Journal of the National Cancer Institute Advance Access originally published online on June 9, 2009
JNCI Journal of the National Cancer Institute 2009 101(12):848-859; doi:10.1093/jnci/djp107
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© The Author 2009. Published by Oxford University Press.
ARTICLES |
Assessment of Pancreatic Cancer Care in the United States Based on Formally Developed Quality Indicators
Affiliations of authors: Cancer Programs, American College Surgeons, Chicago, IL (KYB, CYK); Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL (KYB, DJB, MST); Department of Surgery, Indiana University School of Medicine, Indianapolis, IN (KDL); Department of Surgery, NorthShore University HealthSystem, Evanston, IL (MST); Department of Surgery, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, CA (CYK)
Correspondence to: Karl Y. Bilimoria, MD, MS, Cancer Programs, American College of Surgeons, 633 N St Clair St, 22nd Floor, Chicago, IL 60611 (e-mail: kbilimoria{at}facs.org).
Background: Pancreatic cancer outcomes vary considerably among hospitals. Assessing pancreatic cancer care by using quality indicators could help reduce this variability. However, valid quality indicators are not currently available for pancreatic cancer management, and a composite assessment of the quality of pancreatic cancer care in the United States has not been done.
Methods: Potential quality indicators were identified from the literature, consensus guidelines, and interviews with experts. A panel of 20 pancreatic cancer experts ranked potential quality indicators for validity based on the RAND/UCLA Appropriateness Methodology. The rankings were rated as valid (high or moderate validity) or not valid. Adherence with valid indicators at both the patient and the hospital levels and a composite measure of adherence at the hospital level were assessed using data from the National Cancer Data Base (2004–2005) for 49 065 patients treated at 1134 hospitals. Summary statistics were calculated for each individual candidate quality indicator to assess the median ranking and distribution.
Results: Of the 50 potential quality indicators identified, 43 were rated as valid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (25.6%) assessed structural factors, 19 (44.2%) assessed clinical processes of care, four (9.3%) assessed treatment appropriateness, four (9.3%) assessed efficiency, and five (11.6%) assessed outcomes. Patient-level adherence with individual indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence with individual indicators ranged from 6.8% to 99.9%. Of the 10 component indicators (contributing 1 point each) that were used to develop the composite score, most hospitals were adherent with fewer than half of the indicators (median score = 4; interquartile range = 3–5).
Conclusions: Based on the quality indicators developed in this study, there is considerable variability in the quality of pancreatic cancer care in the United States. Hospitals can use these indicators to evaluate the pancreatic cancer care they provide and to identify potential quality improvement opportunities.
| CONTEXT AND CAVEATS Prior knowledge Pancreatic cancer outcomes vary considerably among hospitals, but the factors responsible for this variability have been difficult to identify because valid indicators of high-quality care for pancreatic cancer patients are not available. Study design A panel of pancreatic cancer experts identified valid quality indicators for pancreatic cancer care, assessed hospital-level compliance with these indicators, and developed a composite measure of adherence at the hospital level using data from the National Cancer Data Base (2004-2005) in the United States. Contribution Of 50 potential quality indicators identified, 43 were rated as valid and assessed structural factors, clinical processes of care, treatment appropriateness, efficiency, and outcomes. Most hospitals were adherent with fewer than half of the 10 component indicators that were used to develop the composite measure of adherence. Implications These quality indicators can be used by hospitals to monitor, standardize, and improve the care they provide to pancreatic cancer patients. Limitations Important indicators may have been missed. Some indicators may have received slightly lower rankings because of how they were worded. The reliability of hospital performance comparisons was limited by the small sample size and an inability to adjust completely for differences in case mix among hospitals. The findings may not be generalizable to all hospitals. From the Editors
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Manuscript received October 19, 2008; revised March 8, 2009; accepted April 3, 2009.
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J Natl Cancer Inst 2009 101: 835.
J Natl Cancer Inst 2009 101: 835.