Quality indicators for non-small cell lung cancer operations with use of a modified Delphi consensus process.

BACKGROUND: The aim of this project was to develop a set of quality indicators to assess surgical decision making in the care of patients with non-small cell lung cancer (NSCLC). METHODS: A multidisciplinary Expert Panel of 16 physicians used a modified Delphi process to identify quality indicators that evaluated the processes of care in patients with NSCLC. A systematic review identified potential indicators, which were rated on actionability, validity, usefulness, discriminability, and feasibility in two rounds of questionnaires. The first questionnaire was completed by the Expert Panel and by the larger thoracic surgical community of practice; the second questionnaire was sent to only the Expert Panel. Expert Panel members attended an in-person meeting to review the results of the two questionnaires and to compile the final list of indicators by consensus. RESULTS: From the literature review, 41 potential indicators were identified. An additional 16 indicators were suggested by the Expert Panel: 13 indicators in the two rounds of questionnaires and three after the discussion at the in-person meeting. One further indicator was identified after the in-person meeting. In the end, 17 indicators were chosen from seven domains: preoperative assessment, staging, surgical procedures, pathology, adjuvant therapy, surgical outcomes, and miscellaneous CONCLUSIONS: By use of a modified Delphi process, 17 indicators to assess the quality of processes of surgical care for patients with NSCLC were developed.

Assessing the management of hepatic colorectal cancer metastases: is treatment consistent in Ontario?

OBJECTIVES: Advances in surgical techniques and chemotherapeutic options have expanded indications for surgery in patients with metastatic colorectal cancer. This study aimed to examine how hepatopancreatobiliary (HPB) surgeons approach the management of patients with hepatic colorectal cancer metastases (HCCM). METHODS: A web-based survey utilizing 10 clinical scenarios was distributed by e-mail to 37 HPB surgeons in Ontario, Canada. The study region has a population of approximately 13 million people and a universal, single-payer health care system. Descriptive analyses were used to tabulate results. RESULTS: Twenty-two (59%) surgeons responded to the survey. The majority (19/22, 86%) of respondents favoured neoadjuvant chemotherapy for patients with multiple synchronous and unilobar metastases; only nine of 22 (41%) respondents favoured neoadjuvant chemotherapy for patients with a single synchronous metastasis. In the setting of residual resectable disease following downstaging chemotherapy, 77% (17/22) of surgeons advocated hepatic resection with either radiofrequency ablation (RFA) or wedge resection of the 'ghost' lesions. Over 80% of surgeons would perform a liver and pulmonary resection in a patient with hepatic and multiple unilobar lung metastases. None would offer liver resection to patients with multiple retroperitoneal node involvement, although 55% (12/22) would do so if a single retroperitoneal node was involved. Preoperative portal vein embolization was favoured over RFA in patients with a small metastasis and inadequate functional hepatic volume. CONCLUSIONS: Notable heterogeneity was observed among Ontario's HPB surgeons in approaches to HCCM.

The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: a systematic review.

BACKGROUND: To determine the role of liver resection in patients with liver and extrahepatic colorectal cancer metastases and the role of chemotherapy in patients in conjunction with liver resection. METHODS: MEDLINE and EMBASE databases were searched for articles published between 1995 and 2010, along with hand searching. RESULTS: A total of 4875 articles were identified, and 83 were retained for inclusion. Meta-analysis was not performed because of heterogeneity and poor quality of the evidence. Outcomes in patients who had liver and lung metastases, liver and portal node metastases, and liver and other extrahepatic disease were reported in 14, 10, and 14 studies, respectively. The role of perioperative chemotherapy was assessed in 30 studies, including 1 randomized controlled trial and 1 pooled analysis. Ten studies assessed the role of chemotherapy in patients with initially unresectable disease, and 5 studies assessed the need for operation after a radiologic complete response. CONCLUSION: The review suggests that: (1) select patients with pulmonary and hepatic CRC metastases may benefit from resection; (2) perioperative chemotherapy may improve outcome in patients undergoing a liver resection; (3) patients whose CRC liver metastases are initially unresectable may benefit from chemotherapy to identify a subgroup who may benefit later from resection; (4) after radiographic complete response (RCR), lesions should be resected if possible.

Back-over collisions in child pedestrians from the Canadian Hospitals Injury Reporting and Prevention Program.

OBJECTIVE: The objective of the current study was to describe the burden of back-over collisions within the context of other child pedestrian collisions as identified through a pediatric emergency room injury surveillance database. METHODS: Injury data for child pedestrian motor vehicle collisions from 1994 to 2003 were obtained from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). Back-over collisions involving children under the age of 14 were identified and classified by written narratives. Characteristics of children involved in back-over collisions were described, and for those admitted to hospital, the nature of injury was compared with other types of child pedestrian collisions. RESULTS: There were 4295 child pedestrian motor vehicle collisions reported to CHIRPP during the study time period. Of the 4295 children, 148 (3.4%) were injured in a back-over collision, with 49 (33.1%) of these collisions involving a vehicle backing out of a driveway. Children involved in back-over collisions were significantly younger than those in forward-moving/other collisions; however, almost 50 percent of back-over collisions involved children older than age 4. Children involved in back-over collisions on driveways were significantly younger than those involved in collisions occurring at other locations. Of those admitted to hospital, children in back-over collisions were more likely to sustain injuries to internal organs. Children in back-over collisions were less likely to sustain severe/mild head injuries and hip/leg fractures. CONCLUSIONS: Although back-over collisions represent a small proportion of pedestrian motor vehicle collisions, they tend to involve more severe injuries, as indicated by their admission to hospital. It was found that older children are also at risk of back-over collisions and back-over collisions occur in areas other than driveways. In order to lessen the burden of back-over collisions, interventions must address children of different ages and a variety of locations.