Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards.

INTRODUCTION: The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. METHODS AND RECOMMENDATIONS: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Clinical indicators in surgery: a critical review of the Australian experience.

BACKGROUND: A set of clinical measures (indicators), developed by an Australian Council on Healthcare Standards (ACHS) and Royal Australasian College of Surgeons (RACS) working party, was introduced into the accreditation programme in 1997. Although early qualitative and quantitative reporting by health-care organizations (HCOs) reflected their value in stimulating change, the number of HCOs reporting data on this set of clinical indicators (CIs) has declined, despite an increase in the number of HCOs reporting data on the CIs programme overall. Possible reasons for this decline were sought. METHODS: A retrospective review of prospectively collected surgical CI data was performed, a national survey of stakeholders in the ACHS programme was conducted and a comparison was made with published international data. RESULTS: From a maximum of 247 HCOs reporting data in 2002, the number fell to 168 by 2011. While favourable trends were evident with some CIs, for example, a decline in the rate of negative histology in childhood appendicectomy and in the rate of in-hospital infection in total hip joint replacement, there was minimal change with many of the CIs, suggesting limited responsiveness as measures of care. In the national survey, stakeholder's response was positive overall, but there was a requirement for regular review of CIs. Although some colleges viewed the CIs as simplistic and not reliable, comparisons with similar measures available in the international literature were favourable. CONCLUSIONS: Possible reasons for the declining number of HCOs reporting surgical CI data are a lack of a recent revision of the CIs and a lack of engagement of clinicians from the RACS. Revision of the surgical CI set is required.

Target and tailor the data.

Brown et al. provide a comprehensive evaluation of the public reporting of healthcare performance data, with, however, some limitation on recommendations for its effectiveness. Experience gained over the past 20 years is predominantly in the US with some in the UK. The small amount of Australian experience is reported in this paper. Accountability appears to override quality improvement as the purpose of publishing. It is easier to recount negative effects than positive ones but the overriding finding is the relatively small impression public disclosure has had on healthcare delivery. In an effort to overcome this problem, the intended audience should be clarified and the information correspondingly tailored. For consumers, information should mainly be concerned with issues of process and patient satisfaction, and for the providers, predominantly outcome data.

Abdominal colporectopexy with pelvic cul-de-sac closure.

PURPOSE: Rectal prolapse and posthysterectomy vaginal vault prolapse often occur together and constitute a management problem. This article describes a combined colorectal and gynecologic approach to surgical management and reports the follow-up results of treatment. METHOD: Patients who presented with both rectal and gynecologic symptoms of prolapse subsequent to hysterectomy and were found on clinical examination to have overt and/or occult prolapse of both the rectum and the vaginal vault were considered suitable for a combined operative procedure. This consisted of an abdominal "mesh" rectopexy, abdominal closure of the pelvic cul-de-sac (enhanced by intravaginal endoscopic transillumination), and a colpopexy attaching forward extensions of the same mesh to the apex of the anatomically restored and reinforced vaginal vault. The operation was also accompanied by a colporrhaphy if prolapse of the lower one-third of the vagina was still evident on completion of the abdominal procedures. RESULTS: Eighty-nine patients underwent combined surgery. Sixty of these patients had a concurrent vaginal repair. The mean follow-up time was approximately five years. There were no perioperative deaths, and the morbidity rate was 9 percent. No injury occurred to the urinary tract, and no wound or pelvic infections were evident. There was no recurrence of either the rectal or vaginal vault prolapse. Improvement occurred in all major symptoms, especially in pelvic pain. CONCLUSIONS: The problem of coexisting rectal and posthysterectomy vaginal vault prolapse can be corrected by combined abdominal colporectopexy and closure of the pelvic cul-de-sac. For 89 patients this operation provided considerable relief of symptoms, with no evidence of recurrence of rectal or vaginal vault prolapse at follow-up.