Establishing a quality measurement system for cancer care in Japan

Developing quality indicators for cancer hospitals in China: a national modified Delphi process

OBJECTIVE

Although demand and supply of cancer care have been rapidly increasing in recent decades, there is a lack of systemic quality measurement for cancer hospitals in China. This study aimed to develop a set of core indicators for measuring quality of care for cancer hospitals in China.

DESIGN

The development of quality indicators was based on a literature review and a two-round modified Delphi survey. The theoretical framework and initial indicators were identified through the comprehensive literature review, and the selection of quality indicators relied on experts' consensus on the importance and feasibility of indicators by the modified Delphi process. In addition, indicator weight was identified using the analytical hierarchical process method and percentage weight method.

SETTING AND PARTICIPANTS

A panel of leading experts including oncologists, cancer care nurses, quality management experts from various regions of China were invited to participate in the two-round modified Delphi process from October to December 2020. A total of 25 experts completed the two-round modified Delphi process.

RESULTS

The experts reached consensus on a set of 47 indicators, comprising 17 structure indicators, 19 process indicators and 11 outcome indicators. Experts gave much higher weight to outcome indicators (accounting for 53.96% relative weight) than to structure (16.34%) and process (29.70%) indicators. In addition, experts also showed concerns and gave suggestions on data availability of specific outcome indicators.

CONCLUSIONS

Drawing on the comprehensive literature review and the modified Delphi process, this study developed a core set of quality indicators that can be used to evaluate quality performance of cancer hospitals. This is helpful in supporting quality cancer care in China and will provide new insights into the systemic measurement of cancer care internationally.

Involvement of orthopaedic surgeons for cancer patients in orthopaedic training facilities certified by the Japanese Orthopaedic Association - A nationwide survey

BACKGROUND

In order to improve cancer care in Japan further, it is now required for orthopaedic surgeons to get actively involved in managing locomotive organs such as bones, muscles and nerves in cancer patients. In 2018, the Japanese Orthopaedic Association (JOA) conducted a questionnaire survey to investigate the current status of cancer treatment at the orthopaedic training facilities certified by the JOA. We analyzed the results of that questionnaire survey, focusing on the data from the core hospitals for cancer care (designated cancer hospitals), to clarify the involvement of orthopaedic surgeons in cancer treatment.

MATERIALS AND METHODS

A nationwide survey was conducted in the orthopaedic training facilities certified by the JOA using an online questionnaire from March 15th to 31st, 2018. To clarify the involvement of orthopaedic surgeons in cancer treatment, we analyzed the results of that questionnaire survey, focusing on the data from the designated cancer hospitals in Japan.

RESULTS

From the questionnaire survey, it became clear that 24% of the orthopaedic training facilities certified by the JOA are designated cancer hospitals. There were significant differences concerning cancer treatment and the prospect of orthopaedic surgeons' involvement in the treatment for bone metastases between institutions classified according to number of both certified orthopaedic surgeons by the JOA and specialists for bone and soft tissue tumors. In addition, in 45% of the designated cancer hospitals, orthopaedic surgeons treated bone metastases that occur in cancer patients, but in the rest of the institutions, orthopaedic surgeons did not yet adequately respond.

CONCLUSION

In order to further improve the locomotive function and quality of life (QOL) in cancer patients, it was seemed to be necessary that all medical professionals engaged in cancer treatment, including orthopaedic surgeons, recognize the importance of locomotive management for cancer patients. In addition, the results of this study suggested that the presence of more than six certified orthopaedic surgeons by the JOA, including one or more specialists for bone and soft tissue tumors, may be able to create an environment conducive to the involvement of orthopaedic surgeons in cancer treatment at the facility.

Establishing quality indicators to comprehensively assess quality assurance and patient safety in radiotherapy and their relationship with an institution's background

BACKGROUND AND PURPOSE

Quality indicators (QIs) for radiotherapy have been proposed by several groups, but no study has been conducted to correlate the implementation of indicators specific to patient safety over the course of the clinical process with an institution's background. An initial large-scale survey was conducted to understand the implementation status of QIs established for quality assurance and patient safety in radiotherapy and the relationship between implementation status and an institutions' background.

MATERIALS AND METHOD

Overall, 68 QIs that were established by this research team after a pilot survey were used to assess structures and processes for quality assurance and patient safety. Data on the implementation of QIs and the institutions' backgrounds were obtained from designated cancer care hospitals in Japan.

RESULTS

Overall, 284 institutions (72 %) responded and had a median QI achievement rate of 60.8 %. QIs with low implementation rates, such as the implementation of an error reporting system and establishment of a quality assurance department, were identified. The QI achievement rate and scale of the institution were positively correlated, and the achievement rate of all QIs was significantly higher (p < 0.001) in institutions capable of advanced treatments, such as intensity-modulated radiotherapy, and those with a quality assurance department.

CONCLUSION

A large-scale survey on QIs revealed their implementation and relationship with a facility's background. QIs that require improvement were identified, and that these QIs might be effective in providing advanced medical care to many patients.

Differences in the performance of adjuvant chemotherapy between hemodialysis and nonhemodialysis patients

BACKGROUND

The survival of hemodialysis (HD) patients with cancer is poor, which may be caused by undertreatment due to renal dysfunction. Particularly, adjuvant chemotherapy after surgery may be considered optional because of its preventive nature. This study investigated the current frequency of administration of adjuvant chemotherapy to HD patients compared with non-HD patients in Japan.

METHODS

We used data from the Hospital-Based Cancer Registries national database linked to health services utilization data to analyze cases of newly diagnosed colon cancer, gastric cancer, breast cancer, and non-small cell lung cancer (NSCLC) at the stages where adjuvant chemotherapy is generally required. We compared the performance rate of adjuvant chemotherapy and the adjuvant chemotherapy regimens between HD and non-HD patients from October 2011 to December 2017.

RESULTS

Of the 99,761 patients who underwent curative surgery, 1207 (1%) were HD patients. HD patients received adjuvant chemotherapy less frequently than non-HD patients (24% vs. 63%, p < 0.001). After adjusting for potential confounders, HD remained negatively related to adjuvant chemotherapy administration for all four cancer types. Among all patients who received adjuvant chemotherapy 0(N = 61,873), HD patients were less likely to receive standard regimens and chemotherapy requiring dose adjustment than non-HD patients (88% vs. 95%, p < 0.001 and 92% vs. 98%, p < 0.001, respectively). This trend was particularly pronounced among patients with gastric cancer.

CONCLUSIONS

HD patients were less likely to receive adjuvant chemotherapy with standard regimens than non-HD patients.

Baseline cardiac function checkup in patients with gastric or breast cancer receiving trastuzumab or anthracyclines

BACKGROUND

Although trastuzumab and anthracyclines are frequently used to treat breast cancer (BC) and gastric cancer (GC), cardiotoxicity is a serious concern. The cardiac function assessment is recommended at baseline before initiating treatment. However, the prevalence rates of baseline cardiac checkups are unknown.

METHODS

The national database of hospital-based cancer registries linked to the health services-utilization data was used to study patients with newly diagnosed stage IV BC and GC (n = 6271) who received trastuzumab (n = 4324, 69.0%) or anthracyclines between January 2012 and December 2015. The baseline ultrasound echocardiogram (UCG) performance rate and factors related to adequate UCG performance for all patients and those receiving trastuzumab were analyzed.

RESULTS

The adequate baseline UCG checkup rate was higher in patients treated with trastuzumab than in those treated with anthracyclines (71.8% vs 44.1%, respectively). Additionally, patients with GC were less likely to receive an adequate baseline UCG performance than those with BC (70.4% vs 75.0%, respectively). After adjusting for potential confounders, patients with anthracycline-treated BC and GC were less likely to receive adequate baseline UCG performance than those with trastuzumab-treated BC (odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.20-0.28, and OR: 0.07, 95% CI: 0.03-0.16, respectively). Furthermore, patients with trastuzumab-treated GC were less likely to receive adequate baseline UCG performance than those with BC (OR: 0.65, 95% CI: 0.50-0.84).

CONCLUSIONS

The baseline UCG was less likely to be performed in patients receiving anthracyclines than in those receiving trastuzumab, as well as in patients with GC than in those with BC.

Association Between Diabetes and Adjuvant Chemotherapy Implementation in Patients with Stage III Colorectal Cancer

Aims/Introduction

Among colorectal cancer (CRC) patients, pre‐existing diabetes is suggested to influence poor prognosis, but the impact on adjuvant chemotherapy implementation is largely unknown. We aimed to compare the implementation rate of adjuvant chemotherapy between CRC patients with and without pre‐existing diabetes in a retrospective cohort study.

Materials and Methods

Colorectal cancer diagnosis information was obtained from the hospital‐based cancer registry of patients with stage III CRC who underwent curative surgery in 2013 in Japan (n = 6,344). Health claims data were used to identify diabetes and chemotherapy. We examined the association between diabetes and the implementation rate of adjuvant chemotherapy using a generalized linear model adjusted for age, sex, updated Charlson Comorbidity Index, hospital type and prefecture. Furthermore, we applied a mediation analysis to examine the extent to which postoperative complications mediated the association.

Results

Of the 6,344 patients, 1,266 (20.0%) had diabetes. The mean ages were 68.2 and 71.3 years for patients without and with diabetes, respectively. Compared with those without diabetes, patients with diabetes were less likely to receive adjuvant chemotherapy (crude rate 58.9 and 49.8%; adjusted percentage point difference 4.6; 95% confidence interval 1.7–7.5). The difference was evident for patients aged <80 years, and larger for platinum‐containing regimens than others. Mediation analysis showed that postoperative complications explained 9.1% of the inverse association between diabetes and adjuvant chemotherapy implementation.

Conclusions

We observed that patients with stage III CRC and diabetes are less likely to receive adjuvant chemotherapy than those without diabetes, and postoperative complications might partially account for the association.

Cancer epidemiology and treatment patterns for older persons in Japan: a review of nationwide data and statistics

Older patients tend to have comorbidities and physiological decline, which require adaptation in terms of standard treatment. Therefore, the care of older patients poses a unique challenge for healthcare providers. Their standard care is relatively less established than for younger patients because older patients are often excluded from clinical trials, resulting in limited representation. This review, using various data sources, such as cancer registries and national statistics, aims to describe the nationwide status of older patients in Japan and the care provided to them. Incidence statistics have revealed that each age group's most common types of cancers are different. Relevant data have also shown that older patients are more likely to be left without treatment compared with their younger counterparts, although the extent of such differences tends to depend on the cancer type. A survey of the general population has shown that older patients are more likely to be treated for common diseases; however, they are found to have undetected diseases when screened for the common diseases. Individuals' life expectancies may vary depending on their physical conditions. The social lives of older persons, which often revolve around their jobs and family structures, vary widely. Thus, clinicians and caregivers should consider the background information of older patients in order to accommodate their special needs.

First-line treatment for lung cancer among Japanese older patients: A real-world analysis of hospital-based cancer registry data

Aging of the population has led to an increase in the prevalence of cancer among older adults. In Japan, single agent chemotherapy was recommended for advanced non-small cell lung cancer (NSCLC) for those, who were aged ≥75 years, while the Western guidelines did not recommend a specific regimen. In clinical practice, physicians are required to decide the treatment based on a lack of enough evidence. This study aimed to examine the prescribing patterns of first-line chemotherapy according to age in the real-world practice. Data from the survey database of Diagnostic Procedure Combination and hospital-based cancer registries of designated cancer centers nationwide were used. The first-line chemotherapy regimens among 9,737 patients who were diagnosed with advanced lung cancer between January and December 2013, were identified and compared based on age. We found that the proportion of patients receiving chemotherapy decreased with age; 80.0%, 70.4%, 50.6%, and 30.2% of patients aged 70–74, 75–79, 80–84, and ≥ 85 years, respectively, received chemotherapy. Among them, platinum doublets were prescribed for 62.7% of the patients who were aged ≥ 70 years, and 60.7% of the patients who were aged ≥ 75 years with no driver mutations in NSCLC; only 37.6% of them received single agents. Patients who were aged ≥ 80 years also preferred platinum doublets (35.6%). Carboplatin was commonly prescribed in all age groups; only 28.4% of those receiving platinum doublets selected cisplatin. In this study, platinum doublets were identified as the most commonly prescribed regimen in those who were aged ≥ 70 years. Despite recommendations of Japanese guidelines for NSCLC, 60.7% of those who were aged ≥75 years received platinum doublets. Additionally, patients who were aged ≥ 80 years also received systemic chemotherapy, including platinum doublets; age did not solely influence regimen selection.

Association between compliance with quality indicators and hospitalisation expenses in patients with heart failure: a retrospective study using quantile regression model in China

OBJECTIVE

To explore the association between compliance with quality indicators and hospitalisation expenses in patients with heart failure.

DESIGN

Generalised linear model and quantile regression model were used to examine the association between compliance with five quality indicators and hospitalisation expenses.

SETTING

Grade A hospital in Fujian Province, China.

PARTICIPANTS

Data on 2568 heart failure admissions between 2010 and 2015 were analysed.

RESULTS

The median (IQR) of hospitalisation expenses of 2568 patients was ¥10.9 (¥6.9-¥31.6) thousand. The rates of compliance with five quality indicators were 90.3% for evaluation of left ventricular function, 43.8% for diuretics, 62.0% for ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB), 67.4% for beta-blockers, and 58.9% for aldosterone receptor antagonists. After adjustment for gender, age, residence, method of payment, number of diseases before admission, number of diseases at admission, number of emergency treatments during hospital stay and length of stay, patients who received evaluation for left ventricular function, diuretics, or ACEI or ARB had lower hospitalisation expenses, and patients who received beta-blockers had higher hospitalisation expenses, compared with their counterparts in generalised linear models. Differences in hospitalisation expenses between compliance and non-compliance with quality indicators became larger across quantile levels of hospitalisation expenses, and were found to be statistically significant when quantile level exceeded 0.80 (¥39.7 thousand) in quantile regression models.

CONCLUSIONS

The quality of care for patients with heart failure was below the target level. There was a negative relationship between compliance with quality indicators and hospitalisation expenses at the extreme quantile of expenses. More attention should be given to patients who may experience extreme expenses, and effective measures should be taken to improve the quality of care they receive.

Epidemiology and practice patterns for male breast cancer compared with female breast cancer in Japan

BACKGROUND

The incidence of male breast cancer (MBC), although rare, has shown an increase. However, the current epidemiology of and practice patterns for MBC remain unclear. This study evaluated the characteristics and care patterns for MBC compared with female breast cancer (FBC) in Japan.

METHODS

Using the National Database of Hospital-Based Cancer Registries (HBCR) linked to the Diagnosis Procedure Combination data, we analyzed newly diagnosed breast cancer cases between January 2012 and December 2015 at participating hospitals in a large quality-of-care monitoring project. We employed logistic regression models to assess cancer treatment differences between MBC and FBC in patients who were indicated for adjuvant radiation therapy and neo-adjuvant/adjuvant chemotherapy.

RESULTS

Of 142,636 breast cancer patients, 870 (0.61%) were MBC patients. At diagnosis, the mean age of MBC patients was 10 years older than FBC patients (70 vs 60 years; P < .001). Advanced-stage cancer was more frequently observed in MBC than in FBC (stage III/IV 18.9%/6.1% vs 10.6%/5.2%). Despite this, MBC patients were less likely to receive adjuvant radiation therapy and neo-adjuvant/adjuvant chemotherapy. Gender was an independent treatment determinant factor for chemotherapy decisions.

CONCLUSION

MBC patients were older and had higher stages of cancer than FBC patients at diagnosis, but received suboptimal treatment.

Impact of adherence to board-certified surgeon systems and clinical practice guidelines on colon cancer surgical outcomes in Japan: A questionnaire survey of the National Clinical Database

AIM

To investigate the effectiveness of the institutional medical structure and of the implemented clinical practice guidelines for improving colon cancer surgical outcomes.

METHODS

We conducted a web-based questionnaire survey among departments registered at the National Clinical Database in Japan from October 2014 to January 2015 to assess the association between quality indicators (QIs), including structure and process indicators (clinical practice guideline adherence), and the risk-adjusted odds ratio for operative mortality (AOR) after right hemicolectomy for colorectal cancer during the study period.

RESULTS

Among the 2064 departments registering at least one colorectal surgery during the study period, we obtained responses from 814 departments (39.4%). Our analysis on data from 22 816 patients with right hemicolectomy demonstrated that three structural QIs (certification of training hospitals by the Japanese Society of Gastroenterological Surgery and the presences of board-certified gastroenterological and colorectal surgeons) were associated with significantly lower AOR (P < .001, P = .02, and P = .05, respectively). The "performed at the doctor's discretion" answer was associated with poorer short-term outcomes in six process QIs than other answers.

CONCLUSION

The board certification system for gastroenterological and colorectal surgeons and the adherence to the clinical guidelines improve the operative mortality after right hemicolectomy. It is desired to clarify the most suitable QIs to reduce the operative mortality after colorectal surgery.

Significance of the board-certified surgeon systems and clinical practice guideline adherence to surgical treatment of esophageal cancer in Japan: a questionnaire survey of departments registered in the National Clinical Database

BACKGROUND

It remains unknown how much institutional medical structure and process of implementation of clinical practice guidelines for esophageal cancers can improve quality of surgical outcome in Japan.

METHODS

A web-based questionnaire survey was performed for departments registered in the National Clinical Database in Japan from October 2014 to January 2015. Quality indicators (QIs) including structure and process indicators (clinical practice guideline adherence) were evaluated on the risk-adjusted odds ratio for operative mortality (AOR) of the patients using registered cases in the database who underwent esophagectomy and reconstruction in 2013 and 2014.

RESULTS

Among 916 departments which registered at least one esophagectomy case during the study period, 454 departments (49.6%) responded to the questionnaire. Analyses of 6661 cases revealed that two structure QIs (certification of training hospitals by Japan Esophageal Society and presence of board-certified esophageal surgeons) were associated with significantly lower AOR (p < 0.001 and p = 0.005, respectively). One highly recommended process QI regarding preoperative chemotherapy had strong tendency to associate with lower AOR (p = 0.053). In two process QIs, the answer "performed at the doctor's discretion" showed a significant negative impact on prognosis, suggesting importance of institutional uniformity.

CONCLUSIONS

The medical institutional structure of board-certified training sites for esophageal surgeons and of participation of board-certified esophageal surgeons improves surgical outcome in Japan. Establishment of appropriate QIs and their uniform implementation would be crucial for future quality improvement of medical care in esophagectomy.

The International Epidemiology of Lung Cancer: Latest Trends, Disparities, and Tumor Characteristics

INTRODUCTION

Our aim was to update global lung cancer epidemiology and describe changing trends and disparities.

METHODS

We presented country-specific incidence and mortality from GLOBOCAN 2012 by region and socioeconomic factors via the Human Development Index (HDI). Between- and within-country incidence by histological type was analyzed by using International Agency for Research on Cancer data on cancer incidence on five continents. Trend analyses including data from the International Agency for Research on Cancer, cancer registries, and the WHO mortality database were conducted using joinpoint regression. Survival was compared between and within countries and by histological type.

RESULTS

In 2012, there were 1.82 and 1.59 million new lung cancer cases and deaths worldwide, respectively. Incidence was highest in countries with a very high HDI and lowest in countries with a low HDI (42.2 versus 7.9 in 100,000 for males and 21.8 versus 3.1 in 100,000 for females, respectively). In most countries with a very high HDI, as incidence in males decreased gradually (ranging from -0.3% in Spain to -2.5% in the United States each year), incidence in females continued to increase (with the increase ranging from 1.4% each year in Australia to 6.1% in recent years in Spain). Although histological type varied between countries, adenocarcinoma was more common than squamous cell carcinoma, particularly among females (e.g., in Chinese females, the adenocarcinoma-to-squamous cell carcinoma ratio was 6.6). Five-year relative survival varied from 2% (Libya) to 30% (Japan), with substantial within-country differences.

CONCLUSIONS

Lung cancer will continue to be a major health problem well through the first half of this century. Preventive strategies, particularly tobacco control, tailored to populations at highest risk are key to reducing the global burden of lung cancer.

Evaluating the effect of clinical care pathways on quality of cancer care: analysis of breast, colon and rectal cancer pathways

PURPOSE

Substantial gaps exist between clinical practice and evidence-based cancer care, potentially leading to adverse clinical outcomes and decreased quality of life for cancer patients. This study aimed to evaluate the usefulness of clinical pathways as a tool for improving quality of cancer care, using breast, colon, and rectal cancer pathways as demonstrations.

METHODS

Newly diagnosed patients with invasive breast, colon, and rectal cancer were enrolled as pre-pathway groups, while patients with the same diagnoses treated according to clinical pathways were recruited for post-pathway groups.

RESULTS

Compliance with preoperative core biopsy or fine-needle aspiration, utilization of sentinel lymph node biopsy, and proportion of patients whose tumor hormone receptor status was stated in pathology report were significantly increased after implementation of clinical pathway for breast cancer. For colon cancer, compliance with two care processes was significantly improved: surgical resection with anastomosis and resection of at least 12 lymph nodes. Regarding rectal cancer, there was a significant increase in compliance with preoperative evaluation of depth of tumor invasion, total mesorectal excision treatment of middle- or low-position rectal cancer, and proportion of patients who had undergone rectal cancer surgery whose pathology report included margin status. Moreover, total length of hospital stay was decreased remarkably for all three cancer types, and postoperative complications remained unchanged following implementation of the clinical pathways.

CONCLUSIONS

Clinical pathways can improve compliance with standard care by implementing evidence-based quality indicators in daily practice, which could serve as a useful tool for narrowing the gap between clinical practice and evidence-based care.

Monitoring and evaluating the quality of cancer care in Japan using administrative claims data

The importance of measuring the quality of cancer care has been well recognized in many developed countries, but has never been successfully implemented on a national level in Japan. We sought to establish a wide‐scale quality monitoring and evaluation program for cancer by measuring 13 process‐of‐care quality indicators (QI) using a registry‐linked claims database. We measured two QI on pre‐treatment testing, nine on adherence to clinical guidelines on therapeutic treatments, and two on supportive care, for breast, prostate, colorectal, stomach, lung, liver and cervical cancer patients who were diagnosed in 2011 from 178 hospitals. We further assessed the reasons for non‐adherence for patients who did not receive the indicated care in 26 hospitals. QI for pretreatment testing were high in most hospitals (above 80%), but scores on adjuvant radiation and chemoradiation therapies were low (20–37%), except for breast cancer (74%). QI for adjuvant chemotherapy and supportive care were more widely distributed across hospitals (45–68%). Further analysis in 26 hospitals showed that most of the patients who did not receive adjuvant chemotherapy had clinically valid reasons for not receiving the specified care (above 70%), but the majority of the patients did not have sufficient reasons for not receiving adjuvant radiotherapy (52–69%) and supportive care (above 80%). We present here the first wide‐scale quality measurement initiative of cancer patients in Japan. Patients without clinically valid reasons for non‐adherence should be examined further in future to improve care.