Development of Quality Indicators of Care for Patients Undergoing Hepatic Resection for Metastatic Colorectal Cancer Using a Delphi Process
Introduction
Research in health care outcomes has generated recent interest due to the increasing demand for services, new technologies, and the increasing costs [1] associated with healthcare. Improving quality of health care delivery, while maximizing efficiency, has been an important paradigm in the development of health care policy. Quality of care can be defined as “the degree to which health care services for individuals and populations increase the likelihood of desired health care outcomes and are consistent with professional knowledge [2].” Indicators of quality health care delivery can be categorized into structure, process, and outcome according to the Donabedian construct of quality care 1, 3. Structure involves the technical characteristics of care; these include the infrastructure and organizational make up of the health care delivery system. Process deals with the multiple steps taken in the care of the patient. Outcome refers to the effects seen in the health status of patients and/or populations [3].
Approximately 130,000 patients in the U.S.A. [4] and 19,600 Canadians developed colorectal cancer in 2005 (Canadian Cancer Society), with nearly 60% developing metastatic disease to the liver. Therefore approximately 80,000 patients in North America will present each year with metastatic colorectal cancer in their liver [4]. Approximately 20% of these patients will present with metastatic disease isolated to the liver [5]. Surgical resection of these isolated hepatic metastases is the accepted standard of care even though these patients have stage IV malignancy [6]. This is a result of overwhelming retrospective evidence that hepatic resection improves survival in these patients compared with palliative chemotherapy 7, 8, 9 and supportive care [10].
Although there are guidelines in place regarding the care of patients with colorectal metastases to liver 11, 12, to our knowledge, a set of quality indicators has not been developed for patients undergoing hepatic resection for metastatic colorectal cancer. Quality indicators differ from practice guidelines in that they provide rigid and well-defined measures of performance rather than flexible recommendations on best practice [13]. Many surgical technologies are introduced on the assumption that they are natural and logical extensions of current therapy, with limited supportive evidence for their use and the possibility of unexpected harm [14]. In the context of hepatic resection of colorectal metastases, this is particularly relevant since this procedure is technically demanding [15], and carries a high risk of morbidity and even mortality for patients 15, 16. Furthermore, its application appears to be increasing dramatically [17], in light of improved perioperative outcomes over the last two decades 15, 16. There also seems to be a great deal of variation in the care provided by experts in the field [16]. Therefore, a set of evidence-based quality indicators would prove helpful in evaluating and making recommendations for patients undergoing hepatic resection for colorectal metastases. A set of quality indicators would provide a means of scoring the quality of care at the hospital and regional levels. This information would be helpful in quality improvement initiatives.
Different consensus methods exist to aid in eliciting expert opinion [18]. The Delphi technique uses a systematic evidence-based approach to develop objective performance measures through consensus among an expert panel. This technique employs a series of questionnaires to elicit anonymous responses in an iterative process. It has been employed to develop quality indicators for other surgical procedures 19, 20, 21, 22, 23. The goal of this study was to establish a set of evidence-based quality indicators for patients undergoing hepatic resection for metastatic colorectal cancer using a Delphi process.
Section snippets
Panel Selection
An expert panel was assembled by seeking nomination from the membership of the Canadian Hepatopancreaticobiliary Society (CHPBS). Nominated members were selected to ensure varied training backgrounds, and included experts in surgical oncology, hepatobiliary surgery, and liver transplant surgery. This group of experts was also asked to nominate other experts in related disciplines of medical oncology, hepatology, gastroenterology, pathology, and from other internationally recognized hepatic
Results
The process of developing quality indicators began in September 2006 and concluded in December of 2007. The completed panel consisted of 16 members. From our literature search, we were able to extract 70 potential quality indicators to be included in round 1 of the Delphi process. These came from a variety of sources and levels of evidence including observational cohort studies, randomized controlled studies, clinical guidelines, and systematic reviews. The summary of the Delphi process is
Discussion
In this study, we have identified 18 quality indicators for patients undergoing hepatic resection for metastatic colorectal cancer. These have been derived using a combination of an evidence-based review of the world literature, and an iterative consensus methodology of experts in the field. There are a number of possible uses for quality indicators. First, they may be used to “score” the quality of care received by individuals, or provided by institutions. The score or level of care received
Conclusions
In summary, we believe that this Delphi process has used the best available evidence, along with a consensus methodology employing the opinion of experts in the field, to identify 18 quality indicators for patients undergoing hepatic resection for metastatic colorectal cancer.
Acknowledgments
ED is supported through a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research (AHFMR), and a New Investigator Award from the Canadian Institute of Health Research. This study was funded through an Establishment Grant from the AHFMR.
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