Most hospitals follow established practice guidelines for surgery involving Medicare beneficiaries with cancer, but in some cases their practice patterns diverge from the guidelines, according to a report published online in Archives of Surgery, one of the JAMA/Archives journals.
According to background information in the article, health care quality has emerged as an important concern in the United States. However, the right care is not always delivered to the right patient at the right time, the authors remark. "Currently, it is well documented that the practice of health care in America varies widely across both institutions and demographic populations," they write. "This is true across specialties and disease sites." These discrepancies may stem from physicians' lack of knowledge about appropriate care, disagreement with generally accepted standards of care or both.
Caprice C. Greenberg, M.D., M.P.H., from Brigham and Women's Hospital, Boston, and colleagues studied National Surveillance, Epidemiology, and End Results data on surgical treatment for five cancers: breast, colon, gastric, rectal, and thyroid. They limited the field to patients ages 65 years and older who were Medicare beneficiaries and were diagnosed with one of those five cancers between January 2000 and December 2005. The researchers analyzed the surgical treatment of these patients for concordance with national cancer-care guidelines classified by the strength of supporting evidence. Specifically, researchers looked at surgical management of the primary tumor, evaluation and treatment of nodes susceptible to cancer, and referral for adjuvant treatment.
The authors identified 11 guidelines for surgical oncology care and determined whether these guidelines were graded by the National Comprehensive Cancer Network (NCCN) as having a high level of evidence or universal consensus but less evidence. For seven of the 11 guidelines, more than 90 percent of hospitals were in concordance, including all guidelines relating to adjuvant therapy. The proportion of hospitals treating 100 percent of their patients in accordance with the guidelines varied; concordance with guidelines was greatest for adjuvant care. patients who were younger, healthier, wealthier, white, had less-aggressive cancers and lived in the Midwest were the most likely to receive appropriate care.
The guidelines most likely to be followed were those which received a high NCCN evidence rating. The authors suggested that the relationship between evidence level and clinical acceptance should be studied further. Additionally, they note, guidelines relating to adjuvant therapy had a high level of concordance. The researchers conclude, "It is critical that surgeons focus on generation of the data necessary to inform clinical decision making and promote high-quality surgical care."
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