1
|
Tang D, Rivard SJ, Weng W, Ramm CA, Cleary RK, Hendren S. Lack of Complete Pretreatment Staging Is Associated With Omission of Neoadjuvant Therapy for Rectal Cancer: A Statewide Study. Dis Colon Rectum 2023; 66:662-670. [PMID: 35195556 DOI: 10.1097/dcr.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Standardized local staging and neoadjuvant therapy are rectal cancer management quality measures supported by the Commission on Cancer and National Accreditation Program for Rectal Cancer for the management of rectal cancer. Previous studies suggested that up to 25% of patients with stage II/III rectal cancer patients do not receive neoadjuvant therapy. We hypothesized that failure to receive neoadjuvant therapy may be caused by failure to properly stage patients before surgery. OBJECTIVE This study aimed to determine whether lack of local rectal cancer staging is associated with underutilization of neoadjuvant therapy and to determine risk factors for omission of neoadjuvant therapy. DESIGN Retrospective cohort study. Bivariate and multivariable analyses were performed on patient, tumor, and 30-day outcome factors associated with neoadjuvant therapy and staging. SETTINGS hospitals participated in the Michigan Surgical Quality Collaborative Colorectal Cancer Project from January 2014 to December 2019. PATIENTS Elective, clinical stage II/III, mid-to-low rectal cancer resections. Patients with upper rectal cancer were excluded. MAIN OUTCOME MEASURES Percentage of patients receiving neoadjuvant therapy. RESULTS The final cohort included 350 patients with clinical stage II/III mid or low rectal cancer-80.9% of patients who had received neoadjuvant therapy and 83.2% of patients who had MRI and/or endoscopic ultrasound. A significant association was found between receiving neoadjuvant therapy and MRI/endorectal ultrasound staging ( p < 0.0001). Eighty-seven percent of patients who had MRI/endorectal ultrasound received neoadjuvant chemoradiotherapy; 49% of patients who did not have MRI/endorectal ultrasound staging received neoadjuvant chemoradiotherapy. Multivariate analysis revealed that risk factors for the omission of neoadjuvant therapy were older age and incomplete staging. LIMITATIONS Observational study with the possibility of unmeasured confounding variables. CONCLUSIONS Neoadjuvant therapy is underused in patients with stage II/III rectal cancer. Omission of pretreatment staging with MRI/endorectal ultrasound is associated with omission of neoadjuvant therapy. These data suggest the need for regional and national quality improvement strategies to standardize the multidisciplinary management of rectal cancer. See Video Abstract at http://links.lww.com/DCR/B923 . LA FALTA DE ESTADIFICACIN COMPLETA PREVIA AL TRATAMIENTO SE ASOCIA CON LA OMISIN DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO UN ESTUDIO ESTATAL ANTECEDENTES: La estadificación local estandarizada y la terapia neoadyuvante son medidas de calidad de la Comisión sobre el Cáncer y el Programa Nacional de Acreditación para el Cáncer de Recto para el tratamiento del cáncer de recto. Estudios previos sugirieron que hasta el 25% de los pacientes con cáncer de recto en estadio II/III no reciben terapia neoadyuvante. Planteamos la hipótesis de que la falla en recibir la terapia neoadyuvante puede deberse a la falla en la estadificación adecuada de los pacientes antes de la cirugía.OBJETIVO: El propósito de este estudio es determinar si la falta de estadificación local del cáncer de recto está asociada con la infrautilización de la terapia neoadyuvante y determinar los factores de riesgo para la omisión de la terapia neoadyuvante.DISEÑO: Estudio de cohorte retrospectivo. Se realizaron análisis bivariados y multivariados sobre el paciente, el tumor y los factores de resultado a los 30 días asociados con la terapia neoadyuvante y la estadificación.AJUSTE: Un total de 31 hospitales que participaron en el Proyecto Quirugico Colaborativo de Cáncer Colorrectal de Calidad de Michigan desde enero de 2014 hasta diciembre de 2019.PACIENTES: Resecciones electivas, en estadio clínico II/III, de cáncer de recto medio a bajo. Se excluyeron los pacientes con cáncer de recto superior.MEDIDA DE RESULTADO PRINCIPAL: Porcentaje de pacientes que reciben terapia neoadyuvante. Porcentaje de pacientes que reciben terapia neoadyuvante.RESULTADOS: La cohorte final fue de 350 casos con cáncer de recto medio o bajo en estadio clínico II/III. El 80,9% tenía terapia neoadyuvante y el 83,2%, resonancia magnética y/o ultrasonido endoscópico. Hubo una asociación significativa entre recibir terapia neoadyuvante y la estadificación MRI/ERUS ( p < 0,0001). El 87% de los pacientes a los que se les realizaron imágenes con MRI/ERUS recibieron NT, mientras que el 49% de los pacientes a los que no se les realizó la estadificación con MRI/ERUS tuvieron NT. El análisis multivariante reveló que los factores de riesgo para la omisión de la terapia neoadyuvante fueron la edad avanzada y la estadificación incompleta.LIMITACIONES: Estudio observacional con posibilidad de confusión de variables no medidas.CONCLUSIONES: La terapia neoadyuvante está infrautilizada en pacientes con cáncer de recto en estadio II/III. La omisión de la estadificación previa al tratamiento con MRI/ERUS se asocia con la omisión de la terapia neoadyuvante. Estos datos sugieren la necesidad de estrategias regionales y nacionales de mejora de la calidad para estandarizar el manejo multidisciplinario del cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B923 . (Traducción-Dr Yolanda Colorado ).
Collapse
Affiliation(s)
- Dalun Tang
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha J Rivard
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Wenjing Weng
- Michigan Surgical Quality Collaborative, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Carole A Ramm
- Department of Academic Research, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
2
|
Raman S, Tsoraides SS, Sylla P, Sarin A, Farkas L, DeKoster E, Hull T, Wexner S. Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer. J Am Coll Surg 2022; 234:368-376. [PMID: 35213501 DOI: 10.1097/xcs.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance. STUDY DESIGN With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification. RESULTS A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited. CONCLUSION During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.
Collapse
Affiliation(s)
- Shankar Raman
- From the MercyOne Des Moines Surgical Group, Des Moines, IA (Raman)
| | - Steven S Tsoraides
- Department of Surgery, University of Illinois College of Medicine at Peoria; Department of Surgery, Springfield Clinic, Peoria, IL (Tsoraides)
| | - Patricia Sylla
- Department of surgery, Mount Sinai Medical Center New York, NY (Sylla)
| | - Ankit Sarin
- Department of surgery, University of California, San Francisco, CA (Sarin)
| | - Linda Farkas
- Department of surgery, University of Texas Southwestern Medical Center, Dallas, TX (Farkas)
| | - Erin DeKoster
- Cancer programs, American College of Surgeons, Chicago, IL (DeKoster)
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH (Hull)
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL (Wexner)
| |
Collapse
|
3
|
Lau LW, Kethman WC, Bingmer KE, Ofshteyn A, Steinhagen E, Charles R, Dietz D, Stein SL. Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study. J Surg Oncol 2021; 124:810-817. [PMID: 34159619 DOI: 10.1002/jso.26572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer. METHODS The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer. RESULTS Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years. CONCLUSION Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.
Collapse
Affiliation(s)
- Lung W Lau
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - William C Kethman
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine E Bingmer
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Asya Ofshteyn
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Emily Steinhagen
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ronald Charles
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David Dietz
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sharon L Stein
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
4
|
Pooni A, Schmocker S, Brown C, MacLean A, Hochman D, Williams L, Baxter N, Simunovic M, Liberman S, Drolet S, Neumann K, Jhaveri K, Kirsch R, Kennedy ED. Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study. Colorectal Dis 2021; 23:1393-1403. [PMID: 33626193 DOI: 10.1111/codi.15599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/17/2022]
Abstract
AIM It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice. METHOD A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators. RESULTS During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators. CONCLUSION A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.
Collapse
Affiliation(s)
- Amandeep Pooni
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carl Brown
- Department of Colorectal Surgery, St Paul's Hospital, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anthony MacLean
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Hochman
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Lara Williams
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nancy Baxter
- University of Toronto, Toronto, ON, Canada.,Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Marko Simunovic
- Department of Surgery, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Sender Liberman
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Sébastien Drolet
- Department of Surgery, Université Laval, Quebec City, QC, Canada
| | - Katerina Neumann
- Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Kartik Jhaveri
- University of Toronto, Toronto, ON, Canada.,Joint Department of Medical Imaging, Mount Sinai Hospital and Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Richard Kirsch
- University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin D Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| |
Collapse
|
5
|
Stringfield SB, Fleshman JW. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2021; 37:101568. [PMID: 33848763 DOI: 10.1016/j.suronc.2021.101568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Sarah B Stringfield
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA
| |
Collapse
|
6
|
Gilshtein H, Wexner SD. National Accreditation Program for Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
7
|
Abelson JS, Bauer PS, Barron J, Bommireddy A, Chapman WC, Schad C, Ohman K, Hunt S, Mutch M, Silviera M. Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy. J Am Coll Surg 2020; 232:27-33. [PMID: 33190785 DOI: 10.1016/j.jamcollsurg.2020.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care. STUDY DESIGN A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution. RESULTS From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival. CONCLUSIONS This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.
Collapse
Affiliation(s)
- Jonathan S Abelson
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
| | - Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - John Barron
- Saint Louis University School of Medicine, Saint Louis, MO
| | - Ani Bommireddy
- Saint Louis University School of Medicine, Saint Louis, MO
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Christine Schad
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Kerri Ohman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| |
Collapse
|
8
|
Pooni A, Schmocker S, Brown C, MacLean A, Williams L, Baxter NN, Simunovic M, Liberman AS, Drolet S, Neumann K, Jhaveri K, Kirsch R, Kennedy ED. The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care. JMIR Res Protoc 2020; 9:e15535. [PMID: 32012108 PMCID: PMC7016615 DOI: 10.2196/15535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. OBJECTIVE This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. METHODS Process indicators for the selected multimodal strategies to optimize rectal cancer care will be selected and prospectively collected for all patients with stages 1 to 3 rectal cancer undergoing TME surgery. KT interventions, including audit and feedback, opinion leaders, and community of practice, will be implemented to increase the uptake of these clinical strategies. RESULTS The uptake of the process indicators over time and the effect of the uptake of the process indicators on short- and long-term oncologic outcomes will be evaluated for each multimodal strategy. CONCLUSIONS This quality improvement initiative will identify existing gaps in care for the selected multimodal strategies and implement KT interventions to close these gaps. The results of this study will inform further efforts to optimize rectal cancer care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/15535.
Collapse
Affiliation(s)
- Amandeep Pooni
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carl Brown
- Department of Surgery, St Paul's Hospital, Vancouver, BC, Canada
| | - Anthony MacLean
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lara Williams
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Surgery and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster Universtiy, Hamilton, ON, Canada
| | | | - Sebastien Drolet
- Department of Surgery, Université Laval, Quebec City, QC, Canada
| | - Katerina Neumann
- Department of Surgery, Queen Elizabeth II Health Sciences Centre, Victoria General Site, Halifax, NS, Canada
| | - Kartik Jhaveri
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, Toronto, ON, Canada
| | - Richard Kirsch
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin Diane Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| |
Collapse
|
9
|
Swords DS, Brooke BS, Skarda DE, Stoddard GJ, Tae Kim H, Sause WT, Scaife CL. Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy. J Gastrointest Surg 2019; 23:1206-1217. [PMID: 30421120 DOI: 10.1007/s11605-018-4039-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood. METHODS The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes. RESULTS Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS. CONCLUSIONS Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.
Collapse
Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
| | - Benjamin S Brooke
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - David E Skarda
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| |
Collapse
|