Adherence to Quality Indicators and Survival in Patients With Breast Cancer

Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
Medical care (Impact Factor: 3.23). 02/2009; 47(2):217-25. DOI: 10.1097/MLR.0b013e3181893c4a
Source: PubMed


International initiatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to breast cancer care protocol is unknown.
This study explores whether 100% adherence to a set of quality indicators applied to individuals with breast cancer is associated with better survival.
Ten quality indicators (4 diagnosis-related and 6 treatment-related indicators) were used to measure the quality of care in 1378 breast cancer patients treated from 1995 to 2001. Adherence to each indicator was based on the number of procedures performed divided by the number of patients eligible for that procedure. The main analysis of adherence was dichotomous (ie, 100% adherence vs. <100% adherence).
The outcome measures studied were 5-year overall survival and progression-free survival, calculated using the Kaplan-Meier method. The Cox's proportional hazard regression model was used for univariate and multivariate analyses.
Most patients received care that demonstrated good adherence to the quality indicators. Multivariate analysis revealed that 100% adherence to entire set of quality indicators was significantly associated with better overall survival [hazard ratio (HR): 0.46; 95% confidence interval (CI): 0.33-0.63] and progression-free survival (HR 0.51; 95% CI, 0.39-0.67). One hundred percent adherence to treatment indicators alone was also associated with statistically significant improvements in overall and progression-free survivals.
Our study strongly supports that 100% adherence to evidence supported quality-of-care indicators is associated with better survival rates for breast cancer patients and should be a priority for practitioners.

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    • "A recent Taiwanese study shows that when breast cancer patients are diagnosed and treated in complete accordance with widely accepted standards of care, they survive longer and have better outcomes [31]. This prospective study followed 1,378 newly diagnosed breast cancer patients from 1995 to 2001 in a single cancer hospital, tracking 10 indicators of care quality and assessing the progression of disease up to June 2007. "
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    ABSTRACT: Background Due to increasing the complexity of breast cancer treatment it is of paramount importance to develop structured care in order to avoid a chaotic and non-consistent management of patients. Clinical pathways, a result of the adaptation of the documents used in industrial quality management namely the Standard Operating Procedures, can be used to improve efficiency and quality of care. They also aim to re-centre the focus on the patient’s overall journey, rather than the contribution of each specialty or caring function independently. Methods The effect of the implementation and prospective systematic evaluation of a clinical care pathway for the management of patients with early breast cancer in a single breast unit is evaluated over a long time interval (between 2002 and 2010). Annual analysis of predefined clinical outcome measures, service indicators, team indicators, process indicators and financial indicators was performed. Pathway quality control meetings were organized at least once a year. Systematic feedback was given to the team members, and if necessary the pathway was adapted according to evidence based literature data and in house pathway related data in order to improve quality. Results The annual number of patients included in the pathway (289 vs. 390, P <0.01), proportion of patients with Tis-T1 tumors (42% vs. 58%, P <0.01), negative lymph nodes (44% vs. 58%, P <0.01) and no metastases at diagnosis (91.5% vs. 95.9%) has risen significantly between 2002 and 2010. Evolution of mandatory quality indicators defined by EUSOMA shows a significant improvement of quality of cancer care. Particularly, the proportion of patients having anti-hormonal therapy (84.8% vs. 97.4%, P = 0.002) and adjuvant chemotherapy according to the guidelines (72% vs. 95.6%, P = 0.028) increased dramatically. Patient satisfaction improved significantly (P <0.05). Progression free 4-year survival was significantly higher for all patients, for T1 tumors only and for T2-T4 tumors only, treated between 2006 to 2008 compared to between 1999 to 2002 and 2003 to 2005 (P = 0.006, P = 0.05, P = 0.06, respectively). Overall 4-year survival of the entire population treated between 2006 and 2008 was significantly better (P = 0.05). Conclusions Although the patient characteristics changed over the years due to better screening, this clinical pathway and regular audit of quality indicators for the treatment of patients with operable breast cancer proved to be important tools to improve the quality of care, patient satisfaction and outcome.
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    • "und that there were significant results across disease stages of colorectal cancer patients using the threshold of 80% as cut - off point to evaluate associa - tion between adherence to quality - of - care indicators and survivals across disease stages of colorectal cancer patients . The analysis approach used was similar to the proceeding paper ( Cheng et al . 2009 ) . With the findings , we confirm that ' the assignment of scores is subjective , and in unusual situations , the scoring system used can have an impact on the test of hypothesis . In most cases , however , different reasonable scoring will lead to the"
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    ABSTRACT: CHIEN T-W., LIN Y-F., CHANG C-H., TSAI M-T. & UEN Y-H. (2012) European Journal of Cancer Care Using a bubble chart to enhance adherence to quality-of-care guidelines for colorectal cancer patients This study examines whether a higher rate of physician adherence to quality-of-care indicators for colorectal cancer patients is associated with improved survival and using a bubble chart to help interpret physician performance. A set of 13 core measures was used to evaluate the quality of care in 708 colorectal cancer patients treated from 2004 to 2007 at a hospital in Taiwan. A 100% adherence standard was used to measure the relationship of adherence to patient survival. Each indicator assigned by each cancer stage was dichotomously coded. The associations between the adherence and survival rates and demographic characteristics were assessed using Cox's proportional hazard regression. Physician adherence to core indicators was plotted using a bubble chart to motivate physicians' performance adhering to quality-of-care guidelines for colorectal cancer patients. The 100% adherence rate criterion contributed to a relatively low hazard ratio of 0.36 (95% confidence interval, 0.14–0.85; P= 0.02). The association between the adherence rate and survival indicated significant improvements for stage III patients compared with stage I patients. A graphical representation of bubble charts helped to monitor physician performance, which improved the adherence rate to quality-of-care guidelines for colorectal cancer patients.
    Full-text · Article · Feb 2012 · European Journal of Cancer Care
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