Organization-based performance measures of cancer care quality: core measure development for breast cancer in Taiwan

Modified lymph node ratio improves the prognostic predictive ability for breast cancer patients compared with other lymph node staging systems

Background

Metastatic regional lymph nodes (LN) is a strong predictor of worse long-term outcome. Therefore, different LN staging systems have been proposed in recent years. In this study, we proposed a modified lymph node ratio (mLNR) as a new lymph node staging system and then compared the prognostic performance of mLNR with American Joint Committee on Cancer N stage, lymph node ratio (LNR) and log odds of metastatic lymph nodes in breast cancer patients.

Methods

Breast cancer patients who underwent surgery between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. Restricted cubic spline functions were calculated to characterize the association between variables and the risk of death. The Cox proportional hazards models were constructed to assess the predictive ability of different lymph node staging systems using the Akaike’s Information Criterion (AIC) and Harrell’s concordance index (C-index).

Results

A total of 264,096 breast cancer patients were enrolled and 187,785 (71.1%) patients had a limited number of LNs harvested. In the limited LN harvest cohort, the prognostic performance of LNR decreased and mLNR could greatly solve this problem. In addition, among the entire cohort, mLNR modeled as a continuous value had the best predictive ability (AIC: 922021.9 and C-index: 0.727) than other lymph node staging systems.

Conclusions

The predictive ability of LNR is restricted by a limited LN harvest. However, mLNR shows superiority to LNR and other lymph node staging systems especially in a limited LN harvest cohort, making mLNR the most powerful lymph node staging systems.

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We selected 264,096 patients, which is enough to support our conclusion.

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We used two indexes to fully verify the fit of different lymph staging systems.

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The mLNR improved the prognostic predictive ability best.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

A Delphi study to develop indicators of cancer patient experience for quality improvement

PURPOSE

The purpose of this study was to develop prioritised indicators to measure cancer patient experience and thus guide quality improvement in the delivery of patient care.

METHODS

A Delphi study, consisting of two surveys and three workshops, was employed to gather expert opinions on the most important indicators to measure. Survey participants were 149 health professionals, academics/technical experts and consumers. The first survey was based on a literature review which identified 105 elements of care within 14 domains of patient experience. These were rated on a 7-point Likert scale, with '1' representing high importance. Elements with mean ratings between 1.0 and 2.0 were retained for the second survey. The 43 least-important elements were omitted, four elements were revised and nine new elements added. Consensus was defined as at least 70% of participants rating an element '1' or '2'. Multivariate and cluster analyses were used to develop 20 draft indicators, which were presented to 51 experts to refine and prioritise at the three workshops.

RESULTS

All elements in the second survey were rated '1' or '2' by 81% of participants. Workshop participants agreed strongly on the four most important indicators: coordinated care, access to care, timeliness of the first treatment, and communication. Other indicators considered highly important were follow-up care for survivors; timeliness of diagnosis; information relating to side effects, pain and medication; comprehensibility of information provided to patients; and needs assessment.

CONCLUSIONS

Experts identified priorities with a high level of consensus, providing a rigorous foundation for developing prioritised indicators of quality in cancer patient experience.

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.

Effect of the Pay-for-Performance Program for Breast Cancer Care in Taiwan

PURPOSE

To evaluate the impact of the nationwide pay-for-performance (P4P) program for breast cancer care (BC-P4P) in Taiwan on care quality, patient survival, and recurrence.

STUDY DESIGN

A population-based observational study with cross-sectional design.

METHODS

Retrospective analysis of population-based cancer registration and claims data was used in this study. A total of 4,528 patients with stage I or II breast cancer diagnosed in 2002 or 2003 who received curative surgery were observed until the end of 2008. This study applied multivariate linear regression to explore the association between BC-P4P enrollment and quality of care. Cox regression was applied to examine the effect of BC-P4P enrollment on 5-year recurrence and overall survival among patients with breast cancer.

RESULTS

After controlling for age, stage, type of surgery, and other factors, BC-P4P enrollees were found to have received better quality care than nonenrollees (P = .001). Cox regression models also indicated that after controlling for patient characteristics, quality of care was related to better 5-year overall survival (odds ratio [OR], 0.212; P = .001) and recurrence (OR, 0.289; P < .001). Even when controlled by quality of care provided to patients and its interaction with status of BC-P4P enrollment, BC-P4P enrollment remained statistically significant regarding 5-year overall survival (OR, 0.167; P < .001) and recurrence (OR, 0.370; P = .002).

CONCLUSION

Patients with breast cancer enrolled in the BC-P4P program received better quality care and had better outcome than nonenrolled patients. Evidence from this study indicates that financial incentives in the payment design had a positive impact on outcome of breast cancer care.

Designing a balanced scorecard for a tertiary care hospital in Pakistan: a modified Delphi group exercise

Balanced Scorecards (BSC) are being implemented in high income health settings linking organizational strategies with performance data. At this private university hospital in Pakistan an elaborate information system exists. This study aimed to make best use of available data for better performance management. Applying the modified Delphi technique an expert panel of clinicians and hospital managers reduced a long list of indicators to a manageable size. Indicators from existing documents were evaluated for their importance, scientific soundness, appropriateness to hospital's strategic plan, feasibility and modifiability. Panel members individually rated each indicator on a scale of 1-9 for the above criteria. Median scores were assigned. Of an initial set of 50 indicators, 20 were finally selected to be assigned to the four BSC quadrants. These were financial (n = 4), customer or patient (n = 4), internal business or quality of care (n = 7) and innovation/learning or employee perspectives (n = 5). A need for stringent definitions, international benchmarking and standardized measurement methods was identified. BSC compels individual clinicians and managers to jointly work towards improving performance. This scorecard is now ready to be implemented by this hospital as a performance management tool for monitoring indicators, addressing measurement issues and enabling comparisons with hospitals in other settings.

Is quality of colorectal cancer care good enough? Core measures development and its application for comparing hospitals in Taiwan

BACKGROUND

Although performance measurement for assessing care quality is an emerging area, a system for measuring the quality of cancer care at the hospital level has not been well developed. The purpose of this study was to develop organization-based core measures for colorectal cancer patient care and apply these measures to compare hospital performance.

METHODS

The development of core measures for colorectal cancer has undergone three stages including a modified Delphi method. The study sample originated from 2004 data in the Taiwan Cancer Database, a national cancer data registry. Eighteen hospitals and 5585 newly diagnosed colorectal cancer patients were enrolled in this study. We used indicator-based and case-based approaches to examine adherences simultaneously.

RESULTS

The final core measure set included seventeen indicators (1 pre-treatment, 11 treatment-related and 5 monitoring-related). There were data available for ten indicators. Indicator-based adherence possesses more meaningful application than case-based adherence for hospital comparisons. Mean adherence was 85.8% (79.8% to 91%) for indicator-based and 82.8% (77.6% to 88.9%) for case-based approaches. Hospitals performed well (>90%) for five out of eleven indicators. Still, the performance across hospitals varied for many indicators. The best and poorest system performance was reflected in indicators T5-negative surgical margin (99.3%, 97.2%-100.0%) and T7-lymph nodes harvest more than twelve(62.7%, 27.6%-92.2%), both of which related to surgical specimens.

CONCLUSIONS

In this nationwide study, quality of colorectal cancer care still shows room for improvement. These preliminary results indicate that core measures for cancer can be developed systematically and applied for internal quality improvement.