The Breast xxx (2014) 1e7

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Original article

Quality improvement by implementing an integrated oncological care pathway for breast cancer patients J. van Hoeve a, *, L. de Munck a, R. Otter a, b, J. de Vries c, S. Siesling a, d a

Comprehensive Cancer Centre, The Netherlands University Medical Centre Groningen, Medical Oncology, The Netherlands c Department of Operations Management, Faculty of Economics and Business, University of Groningen, The Netherlands d Health Technology and Services Research, University of Twente, The Netherlands b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 28 March 2013 Received in revised form 12 December 2013 Accepted 19 January 2014

Background and aim: In cancer care, more and more systemized approaches such as care pathways are used to reduce variation, reduce waiting- and throughput times and to improve quality of care. The aim of this study was to determine whether the implementation of a multidisciplinary breast cancer pathway in three hospitals has improved the care for breast cancer patients. Methods: Retrospectively almost 800 patients with breast cancer were selected from the Netherlands Cancer Registry (NCR). The patients were divided in two groups: before implementation of the pathway in 2006e07 (baseline measurement) and those after implementation in 2009 (post measurement). Fourteen quality indicators were compared before and after the implementation of the care pathway. To estimate the impact of the care pathway relative to evidence based guidelines and profession-based norms, involved project leaders were interviewed. Results: Seven out of eight indicators with medical information and four out of five indicators with information about waiting- and throughput times improved. With the multidisciplinary meeting as key in the breast cancer care, more compliance to national guidelines was observed. E.g. for more patients a HER2neu test was performed after implementation of the pathway (from 92% to 96%, r ¼ 0.016) and more patients started with their first chemotherapy (from 33% to 45%) or their first radiotherapy (from 55% to 59%) within 4 weeks after surgery. Conclusion: Implementing a multidisciplinary breast cancer pathway leads to better compliance with the national guidelines and can improve breast cancer care. Ó 2014 Elsevier Ltd. All rights reserved.

Keywords: Care pathways Multidisciplinary cancer care Integrated healthcare systems Breast cancer

Introduction Breast cancer is the most common cancer in women worldwide, with 464.000 cases in 2012 [1]. The Netherlands Cancer Registry (NCR) showed a 1-year incidence of breast cancer of 13.257 women in 2010 [2]. Due to this large number, the high impact of the diagnosis cancer and the multidisciplinary character of cancer care processes, health care organizations put much effort in improving breast cancer care. Besides, external parties such as the Health Care Inspectorate (IGZ) stimulate and demand transparency of care through publication of indicators to get insight in the patientfocused care and the delivered quality of care. Nowadays patients

* Corresponding author. Department Networks, Comprehensive Cancer Centre The Netherlands, P.O. Box 330, 9700 AH Groningen, The Netherlands. E-mail address: [email protected] (J. van Hoeve).

can choose between hospitals, based on the quality indicators. One of the methods to realize patient-focused care and re-organize care processes is the development and implementation of care pathways in order to improve the quality and efficiency of evidence based care, teamwork and to achieve better accessibility of care [3,4]. Care pathways are also known as clinical pathways, critical pathways, integrated pathways, patient journeys or care maps [3]. In this study care pathways are defined as logical coherent individual care processes which patient with a specific tumor go through from the first need for care to survivor or death [5]. Introducing care pathways usually leads to structuring health care services to improve the compliance with evidence based guidelines or evidence based medicine [6]. However, implementing care pathways in an organization is a complex intervention [3]. To support hospitals with developing, implementing and monitoring multidisciplinary cancer pathways as well as implementing evidence based guidelines, the Comprehensive Cancer Centre the

http://dx.doi.org/10.1016/j.breast.2014.01.008 0960-9776/Ó 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: van Hoeve J, et al., Quality improvement by implementing an integrated oncological care pathway for breast cancer patients, The Breast (2014), http://dx.doi.org/10.1016/j.breast.2014.01.008

2

J. van Hoeve et al. / The Breast xxx (2014) 1e7

Netherlands (IKNL) has introduced the model for Integrated Oncological Care Pathways (IOCP) and a corresponding roadmap [5,7]. This model is based on principles of process management as well as national (evidence based) guidelines. Central elements of the IOCP model are ‘process’, ‘organization’ and ‘planning’. These elements lead to a certain ‘performance’. E.g. agreements about the moments of transfer (process), a better organization of the multidisciplinary meeting (organization and structure) or a better planning of operations (planning) may improve the performance of the care pathway and results in better quality of care. The IOCP model is frequently used for introducing cancer care pathways of several tumor types in Dutch hospitals. As pathways are seen as a method within the field of continuous quality improvement, evidence about the effects of implementing cancer care pathways is essential. In 2001 a literature review was published about the impact of clinical practice guidelines and pathways for several tumor types, including breast cancer. The authors concluded that costs and length of stay can be reduced, practice variations can be minimized, and patient quality of care and satisfaction can be maintained [6]. Next, a study about a mastectomy pathway concluded that the consistency in patient’s treatment as well as the quality of patient outcome improved, and the costs of care and length of hospital stay reduced [8]. More recently, another study reported the following positive effects of a clinical pathway for breast surgery: patient satisfaction increased, patient anxiety levels decreased, and patient’s quality of care improved [9]. To our knowledge no studies exist about the effects of implementing a multidisciplinary breast cancer pathway by using a systematic method for developing and implementing oncological care pathways in more than one hospital. The aim of this study was to determine whether the implementation of a multidisciplinary breast cancer pathway in three hospitals improved the care for breast cancer patients. As care pathways are strongly related to other methods of quality improvement, such as introducing (new) guidelines and quality criteria, it is important to determine the actual influence of introducing the care pathway on the results. Therefore, data from a national database was combined with the opinion of involved project leaders concerning the impact of the breast cancer pathway. Methods Selection of indicators The quality of care before and after having implemented the breast cancer pathway was assessed by selecting fourteen indicators. These indicators were chosen because they are all available in the NCR and because of their focus on the compliance national guidelines, these are the evidence based guideline for breast cancer (www.oncoline.nl) and the norms of the National Breast Cancer Organization of the Netherlands (NABON). The NCR, established in 1989, is a nationwide population-based cancer registry and has data of new cancer patients, such as tumor type, incidence data and stage and NABON indicators, based on information from the pathology laboratories and patient files collected by specially trained registrars. Study population and setting The quality of breast cancer care was assessed in a retrospective study. Included were breast cancer patients diagnosed with primary breast cancer from three medium-sized hospitals in the Northern Netherlands. For the hospital characteristics, see Table 1. Breast cancer patients which were diagnosed with breast cancer in these three hospitals in the period 1 July 2006 until 30 June 2007

Table 1 Hospital information. Hospital

Catchment area Number of residents in whole region: 647.214b Number of breast cancer patients diagnosed with primary breast cancerc New diagnosed breast cancer patientsd:  Whole region: 629  The Netherlands: 14.964 Number of bedsa Number of first hospital visitsa Number of employees (excl. medical specialists)a Number of medical specialista Treatments: all basis specialisms such as oncologya Radiotherapy: patients are referred to the same specialized regional radio therapeutic centrea

A

B

C

140.000*

100.000

121.602

128

139

160

304 87.542 1.393 (1.014,0 fte) 99 (80,0 fte) Yes

221 77.016 1.190 (797,1 fte) 88 (75,7 fte) Yes

339 77.208 1.404 (767,0 fte) 89 (74,7 fte) Yes

Yes

Yes

Yes

a Based on documents of the participated hospitals 2009. *2011 (www. jaarverslagenzorg.nl). b statline.cbs.nl, 1 January 2012. c Based on Netherlands Cancer Registry (NCR), 2009. d www.cijfersoverkanker.nl, 2009.

were identified from the NCR for the baseline measurement. Another group of breast cancer patients which were diagnosed in the period 1 January 2009 until 31 December 2009 were selected for the post measurement. The implementation of the pathway took place in 2008 according the Integrated Oncological Care Pathways model (IOCP) and identifies five phases [5,7]. (1) In the awareness and vision phase commitment was created. A baseline measurement was performed and patient’s satisfaction was measured. (2) The project plan was written and a kick-off meeting was organized. (3) In the next phase the current situation was described, using the results of the baseline measurement, followed by a description of the desired situation. Both situations were compared to identify the measures and actions to be undertaken. (4) In the implementation phase the actions were systematically implemented according to the action plan and continuously monitored. (5) In the last phase the actions were evaluated through a post measurement. Statistical analyses were performed to calculate the difference between the total scores of the post and baseline measurement by using Stata (Statistical Software VCS, TX: Stata Corporation). Only patients which followed the pathway were included in the analysis. The chi2 test was used to calculate significant results of all indicators, except indicator 9, 10 and 12. The t test was used to compare the mean number of days for indicator 9 and 10. And the Fisher’s exact test (two-tailed significance) was used for indicator 12, as the chi2 test was not appropriate because of the low numbers. A r-value of 5 nodes, without ALND by pN0(iþ) Number of breast cancer surgeries per year per surgeon Number of (re-)surgeries Initial Initial þ re-excision Initial þ 2 re-excisions Breastconserving therapy Adjuvant chemotherapy Radiotherapy and chemotherapy not simultaneously Time between first visit and PA-confirmation Time between first visit and first surgery Time between PA-confirmation and first surgery, including direct reconstruction Time between PA-confirmation and neo-adjuvant chemotherapy Time between last surgery and first chemotherapy Time between last surgery and first radiotherapy

NABON norm

Performance Baseline measurement 01 July 2006e30 June 2007

Post measurement 01 Jane31 Dec 2009

Hospital A

Hospital B

Hospital C

Hospital A

Hospital B

Hospital C

N

% Patients

N

% Patients

N

% Patients

N

% Patients

N

% Patients

N

% Patients

126 117 115

100% 95% 77%

104 97 94

100% 96% 75%

136 127 115

100% 87% 73%

128 117 118

100% 98% 75%

139 124 133

100% 95% 82%

160 135 149

100% 96% 77%

50

16%

51

20%

60

17%

52

12%

74

8%

63

6%

5

80%

6

83%

7

71%

4

50%

5

40%

4

25%

42

2%

40

3%

50

2%

46

0%

68

1%

59

2%

105

70%

94

72%

120

78%

112

100%

130

78%

111

100%

115 115 115 57 13

86% 11% 0% 77% 62%

94 94 94 44 5

79% 15% 1% 82% 100%

115 115 115 61 16

83% 14% 1% 75% 100%

118 118 118 64 20

88% 10% 0% 69% 90%

133 133 133 68 15

83% 13% 0% 79% 93%

149 149 149 80 21

85% 10% 2% 81% 86%

32

97%

19

100%

34

71%

49

98%

40

100%

50

100%

median; mean (days)

117

0/5.9

77

0/3.3

125

1/4.6

103

0/3.9

98

0/1.0

129

0/2.3

median; mean (days)

112

26/36.8

94

18/26.1

113

19/22.5

117

27/33.7

131

18/29.3

145

20/21.7

110

86%

89

98%

112

97%

115

80%

131

96%

147

93%

3

67%

1

100%

No obs.

invasive tumors

pT1-2, pN0(i), excl neo-adj pT1-2, pN0(iþ), excl neo-adj pT1 -2, pN0(i), excl neo-adj pT1-2, pN0(iþ), excl neo-adj % >30 operaties in period

T1 pT1-2, pN1, 90% within 5 weeks

invasive, M0

within 5 weeks

1

100%

3

67%

No obs.

invasive tumor

within 4 weeks

21

33%

14

14%

31

42%

46

59%

36

31%

41

41%

within 4 weeks between 4 & 6 weeks

60

48%

49

51%

56

64%

50

64%

71

59%

78

56%

60

28%

49

20%

56

23%

50

18%

71

25%

78

31%

J. van Hoeve et al. / The Breast xxx (2014) 1e7

Please cite this article in press as: van Hoeve J, et al., Quality improvement by implementing an integrated oncological care pathway for breast cancer patients, The Breast (2014), http://dx.doi.org/10.1016/j.breast.2014.01.008

Table 3 Results per hospital.

J. van Hoeve et al. / The Breast xxx (2014) 1e7

5

Table 4 Results overall differences. Performance

1. 2. 3a. 3b. 3c. 3d. 4. 5.

6. 7. 8. 9. 10. 11.

12.

13. 14.

Number of patients HER2neu determination Sentinel node procedure is performed Axillary lymph node dissection by pN0(i) Axillary lymph node dissection by pN0(iþ) Sentinel node procedure with >5 nodes, without ALND by pN0(i) Sentinel node procedure with >5 nodes, without ALND by pN0(iþ) Number of breast cancer surgeries per year per surgeon Number of (re-)surgeries Initial Initial þ re-excision Initial þ2 re-excisions Breastconserving therapy Adjuvant chemotherapy Radiotherapy and chemotherapy not simultaneously Time between first visit and PAconfirmation, median; mean (days) Time between first visit and first surgery, median; mean (days) Time between PA-confirmation and first surgery, including direct reconstruction, >90% within 5 weeks Time between PA-confirmation and neo-adjuvant chemotherapy, within 5 weeks Time between last surgery and first chemotherapy, within 4 weeks Time between last surgery and first radiotherapy, within 4 weeks Time between last surgery and first radiotherapy, between 4 & 6 weeks

Significance

Baseline measurement 01 July 2006e30 June 2007

Post measurement 01 Jane31 Dec 2009

N

% Patients

N

% Patients

366 341 324 161 18 132

100% 92% 75% 17% 78% 2%

427 376 400 189 13 173

100% 96% 78% 8% 38% 1%

4

0%

8

(p < 0.05)

0.016 0.303 0.012 0.06 0.766

0%

319

74%

353

92%

Quality improvement by implementing an integrated oncological care pathway for breast cancer patients.

In cancer care, more and more systemized approaches such as care pathways are used to reduce variation, reduce waiting- and throughput times and to im...
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