Quality of care indicators for prostate cancer: Progress toward consensus

Previously-documented variations in patterns of care and patient outcomes suggest differences in the quality of care provided to men with prostate cancer. Herein we describe ongoing efforts to measure the quality of prostate cancer care, including the development and pilot-testing of the RAND prostate cancer quality indicators and the selection of the consensus-based Physician Performance Measurement Set for Prostate Cancer. We also summarize current payer-led initiatives aimed at measuring quality of care for men with prostate cancer. We conclude that currently-available prostate cancer quality indicators are derived from valid, consensus-based methodologies and capture clinical practices that are necessary for high-quality care in early-stage prostate cancer. Despite this promise, however, the currently available measures have several limitations that should be considered during their implementation in prostate cancer quality assessment and improvement activities.     

Prioritizing Patient‐Reported Outcomes in Breast Cancer Surgery Quality Improvement

Breast‐cancer‐specific tools that measure health‐related quality of life (HRQOL) were developed for use in research or clinical practice, and little is known about these tools’ performance ability for quality improvement. Furthermore, existing tools may not fully reflect all issues that contribute to quality care as seen by patients. Work is needed to identify and validate patient‐reported outcome measures for use in quality improvement in breast cancer surgical care. We conducted an exploratory qualitative study in order to better understand what HRQOL domains and processes of care define high quality surgical care for women undergoing mastectomy for breast cancer from both the patient and clinician perspective. We conducted focus groups and one‐on‐one interviews with 15 women and administered a prioritization questionnaire to participants. We also conducted a prioritization questionnaire among surgical oncologists, general surgeons, and reconstructive surgeons who are members of the Washington State Medical Association. Both the patient and surgeon prioritization questionnaire asked participants to prioritize HRQOL and treatment satisfaction‐related aspects of their breast cancer surgical care at key time points before and after mastectomy. A Stakeholder Advisory Panel was convened to review focus group, interview, and prioritization questionnaire results and make recommendations as to patient‐reported outcome domains to focus on and existing instruments to use for quality improvement. Patients and clinicians largely agreed on important HRQOL domains, including emotional well‐being, education, communication, and process of care. The Stakeholder Advisory Panel, composed of 12 clinicians and five patients, reviewed study findings and existing patient‐reported outcomes measurement tools. The panel recommended that the BREAST‐Q, a flexible tool with independently validated modules designed for research and clinical care, is an ideal tool to begin developing novel quality improvement benchmarks focused on patient‐reported outcomes.     

Improving breast cancer quality of care with the use of patient navigators

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.     

Patients’ opinions on quality of care before and after implementation of a short stay programme following breast cancer surgery

PurposeTo assess breast cancer patients’ opinions on quality of care during an implementation study on short hospital stay, and to formulate patient inspired targets for further quality improvement based on results of the QUOTE (Quality of Care Through the Patients’ Eyes) breast cancer instrument.ResultsQuality of patient education regarding activities at home was in need of improvement in both measurements. Quality of services delivered by the surgeon improved somewhat after implementation. Although quality of waiting and process times improved after implementation, there was still room for further improvement on these aspects.ConclusionA breast cancer care programme in short stay was introduced while, on average, preserving quality of care as perceived by the patient. However, aspects regarding education on drains, prosthesis, exercises after surgery, survival rates, and waiting and process times require continuing attention to enhance patients’ assessment of quality of care.     

Zertifizierungssysteme in der urologischen Versorgung

There have been function and organ-related certification systems in urology for a long time. The aim of such certificates is the optimization of patient care above the defined minimum standards and intensification of interdisciplinary cooperation. Whether such certificates have led to better patient care has not been proven. The obligatory documentation in epidemiological cancer registries, which has been taken up by legislature, will in future lead to so-called clinical cancer registries in which the complete course of treatment must be entered. With these registries the quality of healthcare can be compared between individual institutions. Until now, quality of care data outside oncology are lacking. Urology would also benefit from a registry with quality of care data for these patients.     

Palliative care in advanced cancer

Palliative care represents a new field among clinical approaches to patients with advanced or terminal cancer. The modern concept of palliative care can be considered in several ways: 1) the relationship between palliative care and primary treatments of cancer (surgery, radiotherapy or chemotherapy); 2) the treatment of symptoms and the relationship between symptom control and quality of life; 3) end-of-life care. With regard to the relationship between palliative care and primary cancer treatments, it is common opinion that a continuity of care is needed from diagnosis to the terminal phase of the disease, and oncology departments could represent the ideal dimension in which to fulfil this requirement. In a continuity-of-care setting, symptom control becomes vitally important to improve quality of life of the patient throughout all the stages of the disease. Moreover, support for the patient and his/her family during the terminal phase of the disease is one of the most important dimensions of palliative care. In addition, assistance provided during the last hours of life and support for the family after the patient's death represent the so-called global assistance, which is distinctive of palliative care.     

Importance of patient reported outcome measures versus clinical outcomes for breast cancer patients evaluation on quality of care

IntroductionGiven increasing numbers of breast cancer survivors, there is an increased focus on quality of life and quality of care. This study aims to investigate whether clinical or patient reported outcomes are most important for perceived quality of care by breast cancer patients.MethodsOverall, 606 patients aged 18 years or older, who underwent breast cancer surgery 9–18 months ago in five hospitals in the Netherlands, were invited to complete an internet-based questionnaire. Patients were asked to judge a random selection of 24 patient profiles and choose which of 2 presented patients had received the best quality of care, using conjoint analysis. The individual relative importance (RI) for each outcome was estimated using Hierarchical Bayes Estimation, and averaged over all patients to assess which outcomes were most important.ResultsComplete data were available for 350 patients (58%). Avoiding severe breast symptoms was most important for good quality of care according to patients (RI 23.22 [95% Confidence Interval (95% CI) 22.32–24.12]), followed by a 2 year longer disease free survival (18.30 [17.38–19.22]). However, the importance differed by age: younger patients (<50 years) assigned higher importance to longer disease free survival (21.99 [19.52–24.46]) than older patients (65 + years) (15.03 [13.88–16.18]).ConclusionAvoiding severe breast symptoms rather than 2 year longer disease free survival is considered most important in our population of breast cancer patients for evaluation of quality of care. These data should thus be included in both information provision prior to treatment choices and post treatment quality of care evaluation.     

Providing prostate cancer survivorship care in Japan: Implications from the USA care model

Despite an increasing number of prostate cancer survivors in Japan, the current delivery of prostate cancer survivorship care is insufficient and lacks a multidisciplinary approach. We carried out a study to characterize prostate cancer survivorship care in Japan, examine the Japanese workforce available to deliver survivorship care, introduce a conceptual framework for survivorship and identify opportunities to improve Japanese survivorship care. We systematically searched PubMed for prostate cancer survivorship care studies, including those from Japan. We also searched the internet for prostate cancer guidelines relevant to survivorship care. We found 392 articles, of which 71 were relevant, read in detail and reported here. In Japan, survivorship care is mostly provided by urologists. Primary care as a specialty does not exist in Japan, and there are no independent nurse practitioners or physician assistants to assist with survivorship care. Japanese quality of life studies characterize the long‐term effects of prostate cancer treatment, but routine use of patient‐reported outcomes is not common in Japan. In the USA, in light of a growing comprehensive awareness of challenges facing survivors and their providers, the American Cancer Society prostate cancer survivorship care guidelines serve as a tool for optimizing the management of long‐term treatment effects and coordination of care. In order to deliver high‐quality survivorship care in Japan, urologists need to establish collaborations with other disciplines within the delivery system. A multidisciplinary guideline for prostate cancer survivorship care in Japan appears warranted.     

Health related quality of life using serum testosterone as the trigger to re-dose long acting depot luteinizing hormone-releasing hormone agonists in patients with prostate cancer

PURPOSE: Health related quality of life was assessed in patients with prostate cancer on androgen suppression therapy re-dosed based on serum testosterone, and observations were confirmed regarding the safety, efficacy and cost per patient treated with this method of re-dosing luteinizing hormone-releasing hormone agonists. MATERIALS AND METHODS: The study comprised 22 patients with prostate cancer prospectively enrolled in a control-crossover designed trial of dosing depot luteinizing hormone-releasing hormone agonist based on serum testosterone. Health related quality of life using the Expanded Prostate Index Composite and SF-36 instruments was the primary outcome assessed. RESULTS: Median duration of castrate testosterone was 5.5 months (range 3.5 to 10). Longer durations of castrate testosterone significantly correlated with lower pretreatment serum testosterone and smaller body mass index. No significant change from nadir prostate specific antigen was observed during castrate duration. The yearly cost of care was significantly decreased using the method of re-dosing based on serum testosterone ($3,567.90 versus $7,135.80). Short-term overall health related quality of life and patient satisfaction were significantly improved over baseline measurements. However, by study completion overall health related quality of life was equivalent regardless of the dosing method. CONCLUSIONS: Patient assessed health related quality of life improved in the short term and the cost of care decreased with no loss in the quality of care or patient satisfaction using serum testosterone as the trigger to re-dose 10.8 mg. goserelin in patients with prostate cancer on androgen suppression therapy.     

Zertifizierte Prostatakarzinomzentren der Deutschen Krebsgesellschaft

The 12-month data for 21 of the 44 certified centers were analyzed 2 years after certification of the first prostate cancer centers of the German Cancer Society. Currently about 25% of patients with prostate cancer are being treated in the centers certified by the German Cancer Society. On the one hand, a positive development toward interdisciplinary management can be observed with verifiably good surgical quality in most of the centers and good outpatient care provided by social services, and in some instances psycho-oncological support. On the other hand, there are substantial problems with data documentation. The quality of documentation declines considerably when the patient leaves the hospital. Concerted efforts must be made to improve documentation of patient data and transfer of aftercare information. The association with hospital cancer registries must be enhanced. The quality of both inpatient care and intersectoral care can only be improved on a long-term basis when the insurance providers support this development. Only when there is evidence for improved treatment quality can the long-term development of centers be justified, but until this is corroborated the establishment of centers cannot remain without financing.     

The Structural Landscape of the Health Care System for Breast Cancer Care: Results from The Los Angeles Women's Health Study

Abstract:  The structure of health care has been rapidly evolving in response to financial pressures and demands to improve quality. Little work has documented the structure of care and its impact in the context of breast cancer care. We conducted a survey to characterize Los Angeles physicians caring for breast cancer patients and the structural landscape of the healthcare system in which they practice. Cross-sectional survey of physicians who treated a population-based cohort of breast cancer patients. We surveyed 477 physicians, targeting all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by patients participating in the Los Angeles Women's Health Study (77% response rate). Specialty-specific questionnaires were developed. Items were based on the structure and quality of care literature, cognitive interviews with cancer care specialists, and existing physician survey instruments. Breast cancer care providers in Los Angeles are diverse, with one-third non-white and 46% speaking a non-English language. Group practice is most common, (37% single specialty, 16% group-model HMO, 8% multi-specialty group). Minimal teaching involvement predominates. Mean new breast cancer patient volumes are relatively high (8 per month overall; six for surgeons), representing 46% of new cancer patients. Physicians reported high career satisfaction levels (83–92%). Physicians were least satisfied with the amount of time spent with patients (82%). Data from this study represent important building blocks for further analyses to determine the impact of structural characteristics on the quality of care that breast cancer patient's experience.     

Prostate cancer: palliative care and pain relief

Metastatic prostate cancer is incurable, and both the disease and other comorbidities as well as side effects from treatments can be very disabling for patients who are generally elderly. Past reviews on palliative care in prostate cancer have tended to concentrate on methods of active intervention with palliative intent rather than the principles of palliative care in a broader context. This paper is intended to introduce the principles and practice of modern palliative care as applied to care of patients with prostate cancer. Current National Institute for Clinical Excellence guidelines for urological cancers recommends provision of palliative care for all patients with prostate cancer, according to need. Palliative care aims to improve the quality of life of patients and their families. It is a holistic and personal approach to patient care, consisting of patient centred multiprofessional teams. Symptoms such as pain, psychological, spiritual and social problems are given equal weighting and tackled simultaneously. When treating pain, hormonal manipulation, radiotherapy, chemotherapy and surgery should always be considered alongside analgesic therapy, with realistic aims in mind. Towards the end of life, palliative care for patients will generally increase in line with increasing symptoms and other problems. Achieving a peaceful and comfortable death for our patients should be a priority in hospitals.     

Challenges and economics of private breast cancer surgery practice

The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient’s initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.     

Skeletal Manifestations of Treatment of Breast Cancer

Breast cancer and osteoporosis are common diagnoses in women. Breast cancer survival has improved due to earlier detection and improved treatments. As most breast cancers are estrogen receptor positive, treatment is often aimed at altering the hormonal environment. Both pre and postmenopausal women undergoing these therapies are at risk for bone loss. The patient’s health care team ought to have an awareness of the potential for breast cancer treatments to accelerate bone loss. Women with early stage breast cancer are treated with curative intent and, therefore, maintaining bone health is important and is part of the survivorship care to ensure an optimal quality of life.     

Summary of the 8th Annual Bladder Cancer Think Tank: Collaborating to move research forward

ObjectivesThe 8th Annual Bladder Cancer Think Tank (BCAN-TT) brought together a multidisciplinary group of clinicians, researchers, and patient advocates in an effort to advance bladder cancer research.Methods and MaterialsWith the theme of “Collaborating to Move Research Forward,” the meeting included three panel presentations and seven small working groups.ResultsThe panel presentations and interactive discussions focused on three main areas: gender disparities, sexual dysfunction, and targeting novel pathways in bladder cancer. Small working groups also met to identify projects for the upcoming year, including: (1) improving enrollment and quality of clinical trials; (2) collecting data from multiple institutions for future research; (3) evaluating patterns of care for non-muscle-invasive bladder cancer; (4) improving delivery of care for muscle-invasive disease; (5) improving quality of life for survivors; (6) addressing upper tract disease; and (7) examining the impact of health policy changes on research and treatment of bladder cancer.ConclusionsThe goal of the BCAN-TT is to advance the care of patients with bladder cancer and to promote collaborative research throughout the year. The meeting provided ample opportunities for collaboration among clinicians from multiple disciplines, patients and patient advocates, and industry representatives.     

A pilot study to evaluate the impact of involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan

Multidisciplinary care is the accepted best model of management of breast cancer patients. Current evidence suggests that multidisciplinary care has the potential to reduce mortality, improve quality of life, and reduce health care costs. We investigated the impact of patient involvement in the multidisciplinary meeting. A pilot study was conducted to assess the feasibility and acceptability of directly involving patients diagnosed with breast cancer in multidisciplinary clinic discussions and treatment planning. 30 consecutive breast cancer patients presenting for surgery were invited to attend our weekly multidisciplinary breast meeting at the time of receiving their results of surgery. Patients completed questionnaires before and after the meeting, and participated in a tape-recorded interview with the breast care nurse after the meeting. Members of the multi-disciplinary team also completed a short survey at the end of the study. The intervention was highly valued by most of the participating patients; and acceptable to and welcomed by most health professionals in the multidisciplinary team. Change in anxiety scores was not affected by participation. Patient attendance at the breast multidisciplinary meeting was shown to be potentially acceptable to both patients and health professionals, without unduly raising patient anxiety. A national survey exploring attitudes towards patient involvement in the multidisciplinary team meeting is currently in progress.     

Surgeon-Level Variation in Patients’ Appraisals of Their Breast Cancer Treatment Experiences

Background and Purpose

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.

Methods

Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.

Results

Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4 % for access to care, 3.3 % for care coordination, and 7.5 % for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.

Conclusions

Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.     

New frontiers in palliative care

Palliative care is an interdisciplinary approach provided to patients and their families when the medical expectation of recovery is negligible. Palliative care does not focus on a single disease. However, it takes into account the integrity of the human being, allowing the patient to improve his or her quality of life and relief from the suffering imposed by adverse medical conditions. The increasing need for a comprehensive approach in health care for patients and families suffering from cancer and noncancer chronic degenerative diseases makes palliative care an indispensable resource in today's society. The current demographic changes and the increased incidence of cancer and chronic diseases is consolidating the practice of palliative care and expanding its frontiers to face new research challenges in areas such as palliative care in children and nonmalignant diseases, public health policy, education in palliative care, and euthanasia.     

Supportive and palliative care for metastatic breast cancer: Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life.As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available.The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care.The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support.     

宫颈癌放射性皮肤损伤的标准化护理

目的减轻宫颈癌同期放化疗患者放射性皮肤损伤程度。方法将434例宫颈癌同期放化疗患者随机分为观察组与对照组各217例。两组均接受放疗联合同期化疗,对照组按常规进行放射性皮肤损伤防护;观察组根据患者放疗剂量及患者局部情况设计标准化防护方案、规范评估方法、统一防护操作技术防护流程,进行严格质量控制。结果观察组放射性皮肤损伤严重程度显著轻于对照组,会阴部卫生清洁合格率及内裤穿着合格率显著高于对照组(均P0.01)。结论标准化防护方案的实施可有效减轻宫颈癌同期放化疗患者放射性皮肤损伤程度,提高患者卫生防护行为。