Editorial

Quality Measures, Standards, and Accreditation for Breast Centers in the United States

Quality measurement is necessary to identify gaps in health care quality and to assess the effectiveness of quality improvement initiatives. Multiple reports measuring the quality of breast cancer care provide evidence that inequities and disparities exist. In some cases, variation in care is associated with geography, institution, and surgeon, as well as patient race, socioeconomic status, and insurance status. To search for and address these quality concerns, multiple professional organizations have developed both quality measures and an electronic platform to capture quality data regarding the provider-patient encounter. Armed with this information, peer performance comparisons between providers—benchmarking—can improve quality. This chapter serves as a primer to present the best strategies for quality measurement and performance improvement for breast surgeons.

Electronic health records (EHR) are increasingly being adopted by healthcare systems worldwide. In France, the “Hôpital numérique 2012–2017” program was implemented as part of a strategic plan to modernize health information technology (HIT), including the promotion of widespread EHR use. With significant upfront investment costs as well as ongoing operational expenses, it is important to assess this system in terms of its ability to result in improvements in hospital performances.

The aim of this study was to evaluate the impact of EHR use on the quality of care management in acute care hospitals throughout France.

This retrospective study was based on data derived from three national databases for the year 2011: IPAQSS (indicators of improvement in the quality and the management of healthcare, “IPAQSS”), Hospi-Diag (French hospital performance indicators), and the national accreditation database. Several multivariate models were used to examine the association between the use of EHRs and specific EHR features with four quality indicators: the quality of patient record, the delay in sending information at hospital discharge, the pain status evaluation, and the nutritional status evaluation, while also adjusting for hospital characteristics.

The models revealed a significant positive impact of EHR use on the four quality indicators. Additionally, they showed a differential impact according to the functionality of the element of the health record that was computerized. All four quality indicators were also impacted by the type of hospital, the geographical region, and the severity of the pathology.

These results suggest that, to improve the quality of care management in hospitals, EHR adoption represents an important lever. They complete previous work dealing with EHR and the organizational performance of hospital surgical units.

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.

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.

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%).

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.

The American College of Radiology (ACR) Radiation Oncology Practice Accreditation (ROPA) program has accredited more than 600 sites since 2006, including practices within academic, hospital-based, and freestanding settings. The purpose of this report is to evaluate and compare patterns of change in common deficiencies over time.

The ACR database was queried to analyze the common deficiencies noted by the ACR ROPA program between 2012 and 2014. Deficiencies were ranked and compared to the top 10 items that were reported in 2006.

Between 2012 and 2014, 272 new applications and 306 renewals were received. Timely verification of port films, documentation of physician peer review, inclusion of essential elements of a treatment prescription, evidence of a final physicist chart review, documentation of weekly treatment visits, and inclusion of key elements of brachytherapy documentation all improved when compared with 2000-2005. Deficiencies ranked higher on the current review compared with the previous analysis included documentation of a robust quality assurance program, missing elements from the history and physical documentation, and documentation of follow-up visits.

Our analysis of changes in patterns of deficiencies across radiation oncology practices reflects changes in our field such as the growing reliance on electronic records and imaging. Accreditation continues to play an integral role in establishing national standards and a nonpunitive, peer-reviewed method to evaluate a practice’s compliance with national quality guidelines.

Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, the field of radiation oncology has a long history of organized quality assessment efforts and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. This report provides a comprehensive review of the current state of quality assessment in radiation oncology. Specifically, this report highlights implications of the healthcare quality movement for radiation oncology and reviews existing efforts to define and measure quality in the field, with focus on dimensions of quality specific to radiation oncology within the “big picture” of oncologic quality assessment efforts.