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01-07-2014 | Breast Oncology

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

Authors: Peter Lovrics, MD, Nicole Hodgson, MD, Mary Ann O’Brien, PhD, Lehana Thabane, PhD, Sylvie Cornacchi, MSc, Angela Coates, MEd, Barbara Heller, MD, Susan Reid, MD, Kenneth Sanders, MD, Marko Simunovic, MD

Published in: Annals of Surgical Oncology | Issue 7/2014

Abstract

Background

Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.

Methods

Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005–2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.

Results

Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.

Conclusions

This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.PubMedCrossRef

Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 Suppl 2):II2–45.

Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii–iv, 1–72.

Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Cont Educ Health Prof. 2006;26:13–24.CrossRef

Landercasper J, Ellis RL, Mathiason MA, et al. A community breast cancer report card determined by participation in the national quality measures for breast centers program. Breast J. 2010;16:472–80.PubMedCrossRef

Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg. 2004;198:626–32.PubMedCrossRef

Ko CY, Maggard M, Austin N. Quality in surgery: current issues for the future. World J Surg. 2005;29(10):1204–9.PubMedCrossRef

Maggard MA, McGorgy ML, Ko CY et al. Development of quality indicators: lessons learned in bariatric surgery. Am Surg. 2006;72:870–4.PubMed

10.

Kaufman CA, Landercasper J. Can we measure the quality of breast surgical care? Ann Surg Oncol. 2011;18:3053–60.PubMedCrossRef

11.

American Society of Breast Surgeons Mastery Program. www.breast.surgeons.org/mastery/ (2011). Accessed 20 Sept 2013.

12.

National Quality Measure for Breast Centers. www.nqmbc.org/ (2011). Accessed 20 Sept 2013.

13.

National Accreditation Program for Breast Centers. www.accreditedbreastcenters.org/ (2011). Accessed 6 Nov 2012.

14.

Clifford EJ, De vol EB, Pockaj BA, et al. Early results from a novel quality outcomes program: the American society of breast surgeons’ mastery of breast surgery. Ann Surg Oncol. 2010;17:S233–41.

15.

Olaya W, Bae W, Wong J, et al. Are percutaneous biopsy rates a reasonable quality measure in breast cancer management. Ann Surg Oncol. 2010;17:S268–72.CrossRef

16.

Kao LS, Lally KP, Thoma EJ, et al. Improving quality improvement: a methodologic framework for evaluating effectiveness of surgical quality improvement. J Am Coll Surg. 2009;208:621–6.PubMedCrossRef

17.

Simunovic M, Baxter NN. Knowledge translation research: a review and new concepts from a surgical case study. Surgery. 2009;145:639–44.PubMedCrossRef

18.

Jamtvedt G, Young JM, Kristoffersen DT, et al. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care. 2006;15:433–6.PubMedCentralPubMedCrossRef

19.

Grimshaw J, Eccles M, Walter A, et al. Changing physician’s behaviour; what works and thoughts on getting more things to work. J Cont Educ Health Prof. 2002;22:237–43.CrossRef

20.

Doumit G, Gattellari M, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;(1):CD000125.

21.

O’Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2):CD003030.

22.

O’Brien MA, Oxman AD, Davis DA, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;(2):CD000409.

23.

Breslin TM, Caughran J, Pettinga J, et al. Improving breast cancer care through a regional quality collaborative. Surgery. 2011;150:635–42.PubMedCrossRef

24.

Clarke-Pearson EM, Jacobson AF, Boolbol SK, et al. Quality assurance initiative at one institution for minimally invasive breast biopsy as the initial diagnostic technique. J Am Coll Surg. 2009;208:75–8.PubMedCrossRef

25.

Veerbeek L, van der Geest L, Wouters M, et al. Enhancing the quality of care for patients with breast cancer: Seven years of experience with a Dutch auditing system. EJSO. 2011;37:714–8.PubMedCrossRef

26.

Guadagnoli E, Soumerai S, Gurwitz JH, et al. Improving discussion of surgical treatment options for patients with breast cancer: local medical opinion leaders versus audit and performance feedback. Breast Cancer Res Treat. 2000;61:171–5.PubMedCrossRef

27.

Lovrics PJ, Hodgson N, O’Brien MA, et al. The implementation of a surgeon-directed quality improvement strategy in breast cancer surgery. Am J Surg. 2013 Nov 8. [Epub ahead of print].

28.

Lovrics PJ, Cornacchi SD, Farrokhyar F, et al. The relationship between surgical factors and margin status after breast conservation surgery for early stage breast cancer. Am J Surg. 2009;197:740–6.PubMedCrossRef

29.

Hanley C, Kessaram R. Quality of diagnosis and surgical management of breast lesions in a community hospital: room for improvement? Can J Surg. 2006;49:185–92.PubMedCentralPubMed

30.

Cheater F, Baker R, Gillies C, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2005;(3):CD005470.

31.

Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine; 1967.

32.

Charmaz K. Constructing grounded theory. A practical guide through qualitative analysis. Thousand Oaks: Sage Publications; 2006.

33.

Wheeler DJ, Chambers DS. Understanding statistical process control, 2nd edn. Knoxville: SPC Press; 1992.

34.

Williams PM. Techniques for root cause analysis. BUMC Proc. 2001;14:154–7.

Title: Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario
Authors: Peter Lovrics, MD
Nicole Hodgson, MD
Mary Ann O’Brien, PhD
Lehana Thabane, PhD
Sylvie Cornacchi, MSc
Angela Coates, MEd
Barbara Heller, MD
Susan Reid, MD
Kenneth Sanders, MD
Marko Simunovic, MD
Publication date: 01-07-2014
Publisher: Springer US
Published in: Annals of Surgical Oncology / Issue 7/2014
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-014-3592-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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