A set of expert consensus-based, quality-of-care indicators identified considerable variability in the quality of pancreatic cancer care among hospitals and may be used to evaluate and identify areas for improvement, according to a new study in the June 9 online issue of the Journal of the National Cancer Institute.
Factors responsible for variability in pancreatic cancer patient outcomes among hospitals in the United States have been difficult to identify because valid indicators of high-quality care have not been available. Researchers undertook this study because pancreatic cancer care has shown substantial hospital-to-hospital variability in outcomes.
To identify such indicators, Karl Y. Bilimoria, M.D., M.S., of the American College Surgeons and the Department of Surgery at Northwestern University in Chicago, and colleagues gathered a panel of 20 pancreatic cancer experts to rank potential quality indicators based on the RAND/UCLA Appropriateness Methodology, rating each at high or moderate validity or not valid. Adherence with the indicators at both the patient and hospital levels was assessed using data from the National Cancer Data Base of the American College of Surgeons (2004-2005) for almost 50,000 patients treated at 1,134 hospitals in the United States.
The panel identified 43 valid indicators, which assessed structural factors, clinical processes of care, treatment appropriateness, efficiency, and outcomes. Patient-level adherence with indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence ranged from 6.8% to 99.9%. Of the 10 component indicators that were used to develop a composite score, most hospitals were adherent with fewer than half of the indicators.
"Because the future of health care will certainly involve more measurement of the quality of care, there is a need for rigorously developed quality indicators put forth by clinicians," the authors write. "Moreover, individual quality measures can be used to develop a data-driven composite measure of hospital pancreatic cancer care that assesses care across multiple domains. These quality indicators offer an opportunity to monitor, standardize, and improve the care of patients with pancreatic cancer."
In an accompanying editorial, Murray F. Brennan, M.D., of Memorial Sloan-Kettering Cancer Center in New York, agrees that there is considerable variability in the management of pancreatic cancer in the United States, but questions the study's suggestion that there is variability in the "quality" of pancreatic cancer management.
"Operative mortality and, to a lesser extent, morbidity, do vary widely among hospitals, and for the patient, operative mortality is a crucial matrix," writes Brennan. "However, given the cost of medical care, it seems facetious to suggest that pancreatic cancer patients in most major cities could improve their perioperative survival by 200% to 400% by spending relatively little money to travel to a hospital with a higher quality of pancreatic cancer management."
Centralizing care in high-volume institutions, according to Brennan, would seem to be an appropriate way to improve patient survival. He also points out that one factor, surgeon case volume, was not considered a valid measure in this study, but perhaps should have been because it has been repeatedly associated with hospital performance.
- Karl Y. Bilimoria, David J. Bentrem, Keith D. Lillemoe, Mark S. Talamonti, Clifford Y. Ko, and on behalf of the American College of Surgeons' Pancreatic Cancer Quality Indicator Development Expert Panel. Assessment of Pancreatic Cancer Care in the United States Based on Formally Developed Quality Indicators. Journal of the National Cancer Institute, 2009; DOI: 10.1093/jnci/djp107
- Murray F. Brennan. Quality Pancreatic Cancer Care: It's Still Mostly About Volume. Journal of the National Cancer Institute, 2009; DOI: 10.1093/jnci/djp138
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