Adherence to quality indicators and survival in patients with breast cancer

Evaluating the breast cancer quality of care indicators in Iran; multicenter study

BACKGROUND

Data on quality-of-care indicators for breast cancer patients is limited in low-and middle-income countries. We evaluated the indicators in Iran.

METHOD

A total of 21 quality-of-care indicators of breast cancer management defined by EUSOMA 2017 were selected. The indicators were retrospectively evaluated based on the data from the Clinical Breast Cancer Registry established in 11 provinces of Iran.

RESULT

In the study of 6,293 patients evaluated on 21 indicators, 15 indicators were more than 5% below EUSOMA's standard levels.

CONCLUSION

The defined indicators had a value lower than the suggested standards by EUSOMA. This study's results highlight important clues for intervention in improving breast cancer outcomes in Iran and other low-and middle-income countries.

The Impact of Implementing Indicators of Quality of Oncological Care on Improving Patient Outcomes: A Cross-Sectional Review of Experiences from Countries Using Indicators in the Quality Assessment Process

The implementation of QIs in the pursuit of improving patient outcomes in oncological care has become a primary goal for many countries. The purpose of this cross-sectional review is to present the experiences of several countries that have implemented different strategies in using QIs to assess the quality of cancer care. Countries such as the United States, the United Kingdom, Canada, the Netherlands, Australia, and Israel have been pioneers in integrating QIs into their healthcare systems, which has led to significant improvements in the delivery of care. These indicators help assess adherence to clinical guidelines, timeliness of treatment, safety of practices, and overall patient survival. Data from these countries show that the use of QIs correlates with improved five-year survival rates, earlier diagnosis, better adherence to evidence-based treatment protocols, and increased patient satisfaction. For example, in the Netherlands and Germany, the introduction of quality cancer care programs has led to improved surgical outcomes and overall survival for patients with colorectal cancer. The United Kingdom and Denmark have reported improvements in waiting times for diagnosis and treatment, and in Israel, screening rates for breast and colorectal cancer increased after the introduction of QIs for monitoring these conditions. The current review highlights the fact that countries with robust reporting systems and national cancer registries with high levels of data completeness, such as Denmark, Sweden, and Norway, were able to effectively monitor outcomes and adjust clinical practices accordingly. The findings suggest that implementing QIs in cancer care not only improves clinical outcomes but also promotes accountability and stimulates improved healthcare, ensuring better long-term patient care. This study highlights the value of adopting QIs as a global standard for assessing cancer care.

Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature

OBJECTIVES

Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs.

DESIGN

Scoping review of the scientific and gray literature.

METHODS

Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives.

RESULTS

Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy.

CONCLUSION AND IMPLICATIONS

Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

[Quality of healthcare in oncological patients from health personnel's perspective]

INTRODUCTION

The quality of care in health institutions is a constant challenge, mainly in oncology. The literature shows it has partially evaluated in contrast to it proposed by Donabedian; in addition, health personnel's perspective, who has direct contact with the patient, knows and executes the care process, has not been considered. The objective of the present study was to establish a framework to evaluate the quality of healthcare provided to patients with colorectal or ovarian cancer from health personnel's perspective.

MATERIAL AND METHODS

Cross-sectional study that included health personnel belonging to nine services of a cancer hospital. A questionnaire was applied to evaluate the quality of healthcare through amenities, the interpersonal and scientific-technical dimension (Donabedian's model). The variables were standardized, compliance with them among services was compared using non-parametric tests (Kruskal-Wallis test and Mann-Whitney U test), and 40 indicators were evaluated.

RESULTS

Health personnel's 181 members participated, the evaluated oncology hospital presented regular compliance to the quality of healthcare (bad ≤82, regular 83-109, good ≥110). When comparing this in the nine services, differences were detected between surgery and radiotherapy (higher compliance scores, 132 and 126 respectively) versus the other services P<.05. Both services had more than 25 indicators with compliance ≥80%.

CONCLUSIONS

It is shown that the established framework is useful for evaluating the quality of healthcare from health personnel's perspective (an approach not used so far for this type of evaluation), by detecting differences in its compliance, specific problems and its causes by service.

Expansion of the quality of care index on breast cancer and its risk factors using the global burden of disease study 2019

BACKGROUND

Breast cancer (BC), as the top neoplasm in prevalence and mortality in females, imposes a heavy burden on health systems. Evaluation of quality of care and management of patients with BC and its responsible risk factors was the aim of this study.

METHODS

We retrieved epidemiologic data of BC from the Global Burden of Disease (GBD) 1990-2019 database. Epidemiology and burden of BC and its risk factors were explored besides the Quality of Care Index (QCI) introduced before, to assess the provided care for patients with BC in various scales. Provided care for BC risk factors was investigated by their impact on years of life lost and years lived with disability by a novel risk factor quality index (rQCI). We used the socio-demographic index (SDI) to compare results in different socio-economic levels.

RESULTS

In 2019, 1,977,212 (95% UI: 1,807,615-2,145,215) new cases of BC in females and 25,143 (22,231-27,786) in males was diagnosed and this major cancer caused 688,562 (635,323-739,571) deaths in females and 12,098 (10,693-13,322) deaths in males, globally. The all-age number of deaths and disability-adjusted life years attributed to BC risk factors in females had an increasing pattern, with a more prominent pattern in metabolic risks. The global estimated age-standardized QCI for BC in females in 2019 was 78.7. The estimated QCI was highest in high SDI regions (95.7). The top countries with the highest calculated QCI in 2019 were Iceland (100), Japan (99.8), and Finland (98.8), and the bottom countries were Mozambique (16.0), Somalia (8.2), and Central African Republic (5.3). The global estimated age-standardized rQCI for females was 82.2 in 2019.

CONCLUSION

In spite of the partially restrained burden of BC in recent years, the attributable burden to risk factors has increased remarkably. Countries with higher SDI provided better care regarding both the condition and its responsible risk factors.

Evaluating Quality Indicators of Glioblastoma Care: Audit Results From an Indian Tertiary Care Cancer Center

PURPOSE

There are limited reports of quality metrics in glioblastoma. We audited our adherence to quality indicators as proposed in the PRIME Quality Improvement study.

METHODS

This is a retrospective audit of patients treated between 2017 and 2020. After postsurgical integrated diagnosis, patients received radiotherapy (RT) with concurrent and adjuvant temozolomide (TMZ). Multiparametric magnetic resonance imaging at predefined times guided management. Numbers with proportions for indices were calculated. Survival was estimated using the Kaplan-Meier method.

RESULTS

One hundred six patients were consecutively treated. The median age was 55 years (interquartile range of 47-61 years) with a male preponderance (68%). Ninety-six (90.6%) patients underwent subtotal resection, and 10 (9.4%) biopsy alone. Isocitrate dehydrogenase was wild-type in 96 (91%), and O⁶-methylguanine-DNA methyltransferase was unmethylated in 70 (66.0%) patients. Telomerase reverse transcriptase promoter was mutated in 64 (60.4%), and TP53 was mutated in 22 (20.8%). Concurrent radiation and TMZ were planned for 104 (98.1%), and radiation alone for 2 (1.9%). The median time to concurrent RT-TMZ was 36 days (interquartile range 30-44 days). All patients planned for RT-TMZ completed treatment, but only 81 (76%) completed adjuvant TMZ. Sixty-three (59%) completed six cycles, 18 (17%) received less than six cycles, and 25 (24%) did not receive adjuvant TMZ. At a median follow-up of 24 months (range 21-31 months), the median (95% CI) progression-free survival and overall survival were 11 (95% CI, 9.4 to 13.0) and 20.0 (95% CI, 15 to 26) months, respectively.

CONCLUSION

Our patients met quality indices in most domains; outcomes are comparable with global results. Metrics will be periodically evaluated to include new standards and assess continuous service appropriateness.

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review

INTRODUCTION

Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age.

METHODOLOGY

MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis.

RESULTS

Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age.

CONCLUSIONS

Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.

Impact of geographic distribution of accredited breast centers

The National Accreditation Program for Breast Centers (NAPBCs) is dedicated to improving the quality of care in patients with breast disease. Geographic distribution of health care resources is an important measure of quality, yet little is known regarding breast center allocation patterns concerning population demand and impact on health outcomes. The purpose of this study was to analyze the distribution of NAPBC programs in the United States (USA) and evaluate the impact on breast cancer survival. Using the Centers for Disease Control and Prevention 2014 data base, we identified the incidence and mortality rates for breast cancer by state. We also determined the concentration of NAPBC programs in each state (ie, the number of centers per 1000 cases of breast cancer). Data were analyzed using Spearman's (nonparametric) rank correlation coefficients. Five hundred and seventy NAPBC programs were identified. Across the United States, there was a mean of 2.8 programs/1000 breast cancer diagnoses. A positive correlation (r = .45) between breast cancer incidence and the number of programs was identified (P = .0009). There was no statistically significant correlation between mortality and NAPBC program concentration (r = -0.20, P = .16). NAPBC-accredited program distribution within the United States correlates with breast cancer incidence per state. However, the number of NAPBC programs per state did not alter overall mortality rates. Added measures beyond survival, as well as further insight into referral patterns to NAPBC programs, may be required to demonstrate the value and impact of NAPBC accreditation.

Staff nurses' evaluation of care process quality and patient outcomes in long-term care hospitals: A cross-sectional questionnaire survey

AIM

Despite the large and growing body of research on quality care evaluation and improvements in long-term care facilities, issues regarding the quality of care provided prevail worldwide. Further and more diverse research related to this topic is urgently required. To that end, this study examines the association between the subjective care process evaluations of nurses and selected patient outcomes in Japanese long-term care hospitals.

METHOD

To conduct a cross-sectional survey, we approached 2,000 long-term care hospitals in Japan, of which 263 (13.2%) completed and returned the questionnaires. We recruited ward managers and all full/part-time nurses in one ward from each hospital. We questioned managers about six patient outcome indicators: prevalence of physical restraint, urinary tract infections, indwelling catheter use, monthly incidence of new pressure ulcers, falls and recreational activities. We examined the nurses' care process evaluations using nine questions pertaining to daily caregiving activities developed from previous qualitative research. We examined the association between the ward averages of the nurses' evaluations and selected patient outcomes using the generalised linear model with a negative binomial distribution, with the exception of recreational activities for which we used a Poisson distribution, controlling for ward size and patient case mix.

RESULTS

We analysed the responses with complete data for outcome indicators from 199 (10.0%) managers and 2,508 nurses. Some patient outcome indicators were significantly associated with the nurses' care process evaluations, namely, urinary tract infections (B = -1.28, p < .001), indwelling catheter use (B = -0.57, p < .049), pressure ulcers (B = -1.20, p < .001) and recreational activities (B = 1.48, p < .001). These results suggest that better patient outcomes were associated with higher care process evaluations.

CONCLUSION

The nurses' evaluations and certain patient outcome indicators were associated. When considering potential quality improvement programmes, focusing on these evaluations will be beneficial.

Does regular quality control improve the quality of surgery in Slovenian breast cancer screening program?

Background The aim of our study was to evaluate the quality of surgery of Slovenian breast cancer screening program (DORA) using the requested EU standards. Furthermore, we investigated whether regular quality control over the 3-year period improved the quality of surgical management. Patients and methods Patients who required surgical management within DORA between January 1st, 2016 and December 31st, 2018 were included in the retrospective study. Quality indicators (QIs) were adjusted mainly according to European Society of Breast Cancer Specialists (EUSOMA) and European Breast Cancer Network (EBCN) recommendations. Five QIs for therapeutic and two for diagnostic surgeries were selected. Additionally, variability in achieving the requested QIs among surgeons was analysed. Results Between 2016 and 2018, 14 surgeons performed 1421 breast procedures in 1398 women. There were 1197 therapeutical (for proven breast cancer) and 224 diagnostic surgical interventions respectively. Overall, the minimal standard was met in two QIs for therapeutic and none for diagnostic procedures. A statistically significant improvement in three QIs for therapeutic and in one QI for diagnostic procedures was observed however, indicating that regular quality control improves the quality of surgery. A high variability in achieving the requested QIs was observed among surgeons, which remained high throughout the study period. Conclusions Adherence to all selected surgical QIs in patients from screening program is difficult to achieve, especially to those specifically defined for screen-detected lesions. Regular quality control may improve results over time. Reducing the number of surgeons dedicated to breast pathology may reduce variability of management inside the institution.

Using clinical cancer registry data for estimation of quality indicators: Results from the Norwegian breast cancer registry

INTRODUCTION

Increased focus on quality indicators and the use of clinical registries for breast cancer for real world studies have shown higher compliance to recommended therapy and better survival. In 2010, the European Society of Breast Cancer Specialist (EUSOMA) proposed quality indicators (QI) covering diagnosis, treatment and follow-up. To become a EUSOMA certified Breast Cancer Unit, 14 specified quality indicators, in addition to other requirements, need to be met. To evaluate the compliance and results of recommended treatment in breast cancer care in Norway and to improve the quality of epidemiological data, the Cancer Registry of Norway (CRN) in cooperation with the Norwegian Breast Cancer Group (NBCG) developed the Norwegian Breast Cancer Registry (NBCR). The objective of this study is to assess the feasibility of using the NBCR for estimating the EUSOMA QI individually for all hospitals diagnosing and treating breast cancer in Norway.

METHODS

To provide researchers with high quality cancer data as well as for the purpose of national cancer statistics, the CRN employs a cancer registry system to 1) longitudinal capture data from all patients from all medical entities that diagnose and/or treat cancer patients (e.g., pathology, radiology and clinical departments) in Norway; 2) curate data, i.e. validate the correctness of collected data, and assemble the validated cancer data as cancer cases; 3) provide data for analytics and presentation. Estimates for 10 EUSOMA QI were calculated at national and hospital level. To compare hospitals, a summary score of QIs was defined for each hospital.

RESULTS

All hospitals currently treating breast cancer patients have the technical ability to submit data to the NBCR for estimation of QIs defined by EUSOMA. Data from pathology and surgery are of high quality. However, data from oncological and radiological departments are incomplete, but improving. This currently hinders three QIs from being calculated. QI on benign to malign diagnosis needs to be calculated at the individual Breast Centre. Over time the adherence to guidelines have improved and the hospital variation for the respective QI have decreased. Two hospitals met all minimum standard on ten QIs in year 2016 and one hospital did not meet one minimum standard, but met all other targets.

CONCLUSION

The NBCR has since 2012 published annual reports on breast cancer care and for the year 2016 measured 10 of 14 QI defined by EUSOMA. Increased compliance of recommended treatment in Norway has been observed during the years the registry has been active.

Explaining variation in quality of breast cancer care and its impact: a nationwide population-based study from Slovenia

PURPOSE

To assess and explain variation in quality of care in breast cancer patients and estimate its impact on disease outcome.

METHODS

The Slovenian National Cancer Registry database and clinical records of 1053 women with unilateral primarily non-metastatic invasive breast cancer diagnosed in 2013 were reviewed in this retrospective analysis. Quality care was defined as care fully compliant with quality indicators (QI) defined by European Society of Breast Cancer Specialists (EUSOMA). Multivariate logistic regression was used to determine the predictors of receiving quality care. Differences in overall survival (OS) and event-free survival (EFS, relapse, or progression of disease or death considered an event) based on adherence to QI were analyzed using Kaplan-Meier method and Cox models.

RESULTS

Younger age, no comorbidities, and HER2-negative tumor were associated with increased odds ratios for receiving quality care, whereas tumor stage and type of hospital had no significant association. Median follow-up was 54.5 months. Not receiving quality care resulted in an increased risk of dying [hazard ratio (HR) 1.68; 95% confidence interval (CI) 1.06-2.66; p = 0.026]. Difference in EFS between two groups was significant after adjusting for case mix and type of hospital (HR 1.80; 95% CI 1.29-2.52; p = 0.001) but disappeared when type of treatment was added into the model (HR 1.30; 95% CI 0.89-1.90; p = 0.178).

CONCLUSION

Observed comorbidity and age bias in delivering quality breast cancer care could be medically justifiable, whereas observed deviations dependent on HER2 status are puzzling. Complete adherence of treatment to quality indicators resulted in better OS.

The Global and Regional Survival Rate of Women With Breast Cancer: A Systematic Review and Meta-analysis

Breast cancer is the most common cancer among women in the world. The aim of this study was to measure the global and regional survival rates of women with breast cancer. We searched Medline/PubMed, Web of Science, Scopus, and Google Scholar to identify cohort studies on the survival rate of women with primary invasive breast cancer until the end of June 2017. We used random effect models to estimate the pooled 1-, 3-, 5-, and 10-year survival rates. Subgroup analysis and meta-regression models were used to investigate the potential sources of heterogeneity. One hundred twenty-six studies were included in the meta-analysis. Between-study heterogeneities in the 1-, 3-, 5-, and 10-year survival rates were significantly high (all I²s > 50%; P = .001). The global 1-, 3-, 5-, and 10-year pooled survival rates in women with breast cancer were 0.92 (95% confidence interval [CI], 0.90-0.94), 0.75 (95% CI, 0.71-0.79), 0.73 (95% CI, 0.71-0.75), and 0.61% (95% CI, 0.54-0.67), respectively. Subgroup analysis revealed that survival rates varied in different World Health Organization regions, age and stage at diagnosis, year of the studies, and degree of development of countries. Meta-regression indicated that year of the study (β = 0.07; P = .002) and development of country (β = -0.1; P = .0001) were potential sources of heterogeneity. The survival rate was improved in recent decades; however, it is lower in developing regions than developed ones.

Quality of life of breast cancer survivors following breast-conserving therapy versus mastectomy: a multicenter study in Taiwan

Background

Breast cancer is the most common female malignancy worldwide. The aim of this study was to investigate the influence of surgical procedures and quality-of-care (QoC) on quality-of-life (QoL) among breast cancer survivors who underwent breast-conserving therapy (BCT) or mastectomy, and to identify provider- and patient-related factors pertaining to QoL.

Method

In this cross-sectional study, structured-questionnaires were distributed among breast cancer survivors in 19 hospitals. QoL was evaluated using the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and the breast cancer specific module (EORTC QLQ-BR23). QoC is indicated by adherence to the core measures stipulated for the treatment of breast cancer. Multiple regression and hierarchical linear modeling were used for multivariate analysis.

Results

A total of 544 female survivors of Stage 0-III breast cancer were included, among whom 217 (39.9%) underwent BCT and 327 (60.1%) underwent mastectomy. Surgical modality does not appear to have a notable impact on any QoL domains except body image; i.e. patients who underwent BCT reported better body image (diff = 11.20, P < 0.001), particularly at 1-5 years after the initial treatment. Independent factors including age, education, employment, marital status, income, chemotherapy, duration since treatment, recurrence status, primary hospital accreditation level and location all appear to be correlated to QoL.

Conclusion

Patients with breast cancer should be informed of differences in QoL when discussing treatment options. Furthermore, physicians should recognize that the impact of surgical treatment modality on QoL may vary according to patients' sociodemographic and clinical characteristics.

Improving radiation oncology through clinical audits: Introducing the IROCA project

As radiotherapy practice and processes become more complex, the need to assure quality control becomes ever greater. At present, no international consensus exists with regards to the optimal quality control indicators for radiotherapy; moreover, few clinical audits have been conducted in the field of radiotherapy. The present article describes the aims and current status of the international IROCA "Improving Radiation Oncology Through Clinical Audits" project. The project has several important aims, including the selection of key quality indicators, the design and implementation of an international audit, and the harmonization of key aspects of radiotherapy processes among participating institutions. The primary aim is to improve the processes that directly impact clinical outcomes for patients. The experience gained from this initiative may serve as the basis for an internationally accepted clinical audit model for radiotherapy.

Establishing achievable benchmarks for quality improvement in systemic therapy for early-stage breast cancer

BACKGROUND

Setting realistic targets for performance is a consistent challenge in quality improvement. In the current study, the authors used administrative data to define achievable targets for a panel of 15 previously developed quality indicators (QIs) focusing on systemic therapy in patients with early-stage breast cancer.

METHODS

Deterministically linked administrative databases were used to identify patients with TNM stage I to stage III breast cancer who were diagnosed between 2006 and 2010 in Ontario, Canada. For each individual indicator, data-driven empirical benchmarks were calculated using the pared-mean benchmark approach. Variation in institution-level performance for each indicator was examined through the construction of funnel plots.

RESULTS

A total of 28,303 patients with early-stage breast cancer were identified, 43% of whom received adjuvant chemotherapy. For the 9 QIs for which receiving the service or outcome was desirable (ie, consultation with a medical oncologist), the benchmark varied from 40.9% to 100%. For the 6 indicators for which not receiving the service or outcome was desirable (ie, incidence of febrile neutropenia), the benchmark varied from 0% to 49.0%. There was substantial variation noted with regard to the number of institutions meeting the target and the amount of interinstitution variation between the QIs. Top performing institutions varied by indicator, with no individual institution meeting the benchmark for all indicators. For the majority of indicators, institution size was not found to be correlated with performance.

CONCLUSIONS

Data-derived benchmarking can be used to facilitate quality improvement by identifying areas of both good as well as suboptimal performance while defining an achievable target for which to strive. Cancer 2017;123:3772-3780. © 2017 American Cancer Society.

Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study

BACKGROUND

The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation.

METHODS

Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy).

RESULTS

Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24).

CONCLUSIONS

Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.

Using graphical representations to enhance the quality-of-care for colorectal cancer patients

The study was to enhance adherence to quality-of-care guidelines for colorectal cancer (CRC) patients through plotting graphical representations. Rasch analysis was performed to examine the unidimensional measurement of the 13 core indicators. An author-made Excel module was applied to plot the so-called Wright map and KIDMAP in education field to report physicians' adherence to the quality-of-life guidelines. We found that the scale of the quality-of-care guidelines for patients with colon cancer is unidimensional. A total of 15 (3.8%) and 14 (3.5%) persons' response patterns (i.e., Outfit MNSQs >2.0 and 4.0, respectively) are aberrantly dispersed from the majority of sample according to their estimated parameters of persons and indicators. It can be used for investigating the root cause of the 1ow measures and/or the most unexpected aberrant pattern of responses using Rasch analysis once any one indicator of unexpectedly aberrant treatment (p < .05) presents. The Rasch model can deal with these binary and/or missing data frequently seen in clinical settings. We confirm this computer module can contribute to ensuring that hospitals adhere to the treatment guidelines for patients with colon cancer.

Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely (®) Initiative

BACKGROUND

Current breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely (®) Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged.

METHODS

The Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely (®) Campaign. The resulting list of "appropriateness" measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below.

RESULTS

(1) Don't routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don't routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don't routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don't routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don't routinely perform a double mastectomy in patients who have a single breast with cancer.

CONCLUSIONS

The ASBrS list for the Choosing Wisely (®) campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.

Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data

OBJECTIVE

To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries.

DATA SOURCES/STUDY SETTING

Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer.

STUDY DESIGN

Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable.

DATA COLLECTION

Collected by the insurer from the time an injury was reported, through recovery or last follow-up.

PRINCIPAL FINDINGS

Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW.

CONCLUSIONS

There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.

In real life, one-quarter of patients with hormone receptor-positive metastatic breast cancer receive chemotherapy as initial palliative therapy: a study of the Southeast Netherlands Breast Cancer Consortium

BACKGROUND

The objective of this study was to present initial systemic treatment choices and the outcome of hormone receptor-positive (HR+) metastatic breast cancer.

PATIENTS AND METHODS

All the 815 consecutive patients diagnosed with metastatic breast cancer in 2007-2009 in eight participating hospitals were identified. From the 611 patients with HR+ disease, a total of 520 patients with HER2-negative (HER2-) breast cancer were included. Initial palliative systemic treatment was registered. Progression-free survival (PFS) and overall survival (OS) per initial palliative systemic therapy were obtained using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

From the total of 520 patients with HR+/HER2- metastatic breast cancer, 482 patients (93%) received any palliative systemic therapy. Patients that received initial chemotherapy (n = 116) were significantly younger, had less comorbidity, had received more prior adjuvant systemic therapy and were less likely to have bone metastasis only compared with patients that received initial endocrine therapy (n = 366). Median PFS of initial palliative chemotherapy was 5.3 months [95% confidence interval (CI) 4.2-6.2] and of initial endocrine therapy 13.3 months (95% CI 11.3-15.5), with a median OS of 16.1 and 36.9 months, respectively. Initial chemotherapy was also associated with worse outcome in terms of PFS and OS after adjustment for prognostic factors.

CONCLUSIONS

A high percentage of patients with HR+ disease received initial palliative chemotherapy, which was associated with worse outcome, even after adjustment of relevant prognostic factors.

The adherence paradox: guideline deviations contribute to the increased 5-year survival of breast cancer patients

BACKGROUND

In German breast cancer care, the S1-guidelines of the 1990s were substituted by national S3-guidelines in 2003. The application of guidelines became mandatory for certified breast cancer centers. The aim of the study was to assess guideline adherence according to time intervals and its impact on survival.

METHODS

Women with primary breast cancer treated in three rural hospitals of one German geographical district were included. A cohort study design encompassed women from 1996-97 (N = 389) and from 2003-04 (N = 488). Quality indicators were defined along inpatient therapy sequences for each time interval and distinguished as guideline-adherent and guideline-divergent medical decisions. Based on all of the quality indicators, a binary overall adherence index was defined and served as a group indicator in multivariate Cox-regression models. A corrected group analysis estimated adjusted 5-year survival curves.

RESULTS

From a total of 877 patients, 743 (85 %) and 504 (58 %) were included to assess 104 developed quality indicators and the resuming binary overall adherence index. The latter significantly increased from 13-15 % (1996-97) up to 33-35 % (2003-04). Within each time interval, no significant survival differences of guideline-adherent and -divergent treated patients were detected. Across time intervals and within the group of guideline-adherent treated patients only, survival increased but did not significantly differ between time intervals. Across time intervals and within the group of guideline-divergent treated patients only, survival increased and significantly differed between time intervals.

CONCLUSIONS

Infrastructural efforts contributed to the increase of process quality of the examined certified breast cancer center. Paradoxically, a systematic impact on 5-year survival has been observed for patients treated divergently from the guideline recommendations. This is an indicator for the appropriate application of guidelines. A maximization of guideline-based decisions instead of the ubiquitous demand of guideline adherence maximization is advocated.

Can composite performance measures predict survival of patients with colorectal cancer?

AIM: To assess the relationship between long-term colorectal patient survival and methods of calculating composite performance scores.

METHODS: The Taiwan Cancer Database was used to identify patients who underwent bowel resection for colorectal adenocarcinoma between 2003 and 2004. Patients were assigned to one of three cohorts based on tumor staging: cohort 1, colon cancer stage < III; cohort 2, colon cancer stage III; cohort 3, rectal cancer. A composite performance score (CPS) was calculated for each patient using five different aggregating methods, including all-or-none, 70% standard, equal weight, analytic hierarchy process (AHP), and principal component analysis (PCA) algorithms. The relationships between CPS and five-year overall, disease-free, and disease-specific survivals were evaluated by a Cox proportional hazards model. A goodness-of-fit analysis for all five methods was performed using Akaike’s information criterion.

RESULTS: A total of 3272 colorectal cancer patients (cohort 1, 1164; cohort 2, 790; cohort 3, 1318 patients) with a mean age of 65 years were enrolled in the study. Bivariate correlation analysis showed that CPS values from the equal weight method were highly correlated with those from the AHP method in all cohorts (all P < 0.05). Multivariate Cox hazards analysis showed that CPS values derived from equal weight and AHP methods were significantly associated with five-year survivals of patients in cohorts 1 and 2 (all P < 0.05). In these cohorts, higher CPS values suggested a higher probability of five-year survival. However, CPS values derived from the all-or-none method did not show any significant process-outcome relationship in any cohort. Goodness-of-fit analyses showed that CPS values derived from the PCA method were the best fit to the Cox proportional hazards model, whereas the values from the all-or-none model showed the poorest fit.

CONCLUSION: CPS values may highlight process-outcome relationships for patients with colorectal cancer in addition to evaluating quality of care performance.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Quality measurement in breast cancer

Variation in the quality of breast care affects outcomes. Objective measurement tools are central to this effort. Most quality measures are process measures. Application of these improves quality. Many national organizations are promoting them for purposes ranging from feedback to providers to public reporting and directing payment. Surgeons should evaluate their own practices and should be involved in local, regional and national efforts to assess and improve breast care.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Defining the potential of neoadjuvant chemotherapy use as a quality indicator for bladder cancer care

PURPOSE

Despite known survival benefits, overall use of neoadjuvant chemotherapy before cystectomy is low, raising concerns about quality of care. However, not all patients undergoing cystectomy are eligible for this therapy. We establish the maximum proportion of patients expected to receive neoadjuvant chemotherapy if all those eligible had a consultation with medical oncology.

MATERIALS AND METHODS

From institutional data (January 2010 through December 2012) we identified 215 patients treated with radical cystectomy for bladder cancer. After excluding patients not eligible for neoadjuvant chemotherapy, we fit models assessing patient disease and health factors affecting referral to medical oncology and receipt of neoadjuvant chemotherapy. Expected use of chemotherapy was then determined for increasingly broad groups of patients treated with cystectomy after controlling for factors precluding the use of neoadjuvant chemotherapy.

RESULTS

Of the 215 patients identified 127 (59%) were eligible for neoadjuvant chemotherapy. After additional consideration of patient factors (patient refusal, health status and poor renal function), maximum receipt of neoadjuvant chemotherapy increased from 42% to 71% as more restrictive definitions for the eligible patient cohort were used.

CONCLUSIONS

Substantial variability exists in the proportion of patients eligible for neoadjuvant chemotherapy based on the population identified. While there is substantial underuse of neoadjuvant chemotherapy, the development of quality metrics for this essential therapy depends on correct identification of the cystectomy population being assessed. Even with referral of all appropriate patients for medical oncology evaluation, use of chemotherapy would likely not exceed 50% of patients in nationally representative cystectomy data.

Standardization of morbidity assessment in breast cancer surgery using the Clavien Dindo Classification

INTRODUCTION

There are no published data on standardized scoring systems for morbidity after breast cancer surgery. Aim of the study was to establish the Clavien Dindo Classification (CDC) as assessment tool and to identify risk factors for morbidity after breast surgery investigating new techniques including oncoplastic surgery and neoadjuvant chemotherapy.

PATIENTS AND METHODS

Between 2008 and 2010, data were retrospectively evaluated from 485 women with breast cancer who underwent surgery at a university hospital. The CDC was used to assess the severity of postoperative complications. Multivariable analyses were adjusted by body-mass index, smoking, diabetes mellitus and tumour size.

RESULTS

Overall complications (CDC 1-4) were reported in 28.7%. Second surgery related to major complications (CDC 3-4) was mandatory in 4.7%. Axillary dissection was an independent predictor for CDC 1-4 in all patients (P = 0.008, OR of 1.81, 95%CI 1.17-2.82). We found no independent predictor for CDC 3-4. Oncoplastic surgery increased the rate of wound infections (P = 0.010, OR: 2.94, 95%CI 1.30-6.67) and necroses (P < 0.001, OR: 8.38, 95%CI 3.28-21.4). Axillary dissection elevated wound infection (P = 0.040, OR: 2.07, 95%CI 1.03-4.14) and seroma rates (P < 0.001, OR: 2.46, 95%CI 1.51-4.01). Neoadjuvant chemotherapy had no impact on morbidity.

CONCLUSION

The CDC is a valid assessment tool for future clinical trials and may be useful for hospital quality control. While axillary dissection and oncoplastic surgery raised morbidity, no single factor predicted for morbidity related second surgery.

A dynamic clinical pathway for the treatment of patients with early breast cancer is a tool for better cancer care: implementation and prospective analysis between 2002-2010

Background

Due to increasing the complexity of breast cancer treatment it is of paramount importance to develop structured care in order to avoid a chaotic and non-consistent management of patients. Clinical pathways, a result of the adaptation of the documents used in industrial quality management namely the Standard Operating Procedures, can be used to improve efficiency and quality of care. They also aim to re-centre the focus on the patient’s overall journey, rather than the contribution of each specialty or caring function independently.

Methods

The effect of the implementation and prospective systematic evaluation of a clinical care pathway for the management of patients with early breast cancer in a single breast unit is evaluated over a long time interval (between 2002 and 2010). Annual analysis of predefined clinical outcome measures, service indicators, team indicators, process indicators and financial indicators was performed. Pathway quality control meetings were organized at least once a year. Systematic feedback was given to the team members, and if necessary the pathway was adapted according to evidence based literature data and in house pathway related data in order to improve quality.

Results

The annual number of patients included in the pathway (289 vs. 390, P <0.01), proportion of patients with Tis-T1 tumors (42% vs. 58%, P <0.01), negative lymph nodes (44% vs. 58%, P <0.01) and no metastases at diagnosis (91.5% vs. 95.9%) has risen significantly between 2002 and 2010. Evolution of mandatory quality indicators defined by EUSOMA shows a significant improvement of quality of cancer care. Particularly, the proportion of patients having anti-hormonal therapy (84.8% vs. 97.4%, P = 0.002) and adjuvant chemotherapy according to the guidelines (72% vs. 95.6%, P = 0.028) increased dramatically. Patient satisfaction improved significantly (P <0.05). Progression free 4-year survival was significantly higher for all patients, for T1 tumors only and for T2-T4 tumors only, treated between 2006 to 2008 compared to between 1999 to 2002 and 2003 to 2005 (P = 0.006, P = 0.05, P = 0.06, respectively). Overall 4-year survival of the entire population treated between 2006 and 2008 was significantly better (P = 0.05).

Conclusions

Although the patient characteristics changed over the years due to better screening, this clinical pathway and regular audit of quality indicators for the treatment of patients with operable breast cancer proved to be important tools to improve the quality of care, patient satisfaction and outcome.

Re-examining the significance of surgical volume to breast cancer survival and recurrence versus process quality of care in Taiwan

OBJECTIVE

This study explored the association of surgical volume versus process quality with breast cancer survival and recurrence.

DATA SOURCES/STUDY SETTING

Population-based cancer registration data and National Health Insurance claim data.

STUDY DESIGN

This population-based study linked Taiwan's Cancer Database with Taiwan's National Health Insurance Database to collect data on all patients diagnosed with breast cancer in 2003-2004 who received surgical treatment.

PRINCIPAL FINDINGS

This study included 6,396 female breast cancer patients, reported by 26 hospitals. After controlling for patient and provider characteristics, Cox's regression models did not reveal any association between a physician's surgical volume and breast cancer recurrence or survival, although hospital volume was marginally associated with positive 5-year recurrence (HR: 1.001, 95%CI: 1.000, 1.001). After controlling for hospital or physician volume of surgery, we found a significant association between quality of care and both 5-year survival and recurrence. Random effects were also identified between patients and providers based on 5-year survival and 5-year recurrence.

CONCLUSIONS

Process quality of care was significantly more related to survival or recurrence than to surgical volume. The random effects found within hospital-patient clustered data indicated that the effect of the clustered feature of this data should be considered when performing volume-outcome related studies.

Quality assessment in oncology

The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.