Quality assurance and improvement in oncology using guideline-derived quality indicators - results of gynaecological cancer centres certified by the German cancer society (DKG)

PURPOSE

Based on the example of Gynaecological Cancer Centres (GCCs) certified by the German Cancer Society, this study evaluates the results of medical-guideline-derived quality indicators (QIs) for cervical cancer (CC) and ovarian cancer (OC), examines the development of indicator implementation over time as well as the status of guideline-compliant care and identifies improvement measures.

METHODS

QI results for patients with CC and OC treated in GCCs between 2015 and 2019 are analysed. The median, overall proportion and standard deviation of each QI were calculated. Two-sided Cochran-Armitage tests were applied.

RESULTS

QIs are divided into two categories: process-organization (PO-QIs) and treatment-procedures (TP-QIs), to allow a differentiated analysis for identifying improvement measures. PO-QIs that reflect the implementation of processes and structures show a high degree of application. PO-QIs have a tremendous influence on the quality of care and are easy to implement through SOPs. TP-QIs report on treatments that are performed in the GCC. TP-QIs that report on systemic therapies reach a plateau where the guideline is known, but patient-related-factors meaningfully prevent further increase. TP-QIs that report on surgical interventions fluctuate. The most relevant factors are practitioners' personal skills. Besides the discussion of results amongst peers during the audit, improvement measures could include surgical courses or coaching.

CONCLUSION

The analysis shows that a combination of different measures is necessary to anchor quality sustainably in health care and thus improve it.

[Surgical Therapy for Lung Cancer: Why it Should be Performed in High Volume Centres]

Data on surgical lung cancer cases were extracted from the German Federal Statistics on Diagnosis-related groups (DRG) and a possible association between hospital volume and surgical mortality was explored. All treatment cases documented between 2005 and 2015 with the main diagnosis of lung cancer (International Classification of Disease code C34) and the German Operations and Procedure Key (OPS) codes 5-323 to 5-328 for anatomical lung resections were analysed. The treatment cases were assigned to hospital groups, defined according to the number of procedures performed per year. The total number of anatomical lung resections for the diagnosis of lung cancer increased by 24 % from 9376 resections in 2005 to 11,614 resections in 2015. In 2015, 57 % of anatomical lung resections in patients with lung cancer were performed in 47 high volume centres (hospitals with ≥ 75 resections/year); the remaining 43 % of the resections were distributed among 271 hospitals performing fewer than 75 resections per year. In hospitals performing fewer than 25 procedures/year, hospital mortality was almost twice as high as in large centres with ≥ 75 resections per year (5.7 vs. 3.0 %, mean value 2005 to 2015). In summary, our data indicate that a small number of high-volume hospitals perform the major part of lung resections of lung cancer in Germany with better survival as compared to low-volume hospitals. Based on current nationwide data a clear association between hospital volume and surgical mortality could be demonstrated.

The Ipaac Evaluation Tool: how to select Quality Indicators for Comprehensive Cancer Care Networks

Background

The Comprehensive Cancer Care Networks (CCCNs) represent innovative approaches for the management of cancer patients consisting of multiple cooperating health units with specific expertise in the different steps of care. Quality Indicators (QIs) constitute valid and reliable tools that allow to measure the quality of care among similar structures belonging to different health systems. Objective of this project was to develop a standardized tool in order to define a multi-step process for the selection of QIs for the evaluation of CCCNs.

Methods

Under the coordination of the Innovative Partnership for Action Against Cancer (IPAAC) joint action, our research team performed a systematic review of the scientific literature to identify the reported methodology for the selection of QIs applicable for the CCCNs' setting. An additional search of national and international Quality Assurance organizations was performed to detect any missing information.

Results

The IET (Ipaac Evaluation Tool) for QIs was developed: a methodological tool describing an 8-step process that leads to the selection of QIs feasible for the CCCN setting. The tool was implemented accordingly with the reporting standards for guideline-based performance measures of the Guideline International Network (GIN). A pilot testing of the tool was performed in order to identify its strengths and weaknesses.

Conclusions

The IET for QIs represents an innovative methodological instrument to select valid and reliable indicators for the assessment of the quality of care within the CCCN settings.

Key messages

The Quality Indicators represent valid and reliable tools to measure and compare the quality of care delivered to cancer patients in Comprehensive Cancer Care Networks. The development of the Ipaac Evaluation Tool leads to a standardized assessment of the quality of care provided for cancer patients within the CCCN setting.

Tackling challenges in cancer care and improving its governance in the European Union

Background

The aim of a cancer care system should be to give all patients access to a high-quality care that covers all components of the cancer continuum from early diagnosis to treatment and palliative care. Fragmentation of health services providers among different levels of care and lack of coordination among them is the main obstacle to achieving the desired continuity of patient care.

Results

These can be summarized in the following main outputs: Strategies to improve cancer outcomes in pancreatic cancer as case study. A consensus among relevant stakeholders was developed and analysis of outcomes in several countries will be presented to support the proposed measures.Impact of Information Technologies on Multidisciplinary care will have consequences on the way care is organized.Comprehensive cancer care networks (CCCNs) are based on tumor specific management groups. Patient pathways are to provide continuity of care along the whole chain of health care, while quality of care will be measured using tumor specific quality indicators and Patient Reported Outcome Measures and a process for continuous quality improvement must be in place. The CCCN concept will be implemented in two pilot sites and the implementation process will be evaluated.

Conclusions

Development of strategies on how to improve outcomes for pancreatic cancer Development of a list of quality indicators for different areas of cancer care Criteria and standards for CCCNs and their implementation in two sites Definition of patient pathways in cancer care and their practical implementation Amend the existing structure of National Cancer Control Programmes to include all the challenges mentioned above.

Key message

International expert collaboration across countries with the support of the EU provides an excellent framework for the development of important policy responses to the current challenges in the organization of cancer care.

Comparing quality of care using patient-reported outcomes in patients with localized prostate cancer

Introduction

The Prostate Cancer Outcomes (PCO) study, funded by the Movember Foundation, has been recruiting patients in prostate cancer centers in Germany, Austria and Switzerland certified by the German Cancer Society (DKG) since July 2016. It is a joint project of the Federal Prostate Cancer Self-Help Association (BPS), DKG, OnkoZert and meanwhile over 100 participating centers. The aim of the study is to compare the outcome quality between the centers for mutual learning and to use patient-specific evaluations for treatment planning.

Materials and Methods

The protocol was set up according to the International Consortium for Health Outcomes Measurement (ICHOM) Standard Data Set with patients filling out the EPIC-26 before and at least once (after 12 months) after treatment. The EPIC-26 includes the functional outcome domains 'incontinence', 'irritative / obstructive', 'gastrointestinal', 'sexuality', and 'hormonal “. Questionnaire data are linked to disease and treatment data in the centers. The EPIC-26 domain scores are then analyzed centrally to provide case mix adjusted center comparisons stratified by treatment.

Results

As of May 2019, 11,303 patients were recruited the PCO study. For 3,953 of them, results of the follow-up survey after 12 months were available for analysis. The results show changes in the scores similar (e.g. an adjusted decrease in the incontinence domain by 15 points for patients receiving radical prostatectomy) to what was known from the international literature 12 months after primary therapy. Results vary significantly between the centers, suggesting differences between providers that warrant improvement interventions.

Conclusions

The results are used to develop strategies for improvement together with providers and patients and to implement patient-specific evaluations for treatment planning in everyday treatment.

Key messages

A patient-reported outcome routine was successfully implemented in over 100 prostate cancer units in central Europe adopting the same data infrastructure. Benchmarking results demonstrate meaningfully differences across units that warrant improvement interventions.

Recommendation of adjuvant trastuzumab treatment in HER-2-positive breast cancer patients: insights from quality indicator data collected in certified breast cancer centers in Germany, Italy, Austria, and Switzerland

PURPOSE

In 2003, a certification system was introduced to ensure high standards of oncological care in breast cancer patients in Germany. Certified breast cancer centers (BCCs) must fulfill specific requirements including quality indicators (QI) derived from the clinical guidelines that are evaluated in annual audits. When target values for QIs are not fulfilled, centers need to give explanations. We analyzed data from BCCs for a selected indicator: the recommendation of trastuzumab for patients with early HER-2-positive invasive breast cancer. We investigated explanations given in cases when trastuzumab was not recommended to see whether this was justified.

METHODS

Patient data from 274 BCCs treating 53,777 primary cases in 2015 were analyzed using descriptive statistics.

RESULTS

In the 274 BCC sites, 5700 primary patients with early HER-2-positive breast cancer were treated in 2015. 128 sites (46.7%) did not reach the target value of 95% trastuzumab recommendation and thus had to give explanations. In these 128 sites, 2663 primary HER-2-positive breast cancer patients were treated, 343 (12.9%) of whom did not receive a recommendation for adjuvant trastuzumab treatment. All 128 sites delivered explanations. Overall, 450 explanations were given, allowing multiple explanations for single patients. No explanation was given for 8 of the 343 patients (2.3%). The most common given explanation was multi-/comorbidity (45.5%).

CONCLUSIONS

The analysis suggests thorough decision-making when quality indicator target values for a trastuzumab recommendation were not fulfilled. Our data do not provide information on whether such decisions have an impact on treatment outcome for these patients.

[Obstacles and facilitators of conducting studies - the perspective of colorectal cancer centers' coordinators]

INTRODUCTION

Clinical trials and health services research are crucial pillars for improving patient care. This paper examines factors inhibiting and promoting the study activity and the knowledge and use of trial registries (e. g. DRKS, StudyBox) as an opportunity to learn about existing studies.

MATERIAL AND METHODS

The coordinators of 274 cancer center sites certified according to the requirements of the German Cancer Society were surveyed using a standardized online questionnaire. Data were analyzed using descriptive and bivariate statistics to identify associations with characteristics of the sites (e. g. patient volume, ownership, teaching status).

RESULTS

176 sites participated in the survey (64.2 %). The central obstacle to study participa-tion from the centers' view is the low number of existing studies. General knowledge of the population about studies was considered low. Trial registries are known to almost all respondents, but are rarely used.

DISCUSSION

The results of the survey suggest that comprehensive measures are needed to sustainably increase the study activity. These include, for example, better information about studies, for example through appropriate databases, and (industry-independent) research funding. One possible way to sensitize patients for studies could be the comprehensive education of the population about the purpose of studies.

Considerations on the Improved Integration of Medical Guidelines into Routine Clinical Practice - a Review and Concept Proposal

Medical guidelines have become established as the standard for the comprehensive synopsis of all available information (scientific trials, expert opinion) on diagnosis and treatment recommendations. The transfer of guidelines to clinical practice and subsequent monitoring has however proven difficult. In particular the potential interaction between guideline developers and guideline users has not been fully utilised. This review article analyses the status quo and existing methodological and technical information solutions supporting the guideline life cycle. It is shown that there are numerous innovative developments that in isolation do not provide comprehensive support. The vision of the "Living Guidelines 2.0" is therefore presented. This outlines the merging of guideline development and implementation on the basis of clinical pathways and guideline-based quality control, and building on this, the generation of information for guideline development and research.

[Requirements for organ-specific oncology centers]

BACKGROUND

The interdisciplinary, interprofessional, and transsectoral cooperation of partners in a network is prerequisite for the certification of a prostate cancer center. The network reflects all phases and aspects of the disease from the patient's point of view. On the basis of quality indicators that are audited annually, the qualified partners of the network ensure quality of care. Quality indicators reflect the quality of the cooperation in the network, the treatment according to the evidence-based guideline, and the specific expertise of the partners.

METHODS

The results of the quality indicators are evaluated annually and summarized in individual and general reports. The system of the quality indicators is an important tool for quality management and to improve daily oncological care. In the future, this system will be extended to include patient-reported outcomes in combination with the OncoBox.

CONCLUSIONS

The ongoing quantitative and qualitative improvement makes the certification system a relevant instrument for health policy institutions and is useful in political discussions regarding quality assurance and improvement.

[Quality of Care in Certified Lung Cancer Centers]

BACKGROUND

Since 2008, lung cancer centers can be certified in accordance with the criteria set out by the German Cancer Society (Deutsche Krebsgesellschaft). This paper reports on the certification program for lung cancer centers and presents data on 18 quality indicators collected during certification.

METHODS

After checks for plausibility and completeness, data on quality indicators for the 2011 and 2012 patient cohorts as well as data of the treating centers were analyzed descriptively (relative/absolute frequencies, means, site medians).

PATIENTS

23,222 patients with ICD-10 diagnoses C33 und C34 from 35 (2012) and 24 operating sites (2011), respectively.

RESULTS

From 2011 to 2012, both the number of certified sites and the number of patients treated increased. Fulfillment of the certification requirements is already high and improved slightly from 2011 to 2012. The implementation of indicators without target values is less advanced.

CONCLUSION

Thanks to the medical and professional associations as well as the oncologic medical experts, the lung cancer certification program is evolving continuously. There has been a steady increase both in the number of patients treated and the number of lung cancer centers; certification requirements are also being increasingly fulfilled.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.

Establishment of the Certification System "Gynaecological Dysplasia" in Germany

Gynaecological cancer centres have been established nationwide in Germany since 2008 according to the certification system of the German Cancer Society (Deutsche Krebsgesellschaft e. V. [DKG]) and the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V. [DGGG]). However, patient access to the certified gynaecological cancer centres is currently only possible through direct referrals. A longitudinal structure with the corresponding long-term documentation of both the high-grade precursors as well as the cancers does not exist as yet. According to the aims of the National Cancer Plan, a corresponding structure for the cancer entity "cervix carcinoma" should be established. The foundations for such a structure are appropriate diagnostic units that are responsible, after nationwide screening, for clarification according to guideline-conform principles. On the basis of the vote of the certification commission for gynaecological cancer centres under the chairmanship of the DKG, the Working Group for Gynaecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie e. V. [AGO]), the Committee on Cervical Pathology and Colposcopy (Arbeitsgemeinschaft Zervixpathologie & Kolposkopie [AG-CPC]) and the DGGG the certification system for gynaecological dysplasia has been established. As a general principle, a distinction is made between the certification of a consulting practice for gynaecological dysplasia and a gynaecological dysplasia facility in order to integrate both outpatient and inpatient health-care facilities into the certification system. In analogy to the further catalogue of requirements from the DKG, quantitative and qualitative minimum numbers are demanded. Furthermore, the requirements of the certification process include a summary of patient information, the applied guidelines, continuing and further training, interdisciplinary cooperation in tumour boards, contents or, respectively, procedure descriptions for consulting practices and the trial participations. Central components of the questionnaire are quality indicators that can be used as specific and measurable elements to evaluate the quality of treatment. After successful pilot certification, finalisation of the updated version of the questionnaire and a completed specialist auditor training course for the certification of gynaecological dysplasia, it will be possible to establish a nationwide treatment system for dysplasia within certified structures.

[The development process of colon cancer centres]

Colon carcinomas are the most common malignant tumours in the Western world. Important findings about the overall quality of medical care have been reported in multi-centre observational studies. A quality enhancement of therapeutic care can be achieved by an additional increase in diagnostic and therapeutic measures in the interdisciplinary setting. The development of colon cancer centres improves the chance to objectively observe the results of medical care induced by the development of an interdisciplinary and cross-sectoral unit that includes a comprehensive medical care for patients. The implementation of the current medical findings based on evidence in clinical routine, the inspection of the usage of guidelines by external specialists as part of an audit and the continuous correction of analysed deficits in the course of treatment guarantee a continuous improvement of service.

Zertifizierte Darmkrebszentren aus Sicht der Zentrumsleitungen: Ergebnisse einer Schlüsselpersonenbefragung

Seit 2003 zertifiziert die Deutsche Krebsgesellschaft (DKG) Organkrebszentren in Deutschland: Nach 8 Jahren Praxis gibt es mehr als 600 zertifizierte Krebszentren, die eine wie im Nationalen Krebsplan geforderte „qualitätsgesicherte onkologische Versorgung“ in Deutschland ermöglichen. Dabei behandeln die mehr als 200 zertifizierten Darmkrebszentren rund 25 % aller Darmkrebsneuerkrankungen. In diesem Artikel wird der Frage nachgegangen, welche Veränderungen das Zertifizierungskonzept in die Zentren gebracht hat.

Key Informants' Perspectives on Accredited Breast Cancer Centres: Results of a Survey

This paper presents the results of a survey among key informants that was conducted between June and September 2011 in Breast Cancer Centers that were accredited according to the criteria of the German Cancer Society (DKG). The survey intended to assess the degree to which the breast cancer center concept was accepted among the key informants as well as to gain an overview over structures and processes in the centers. The Questionnaire for Breast Cancer Centres Key Informants 2011 (FRIZ 2011) was used with two reminders having been sent out. Questionnaires were sent back from 149 of the 243 initially contacted hospitals (response rate: 61.3 %). The vast majority of respondents indicated to be part of the Breast Cancer Center management. 110 of the 149 hospitals did also participate in the patient survey conducted in 2010. Among the key informants surveyed, the concept is highly accepted with regard to improvements in patient care. Overall, the concept is regarded as "good" or "very good" by almost all respondents. Both contact to resident doctors and the hospitals' reputations improved since the implementation of the concept. Quality and patient safety were more often on the agenda than financial performance in the quality circles with the main co-operation partners of the Breast Cancer Centers.

The Patients' View On Accredited Breast Cancer Centers: Strengths and Potential for Improvement

Breast Care Centers that were accredited according to the German Cancer Society criteria were offered to participate in a standardized patient survey in 2010, which was conducted by the Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine, University of Cologne. Patients were included consecutively between March and November 2010. The Cologne Patient Questionnaire-Breast Cancer (CPQ-BC) was used, which assesses a number of aspects of hospital care as perceived by the patients, among them provider-patient interaction, the disease-specific information provided, the quality of organization, and room amenities. 128 of 195 Breast Care Centers and 160 of 251 hospitals participated in the study. 8226 patients consented to the survey. The questionnaires of 7301 patients could be included in the analyses (89 %). Overall, the results showed that patients are satisfied with their hospital stay and that the accreditation criteria are implemented in a way that serves the patients. However, there is room for improvement for a number of issues, for example with regard to the provision of information and patient involvement in decision making. In addition, for a number of indicators substantial differences were found between the hospitals. The results of the survey provide information on the breast centers' development and can be used by the centers' surgery locations for benchmarking purposes, to identify strengths and weaknesses, and to take actions.