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Simunovic M, Urbach DR, Fahim C, O’Brien MA, Earle CC, Brouwers M, Gatov E, Grubac V, McCormack D, Baxter N. High-Intensity vs Low-Intensity Knowledge Translation Interventions for Surgeons and Their Association With Process and Outcome Measures Among Patients Undergoing Rectal Cancer Surgery. JAMA Netw Open 2021; 4:e2117536. [PMID: 34269805 PMCID: PMC8285735 DOI: 10.1001/jamanetworkopen.2021.17536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Surgeon-directed knowledge translation (KT) interventions for rectal cancer surgery are designed to improve patient measures, such as rates of permanent colostomy and in-hospital mortality, and to improve survival. OBJECTIVE To evaluate the association of sustained, iterative, integrated KT rectal cancer surgery interventions directed at all surgeons with process and outcome measures among patients undergoing rectal cancer surgery in a geographic region. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used administrative data from patients who underwent rectal cancer surgery from April 1, 2004, to March 31, 2015, in 14 health regions in Ontario, Canada. Follow-up was completed on March 31, 2020. EXPOSURES Surgeons in 2 regions were offered intensive KT interventions, including annual workshops, audit and feedback sessions, and, in 1 of the 2 regions, operative demonstrations, from 2006 to 2012 (high-intensity KT group). Surgeons in the remaining 12 regions did not receive these interventions (low-intensity KT group). MAIN OUTCOMES AND MEASURES Among patients undergoing rectal cancer surgery, proportions of preoperative pelvic magnetic resonance imaging (MRI), preoperative radiotherapy, and type of surgery were evaluated, as were in-hospital mortality and overall survival. Logistic regression models with an interaction term between group and year were used to assess whether process measures and in-hospital mortality differed between groups over time. RESULTS A total of 15 683 patients were included in the analysis (10 052 [64.1%] male; mean [SD] age, 65.9 [12.1] years), of whom 3762 (24.0%) were in the high-intensity group (2459 [65.4%] male; mean [SD] age, 66.4 [12.0] years) and 11 921 (76.0%) were in the low-intensity KT group (7593 [63.7%] male; mean [SD] age, 65.7 [12.1] years). A total of 1624 patients (43.2%) in the high-intensity group and 4774 (40.0%) in the low-intensity KT group underwent preoperative MRI (P < .001); 1321 (35.1%) and 4424 (37.1%), respectively, received preoperative radiotherapy (P = .03); and 967 (25.7%) and 2365 (19.8%), respectively, received permanent stoma (P < .001). In-hospital mortality was 1.6% (59 deaths) in the high-intensity KT group and 2.2% (258 deaths) in the low-intensity KT group (P = .02). Differences remained significant in multivariable models only for permanent stoma (odds ratio [OR], 1.67; 95% CI, 1.24-2.24; P < .001) and in-hospital mortality (OR, 0.67; 95% CI, 0.51-0.87; P = .003). In both groups over time, significant increases in the proportion of patients undergoing preoperative MRI (from 6.3% to 67.1%) and preoperative radiotherapy (from 16.5% to 44.7%) occurred, but there were no significant changes for permanent stoma (25.4% to 25.3% in the high-intensity group and 20.0% to 18.3% in the low-intensity group) and in-hospital mortality (0.8% to 0.8% in the high-intensity group and 2.2% to 1.8% in the low-intensity group). Time trends were similar between groups for measures that did or did not change over time. Patient overall survival was similar between groups (hazard ratio, 1.00; 95% CI, 0.90-1.11; P = .99). CONCLUSIONS AND RELEVANCE In this quality improvement study, between-group differences were found in only 2 measures (permanent stoma and in-hospital mortality), but these differences were stable over time. High-intensity KT group interventions were not associated with improved patient measures and outcomes. Proper evaluation of KT or quality improvement interventions may help avoid opportunity costs associated with ineffective strategies.
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Affiliation(s)
- Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Mary Ann O’Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Craig C. Earle
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Brouwers
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Evgenia Gatov
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Vanja Grubac
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel McCormack
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Nancy Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Francescutti VA, Skitzki JJ, Kane JM, Simunovic M. Barriers to Referral for CS/HIPEC Identified Using a Tailoring Grid Methodology: Interviews With Stakeholders in New York State. J Surg Res 2021; 267:235-242. [PMID: 34157492 DOI: 10.1016/j.jss.2021.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/22/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has variable uptake, with referrals reliant on other physicians. To characterize barriers to referral for CS/HIPEC, we created a pragmatic "tailoring grid", incorporating the concepts of Pathman's 4 As of awareness, agreement, adoption, and adherence and barriers acting at the individual, practice group, and organization level. METHODS AND MATERIALS We invited surgeons and medical oncologists from Western New York State who potentially refer patients for CS/HIPEC to participate in tailoring grid interviews. RESULTS Interviews of 10 surgeons and 10 medical oncologists were completed. The participants were positioned in the Pathman 4 A's with respect to referrals for CS/HIPEC as follows: (1) A 19 aware (1 not aware); (2) A 3 in agreement (17 not in agreement); (3) A 9 adopters; and (4) A 6 adherent. Among the 9 participants who had referred at least one patient for CS/HIPEC (adopters/adherent), only 2 were in agreement with the appropriateness of CS/HIPEC. Barriers to awareness of included lack of interaction with colleagues and knowledge of indications. Barriers to agreement included lack of high quality of evidence supporting CS/HIPEC such as well-designed RCTs. Barriers to adoption included lack of communication with CS/HIPEC surgeons; lack of inclusion of the procedure into algorithms and defined morbidity/mortality rates. Barriers to adherence included lack of inclusion into guidelines by major societies; perceptions that the procedure is resource-intensive; lack of defined quality measures. CONCLUSIONS The tailoring grid efficiently identified barriers to awareness, agreement, adoption and adherence for routine referral for CS/HIPEC. Barriers to increased referrals included lack of high-quality evidence supporting CS/HIPEC. Barriers more easily addressed included communication between referring and CS/HIPEC surgeons, and outcomes at the individual patient and hospital level.
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Affiliation(s)
- Valerie A Francescutti
- Division of General Surgery, Department of Surgery, McMaster University and Juravinski Cancer Center, Hamilton, Ontario, Canada..
| | - Joseph J Skitzki
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - John M Kane
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Marko Simunovic
- Division of General Surgery, Department of Surgery, McMaster University and Juravinski Cancer Center, Hamilton, Ontario, Canada
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Simunovic M, Fahim C, Coates A, Urbach D, Earle C, Grubac V, Brouwers M, O'Brien MA, Baxter N. A method to audit and score implementation of knowledge translation (KT) interventions in large health regions - an observational pilot study using rectal cancer surgery in Ontario. BMC Health Serv Res 2020; 20:506. [PMID: 32503592 PMCID: PMC7275399 DOI: 10.1186/s12913-020-05353-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Across Ontario, since the year 2006 various knowledge translation (KT) interventions designed to improve the quality of rectal cancer surgery have been implemented by the provincial cancer agency or by individual researchers. Ontario is divided administratively into 14 health regions. We piloted a method to audit and score for each region of the province the KT interventions implemented to improve the quality of rectal cancer surgery. Methods We interviewed stakeholders to audit KT interventions used in respective regions over years 2006 to 2014. Results were summarized into narrative and visual forms. Using a modified Delphi approach, KT experts reviewed these data and then, for each region, scored implementation of KT interventions using a 20-item KT Signature Assessment Tool. Scores could range from 20 to 100 with higher scores commensurate with greater KT intervention implementation. Results There were thirty interviews. KT experts produced scores for each region that were bimodally distributed, with an average score for 2 regions of 78 (range 73–83) and for 12 regions of 30.5 (range 22–38). Conclusion Our methods efficiently identified two groups with similar KT Signature scores. Two regions had relatively high scores reflecting numerous KT interventions and the use of sustained iterative approaches in addition to those encouraged by the provincial cancer agency, while 12 regions had relatively low scores reflecting minimal activities outside of those encouraged by the provincial cancer agency. These groupings will be used for future comparative quantitative analyses to help determine if higher KT signature scores correlate with improved measures for quality of rectal cancer surgery.
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Affiliation(s)
- Marko Simunovic
- Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. .,Department of Surgical Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Christine Fahim
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Angela Coates
- Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - David Urbach
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Craig Earle
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vanja Grubac
- Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Melissa Brouwers
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Mary Ann O'Brien
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nancy Baxter
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Flodgren G, O'Brien MA, Parmelli E, Grimshaw JM. Local opinion leaders: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2019; 6:CD000125. [PMID: 31232458 PMCID: PMC6589938 DOI: 10.1002/14651858.cd000125.pub5] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011. OBJECTIVES To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field. SELECTION CRITERIA We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention. MAIN RESULTS We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs. AUTHORS' CONCLUSIONS Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthDivision of Health ServicesMarcus Thranes gate 6OsloNorway0403
| | - Mary Ann O'Brien
- University of TorontoDepartment of Family and Community Medicine500 University AvenueFifth FloorTorontoONCanadaM5G 1V7
| | - Elena Parmelli
- Lazio Regional Health Service ‐ ASL Roma1Department of EpidemiologyRomeItaly
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
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Bogach J, Tsai S, Zbuk K, Wong R, Grubac V, Coates A, Pond GR, Simunovic M. Quality of preoperative pelvic computed tomography (CT) and magnetic resonance imaging (MRI) for rectal cancer in a region in Ontario: A retrospective population-based study. J Surg Oncol 2018; 117:1038-1042. [PMID: 29473947 DOI: 10.1002/jso.25000] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/29/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Treatment decisions for rectal cancer rely on preoperative staging with CT and MRI scans. We assessed the quality of such scans in a region of Ontario. METHODS We retrospectively collected data for patients undergoing rectal cancer surgery between July 2011 and December 2014. We measured three aspects of quality: use; comprehensiveness of reporting T-category, N-category, mesorectal fascia (MRF) status; and in non-radiated patients sensitivity and specificity of reports for relevant elements. RESULTS A total of 559 patients underwent major rectal cancer surgery. Preoperative staging with CT and MRI was performed in 93% and 50% of patients. CT scan reports provided information on T-category, N-category, and MRF status in 41%, 92%, and 16% of cases. These same elements were reported on MRI in 88%, 93%, and 62% of cases. CT scan sensitivity and specificity was 80% and 80% for T-category, and 85% and 39% for N-category. MRI sensitivity and specificity was 75% and 81% for T-category, 79% and 37% for N-category, and 33% and 89% for MRF status. CONCLUSION In this region of Ontario, pre-operative MRI was underutilized, CT reporting of MRF status was low, and when reported sensitivity and specificity of T- and N-category were similar for CT and MRI.
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Affiliation(s)
- Jessica Bogach
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Scott Tsai
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Kevin Zbuk
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Raimond Wong
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Vanja Grubac
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Angela Coates
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gregory R Pond
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Escarpment Cancer Research Institute, Ontario, Canada
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The research activities of Ontario's large community acute care hospitals: a scoping review. BMC Health Serv Res 2017; 17:566. [PMID: 28814304 PMCID: PMC5559849 DOI: 10.1186/s12913-017-2517-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 08/07/2017] [Indexed: 11/18/2022] Open
Abstract
Background Ontario’s large community hospitals (LCHs) provide care to 65% of the province’s hospitalized patients, yet we know very little about their research activities. By searching for research publications from 2013 to 2015, we will describe the extent, type and collaborative nature of Ontario’s LCHs’ research activities. Methods We conducted a scoping review by searching PubMed, Embase and the Cumulative Index to Nursing and Allied Health Literature databases from January 1, 2013 until December 31, 2015 for all publication types whose author(s) was affiliated with any of the 44 LCHs. Articles were screened and abstracted by three reviewers, independently. The data were charted and results described using summary statistics, scatter plots, and bar charts. Results We included 798 publications from 39 LCHs and 454 authors. The median number of publications was 7 (Interquartile range (IQR) 23). Observational study design was most commonly reported in over 50% of publications. Program evaluation was the focus in 40% of publications. Primary LCH authorship was observed for 535 publications. Over 25% and 65% of the publications were attributable to 24 authors and 9 LCHs, respectively. There was minimal collaboration both within (21.2%) and between (7.8%) LCHs. LCH size and geographic proximity to academic hospitals had minimal impact on research activity. Conclusions Ontario’s LCHs publish infrequently, collaborate infrequently, and their role in translational research activity is not well defined. A future survey questionnaire to LCH researchers identified through this review is planned to both validate and elicit their interpretations of our study findings and opinions about LCH involvement in research.
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Keng C, Coates A, Grubac V, Lovrics P, DeNardi F, Thabane L, Simunovic M. The Need for Consensus and Transparency in Assessing Population-Based Rates of Positive Circumferential Radial Margins in Rectal Cancer: Data from Consecutive Cases in a Large Region of Ontario, Canada. Ann Surg Oncol 2015; 23:397-402. [DOI: 10.1245/s10434-015-4893-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Indexed: 11/18/2022]
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Francescutti V, Amin N, Cadeddu M, Eskicioglu C, Forbes S, Kelly S, Yang I, Tsai S, Coates A, Grubac V, Simunovic M. An Internet-Based Collaborative Cancer Conference for Rectal Cancer Influenced Surgeon Treatment Recommendations. Ann Surg Oncol 2014; 22:2143-50. [PMID: 25384703 DOI: 10.1245/s10434-014-4216-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million). METHODS Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review. RESULTS From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change. CONCLUSIONS An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.
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Affiliation(s)
- Valerie Francescutti
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
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