer Care

Patients with gynecologic cancers experience better outcomes when treated by specialists and institutions with experience in their diseases. Unfortunately, high-volume centers tend to be located in densely populated regions, leaving many women with geographic barriers to care. Remote management through telemedicine offers the possibility of decreasing these disparities by extending the reach of specialty expertise and minimizing travel burdens. Telemedicine can assist in diagnosis, treatment planning, preoperative and postoperative follow-up, administration of chemotherapy, provision of palliative care, and surveillance. Telemedical infrastructure requires careful consideration of the needs of relevant stakeholders including patients, caregivers, referring clinicians, specialists, and health system administrators.

Current Quality of Gynecologic Cancer Care in North America

Evaluating the quality of care received by gynecologic cancer patients in the real world is essential for excellent outcomes. The recent population-based literature looking at quality of care was reviewed for all gynecologic malignancies. Outcomes are generally highest when care is provided by high-volume providers in high-volume cancer centers. Provision of care according to clinical practice guidelines has also been demonstrated to improve outcomes in many situations. Disparities exist for marginalized groups in terms of the care they receive and subsequent outcomes. Health systems need to improve care for these populations.

Being treated in higher volume hospitals leads to longer progression-free survival for epithelial ovarian carcinoma patients in the Rhone-Alpes region of France

BACKGROUND

To investigate the relationship between hospital volume activities and the survival for Epithelial Ovarian Carcinoma (EOC) patients in France.

METHODS

This retrospective study using prospectively implemented databases was conducted on an exhaustive cohort of 267 patients undergoing first-line therapy during 2012 in the Rhone-Alpes Region of France. We compared Progression-Free Survival for Epithelial Ovarian Carcinoma patients receiving first-line therapy in high- (i.e. ≥ 12 cases/year) vs. low-volume hospitals. To control for selection bias, multivariate analysis and propensity scores were used. An adjusted Kaplan-Meier estimator and a univariate Cox model weighted by the propensity score were applied.

RESULTS

Patients treated in the low-volume hospitals had a probability of relapse (including death) that was almost two times (i.e. 1.94) higher than for patients treated in the high-volume hospitals (p < 0.001).

CONCLUSION

To our knowledge, this is the first study conducted in this setting in France. As reported in other countries, there was a significant positive association between greater volume of hospital care for EOC and patient survival. Other factors may also be important such as the quality of the surgical resection.

Disparities in Gynecological Malignancies

Objectives

Health disparities and inequalities in access to care among different socioeconomic, ethnic, and racial groups have been well documented in the U.S. healthcare system. In this review, we aimed to provide an overview of barriers to care contributing to health disparities in gynecological oncology management and to describe site-specific disparities in gynecologic care for endometrial, ovarian, and cervical cancer.

Methods

We performed a literature review of peer-reviewed academic and governmental publications focusing on disparities in gynecological care in the United States by searching PubMed and Google Scholar electronic databases.

Results

There are multiple important underlying issues that may contribute to the disparities in gynecological oncology management in the United States, namely geographic access and hospital-based discrepancies, research-based discrepancies, influence of socioeconomic and health insurance status, and finally the influence of race and biological factors. Despite the reduction in overall cancer-related deaths since the 1990s, the 5-year survival for Black women is significantly lower than for White women for each gynecologic cancer type and each stage of diagnosis. For ovarian and endometrial cancer, black patients are less likely to receive treatment consistent with evidence-based guidelines and have worse survival outcomes even after accounting for stage and comorbidities. For cervical and endometrial cancer, the mortality rate for black women remains twice that of White women.

Conclusion

Health care disparities in the incidence and outcome of gynecologic cancers are complex and involve biologic factors as well as racial, socioeconomic, and geographic barriers that influence treatment and survival. These barriers must be addressed to provide optimal care to women in the U.S. with gynecologic cancer.

Disparities in Vulvar Cancer Reported by the National Cancer Database: Influence of Sociodemographic Factors

OBJECTIVE

To assess whether there is an association of patient sociodemographic factors with stage at diagnosis, treatment, and overall survival in patients with vulvar cancer in the National Cancer Database.

METHODS

This was a retrospective cohort study of patients with primary squamous vulvar carcinoma identified from the National Cancer Database (1998-2004). Multivariate logistic regression was conducted to examine risk factors associated with advanced-stage (stage III or IV) disease at diagnosis. Multivariable Cox regression models were performed to explore risk factors associated with 5-year all-cause mortality.

RESULTS

Of 11,153 patients, 42.3% (n=4,713) were diagnosed with stage I disease, 24.6% (n=2,745) stage II, 22.9% (n=2,556) stage III, and 10.2% (n=1,139) stage IV. Advanced stage was significantly associated with older age, nonprivate insurance, and treatment at a lower case volume center (P<.01). Of note, roughly 30% of patients with advanced-stage disease did not receive radiation therapy. Within the advanced stages, age 60 years or older and insurance type were associated with decreased survival (P<.01). In stage III disease, only black race and treatment at a community hospital were associated with a lower risk of death (P<.01).

CONCLUSION

Patient sociodemographic and clinical characteristics are significantly associated with vulvar cancer stage presentation, treatment, and survival. Unfortunately, within this disease, surgical approaches and adjuvant radiation do not appear consistent.

LEVEL OF EVIDENCE

II.

Is It Time to Centralize Ovarian Cancer Care in the United States?

PURPOSE

The purpose of this article was to broadly review the most up-to-date information pertaining to the centralization of ovarian cancer care in the United States (US) and worldwide.

METHODS

Much of the present literature pertaining to disparities in, and centralization of, ovarian cancer care in the US and internationally was reviewed, and specifically included original research and review articles.

RESULTS

Data show improved optimal debulking rates, National Comprehensive Cancer Network (NCCN) guideline adherence, and overall survival rates in higher-volume, more specialized hospitals, and amongst higher-volume providers.

CONCLUSIONS

Patients with invasive epithelial ovarian cancer, especially those with higher stages (III and IV), are better served by centralized care in high-volume hospitals and by high-volume physicians, who adhere to NCCN guidelines wherever possible. More research is needed to determine the policy changes that can increase NCCN guideline adherence in low-volume hospitals and low-provider caseload scenarios. Policy and future research should be aimed at increasing patient access, either directly or indirectly, to high-volume hospital and high-volume providers, especially amongst Medicare, lower socioeconomic status, and minority patients.

Lung cancer care: the impact of facilities and area measures

Lung cancer is the leading cause of cancer related mortality in the US, and while treatment disparities by race and class have been well described in the literature, the impact of social determinates of health, and specific characteristics of the treatment centers have been less well characterized. As the treatment of lung cancer relies more upon a precision and personalized medicine approach, where patients obtain treatment has an impact on outcomes and could be a major factor in treatment disparities. The purpose of this manuscript is to discuss the manner in which lung cancer care can be impacted by poor access to high quality treatment centers, and how the built environment can be a mitigating factor in the pursuit of treatment equity.

Teleoncology for gynecologic cancers

Teleoncology describes cancer care provided remotely to improve access to care in rural or underserved areas. In the United States, 14.8 million women live more than 50 miles away from the closest gynecologic oncologist; 4.3 million women live more than 100 miles distant. Teleoncology may therefore partially relieve the geographic barriers to high-quality gynecologic cancer care these women experience. Little has been published on the feasibility of remote provision of high-quality care for gynecologic cancers, perhaps owing to the particular difficulties inherent in remote management of patients who may require both medical and surgical intervention. In this article, we review the data supporting the use of telemedicine in the treatment of cancer patients with a specific focus on applicability to management of gynecologic malignancies. We further add our group's experience with the treatment of rural, underserved gynecologic cancer patients. We believe that development of teleoncologic systems is critical to ensure that all women have access to high-quality gynecologic cancer care, regardless of where they reside.

Impact of National Cancer Institute Comprehensive Cancer Centers on ovarian cancer treatment and survival

BACKGROUND

The regional impact of care at a National Cancer Institute Comprehensive Cancer Center (NCI-CCC) on adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines and survival is unclear.

STUDY DESIGN

We performed a retrospective population-based study of consecutive patients diagnosed with epithelial ovarian cancer between January 1, 1996 and December 31, 2006 in southern California. Patients were stratified according to care at an NCI-CCC (n = 5), non-NCI high-volume hospital (≥ 10 cases/year, HVH, n = 29), or low-volume hospital (<10 cases/year, LVH, n = 158). Multivariable logistic regression and Cox-proportional hazards models were used to examine the effect of NCI-CCC status on treatment guideline adherence and ovarian cancer-specific survival.

RESULTS

A total of 9,933 patients were identified (stage I, 22.8%; stage II, 7.9%; stage III, 45.1%; stage IV, 24.2%), and 8.1% of patients were treated at NCI-CCCs. Overall, 35.7% of patients received NCCN guideline adherent care, and NCI-CCC status (odds ratio [OR] 1.00) was an independent predictor of adherence to treatment guidelines compared with HVHs (OR 0.83, 95% CI 0.70 to 0.99) and LVHs (OR 0.56, 95% CI 0.47 to 0.67). The median ovarian cancer-specific survivals according to hospital type were: NCI-CCC 77.9 (95% CI 61.4 to 92.9) months, HVH 51.9 (95% CI 49.2 to 55.7) months, and LVH 43.4 (95% CI 39.9 to 47.2) months (p < 0.0001). National Cancer Institute Comprehensive Cancer Center status (hazard ratio [HR] 1.00) was a statistically significant and independent predictor of improved survival compared with HVH (HR 1.18, 95% CI 1.04 to 1.33) and LVH (HR 1.30, 95% CI 1.15 to 1.47).

CONCLUSIONS

National Cancer Institute Comprehensive Cancer Center status is an independent predictor of adherence to ovarian cancer treatment guidelines and improved ovarian cancer-specific survival. These data validate NCI-CCC status as a structural health care characteristic correlated with superior ovarian cancer quality measure performance. Increased access to NCI-CCCs through regional concentration of care may be a mechanism to improve clinical outcomes.

Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status

OBJECTIVE

To determine the impact of geographic location on advanced-stage ovarian cancer care adherence to the National Comprehensive Cancer Network (NCCN) guidelines in relation to race and socioeconomic status (SES).

METHODS

Patients diagnosed with stage IIIC/IV epithelial ovarian cancer (1/1/96-12/31/06) were identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, proximity to a high-volume hospital (≥20 cases/year), distance traveled to receive care, race, and SES on adherence to NCCN guidelines, with simultaneous smoothing of geographic location and adjustment for confounding variables. Disparities in geographic predictors of treatment adherence were analyzed with the x(2) test for equality of proportions.

RESULTS

Of the 11,770 patients identified, 45.4% were treated according to NCCN guidelines. Black race (OR=1.49, 95%CI=1.21-1.83), low-SES (OR=1.46, 95%CI=1.24-1.72), and geographic location ≥80 km/50 mi from a high-volume hospital (OR=1.88, 95%CI=1.61-2.19) were independently associated with an increased risk of non-adherent care, while high-volume hospital treatment (OR=0.59, 95%CI=0.53-0.66) and travel distance to receive care ≥32 km/20 mi (OR=0.80, 95%CI=0.69-0.92) were independently protective. SES was inversely associated with location ≥80 km/50 mi from a high-volume hospital, ranging from 6.3% (high-SES) to 33.0% (low-SES) (p<0.0001). White patients were significantly more likely to travel ≥32 km/20 mi to receive care (21.8%) compared to Blacks (14.4%), Hispanics (15.9%), and Asian/Pacific Islanders (15.5%) (p<0.0001).

CONCLUSION

Geographic proximity to a high-volume hospital and travel distance to receive treatment are independently associated with NCCN guideline adherent care for advanced-stage ovarian cancer. Geographic barriers to standard ovarian cancer treatment disproportionately affect racial minorities and women of low-SES.

Adherence to treatment guidelines for ovarian cancer as a measure of quality care

OBJECTIVES

To validate National Comprehensive Cancer Network ovarian cancer guideline adherence as a quality process measure associated with improved survival, and to identify structural health care characteristics predictive of adherence to National Comprehensive Cancer Network guideline care.

METHODS

Consecutive patients with epithelial ovarian cancer diagnosed between 1 January 1999 and 31 December 2006 were identified from the California Cancer Registry. Adherence to National Comprehensive Cancer Network guideline care was defined by stage-appropriate surgical procedures and recommended chemotherapy. Multivariable logistic regression models were used to identify characteristics predictive of National Comprehensive Cancer Network guideline adherence and ovarian cancer-specific survival.

RESULTS

A total of 13,321 patients were identified. Overall, 37.2% of patients received National Comprehensive Cancer Network guideline-adherent care. Guideline-adherent care was associated with high-volume hospitals (20 or more cases per year; 50.8% compared with 34.1%; P<.001) and high-volume physicians (10 or more cases per year; 47.6% compared with 34.5%; P<.001). After controlling for other factors, both low-volume hospitals (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.66-2.01) and low-volume physicians (OR 1.19, 95% CI 1.07-1.32) were independently associated with deviation from National Comprehensive Cancer Network guidelines. On multivariable survival analysis, nonadherence to National Comprehensive Cancer Network guideline care was associated with decreased disease-specific survival (hazard ratio [HR] 1.33, 95% CI 1.26-1.41). Both low-volume hospitals (HR 1.08, 95% CI 1.01-1.16) and low-volume physicians (HR 1.18, 95% CI 1.09-1.28) were associated with decreased disease-specific survival after adjusting for National Comprehensive Cancer Network guideline-adherent care.

CONCLUSIONS

Adherence to National Comprehensive Cancer Network guidelines for treatment of ovarian cancer is correlated with improved survival and may be a useful process measure of quality cancer care. Ovarian cancer case volume correlates with a higher likelihood of recommended care and improved survival and may be a useful structural quality measure. Increased efforts to concentrate ovarian cancer care are warranted.

Consolidation of the North Shore-LIJ Health System anatomic pathology services: the challenge of subspecialization, operations, quality management, staffing, and education

OBJECTIVES

To describe our experience, both in meeting challenges and in reporting outcomes, of the consolidation of anatomic pathology services in the North Shore-LIJ Health System in February 2011.

METHODS

We addressed issues of governance, personnel, physical plant, quality programming, connectivity, and education.

CONCLUSIONS

The highly regulated nature of the laboratory industry and the fact that patient care necessarily never pauses require that such a consolidation take place without a break in service or degradation in turnaround time and quality while engaging personnel at all levels in the extra duties related to consolidation. Subspecialization has allowed us to better meet the needs of our in-system health care community while increasing our access to the competitive outreach marketplace.