Treatment delays from transfers of care and their impact on breast cancer quality measures.

PURPOSE: Despite delays between diagnosis and surgery adversely affecting survival, patients frequently transfer their breast cancer care between institutions. This study was performed to assess the prevalence and effect of such transfers of care (TsOC) on the time to surgery, and its impact on current time-dependent breast cancer quality metrics at Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC)-accredited institutions. METHODS: Patients having non-metastatic invasive breast cancer diagnosed between 2006 and 2015 at CoC and NAPBC centers ("reporting facilities") in the National Cancer Database were reviewed. TsOC refer to transferring into or out of a reporting facility between diagnosis and surgery. RESULTS: Among 622,793 patients, 36.6% of patients transferred care. TsOC add 7.3, 7.8, 8.7, and 9.8 days in time to surgery, chemotherapy, radiotherapy, and endocrine therapy, respectively (p's < 0.0001). On multivariable analysis, the odds of surgery occurring > 90 days from diagnosis were greatest for patients undergoing unilateral or bilateral mastectomy, Black or Hispanic patients, and those having TsOC (ORs > 1.73, p's < 0.0001). TsOC increase the odds of non-compliance, per patient, for chemotherapy, radiotherapy and endocrine therapy time-dependent measures by 65.4%, 25.6%, and 56.5%, respectively (p < 0.0001). CONCLUSIONS: TsOC for newly diagnosed breast cancers to or from an accredited facility result in delays in time to surgery which can affect compliance with time-dependent quality measures. Facilities frequently receiving transferred patients may be most adversely affected. Although non-compliance with these quality measures is low, institutions and accrediting bodies should be aware of these associations in order to comply with time-dependent standards.

Impact of Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers.

PURPOSE: This study was designed to determine whether accreditation by the National Accreditation Program for Breast Centers (NAPBC) is associated with improved performance on six breast quality measures pertaining to adjuvant treatment, needle/core biopsy, and breast conservation therapy rates at Commission on Cancer (CoC) centers. METHODS: National Cancer Database 2015 data were retrospectively reviewed to compare patients treated at CoC centers with and without NAPBC accreditation for compliance on six breast cancer quality measures. Mixed effects modeling determined performance on the quality measures adjusting for patient, tumor, and facility factors. RESULTS: Of 1308 CoC facilities, 484 (37%) were NAPBC-accredited and 111,547 patients (48%) were treated at NAPBC centers. More than 80% of patients treated at both NAPBC and non-NAPBC centers received care in compliance with breast quality measures. NAPBC centers achieved significantly higher performance on four of the five quality measures than non-NAPBC centers at the patient level and on five of six measures at the facility level. For two measures, needle/core biopsy before surgical treatment of breast cancer and breast conservation therapy rate of 50%, NAPBC centers were twice as likely as non-NAPBC centers to perform at the level expected by the CoC (respectively odds ratio [OR] 1.96, 95% confidence interval [CI] 1.85-2.08, p < 0.0001; and OR 2.05, 95% CI 1.94-2.15, p < 0.0001). CONCLUSIONS: While NAPBC accreditation at CoC centers is associated with higher performance on breast quality measures, the majority of patients at all centers receive guideline-concordant care. Future studies will determine whether higher performance translates into improved oncologic and patient-reported outcomes.

Are We Supporting Surgical Quality Improvement in Training and Beyond? A Qualitative Study of Surgical Trainees and Practicing Surgeons.

BACKGROUND: We conducted a qualitative study to describe surgeon and surgical trainee perspectives of quality improvement (QI) in training and practice to elucidate how surgeons and trainees interact with barriers and leverage facilitators to learn and conduct QI. STUDY DESIGN: Surgeons and surgical trainees of the American College of Surgeons were recruited via email and snowball sampling to participate in focus groups. Eligible individuals were English speaking surgical trainees or practicing surgeons. We developed a semi-structured focus group protocol to explore barriers and facilitators of quality training and improvement. An inductive thematic approach was used to identify actionable items. RESULTS: Thirty-two surgical trainees and surgeons participated in six focus groups. 28% of participants were trainees (8 residents, 1 fellow) and 72% were practicing surgeons, representing practice settings in university, community, and Veterans Affairs hospitals in urban and suburban regions. Thematic analysis revealed the central theme among trainees was that they lacked necessary support to effectively learn and conduct QI. Dominant sub-themes included lack of formal education, insufficient time, inconsistent mentorship, and maximizing self-sufficiency to promotes success. The central theme among surgeons was that effective QI initiatives require adequate resources and institutional support; however, surgeons in this study were ultimately constrained by institutional limitations. Sub-themes included difficulties in data acquisition and interpretation, financial limitations, workforce and staffing challenges, misaligned stakeholder priorities, and institutional culture. CONCLUSION: This qualitative evaluation further details gaps in QI demonstrated by previous quantitative studies. There is an opportunity to address these gaps with dedicated QI training and mentorship for surgical trainees and by creating a supportive environment with ample resources for surgeons.

How Well Is Surgical Improvement Being Conducted? Evaluation of 50 Local Surgery-Related Improvement Efforts.

BACKGROUND: Delivering high-quality care is paramount; however, evaluations show mixed results. Studies assessing improvement efforts in nonsurgical disciplines show suboptimal conduct, yet little is known about how well improvement efforts in surgery are conducted. This study evaluates local surgical improvement efforts to determine whether opportunities exist to improve their conduct. STUDY DESIGN: Fifty consecutive improvement efforts were collected from hospitals participating in 1 of 5 American College of Surgeons Quality Accreditation/Verification Programs. Conduct of these efforts was evaluated using a quality framework (with 39 criteria grouped into 8 components). Descriptive, paired, and 1-way ANOVA analyses were undertaken. RESULTS: The mean percentage of 39 criteria fulfilled for the 50 improvement efforts was 36% (range 0% to 72%). Individual criterion scores ranged from 0% to 82%. The 2 highest scoring criteria were improvement planning and problem documentation; the 2 lowest scoring were value assessments and stakeholder value perspective. The highest scoring framework component addressed End-of-Project Decision-Making (47%); the lowest was Cost Evaluation (3%). Twenty-four percent of 50 improvement efforts reported full achievement of project goals, 32% reported partial achievement, and 44% reported no achievement. Higher scores were associated with projects having full/partial achievement of stated project goals vs projects not achieving project goals (p < 0.05). Higher scores were not associated with hospital characteristics (eg bed size, teaching status) or improvement characteristics (eg improvement strategy). CONCLUSIONS: Evaluation of local surgical improvement efforts shows opportunities for improvement. Better-conducted improvement efforts were associated with more effective improvement. To support better surgical quality of care, improvement efforts need to improve.

National Accreditation Program for Breast Centers Demonstrates Improved Compliance with Post-Mastectomy Radiation Therapy Quality Measure.

BACKGROUND: The National Accreditation Program for Breast Centers (NAPBC) was established in 2008 by the American College of Surgeons as a quality-improvement program for patients with breast disease. An NAPBC quality measure states post-mastectomy patients with ≥4 positive lymph nodes should receive lymph node radiation therapy (PMRT). Our objective was to examine how NAPBC accreditation has affected compliance with this quality measure. STUDY DESIGN: Women who underwent mastectomy at either an NAPBC-accredited center or a Commission on Cancer-only accredited hospital were identified (2006 to 2013) in the National Cancer Data Base. The NAPBC centers accredited from 2009 to 2011 were included in the analysis. Patients were nested within centers using a mixed effects model to identify PMRT rates at each center before and after accreditation, adjusting for patient and tumor characteristics. RESULTS: Of 34,752 patients from 477 NAPBC-accredited centers and 958 Commission on Cancer-only accredited hospitals who underwent mastectomy with ≥4 positive lymph nodes, 21,638 patients received PMRT during the study period (62.3%). The NAPBC centers yielded a significantly higher rate of PMRT than Commission on Cancer hospitals (66.0% vs 59.2%; p < 0.001). For each year of accreditation (2009 to 2011), centers had significantly higher rates of radiation in the accreditation year compared with the year before accreditation (p < 0.001). Within those centers, the rate of radiation increased post-accreditation in each accreditation year (2009: 62.1% to 71.9%; 2010: 65.5% to 73.2%; 2011: 67.5% to 70.4%). CONCLUSIONS: The NAPBC accreditation is associated with higher PMRT rates and better adherence to the PMRT quality measure. Future studies with more centers and longer follow-up are needed to determine whether this trend continues.