Identifying indicators of colorectal cancer care coordination: a Delphi study

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators

AIM

To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs).

METHODS

The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance.

RESULTS

A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level.

CONCLUSION

This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study

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.

Health Risk Assessment Indicators for the Left-Behind Elderly in Rural China: A Delphi Study

In China, many young and middle-aged rural residents move to urban areas each year. The rural elderly are left behind. The number of the rural left-behind elderly is increasing with urbanization, but it is unclear which indicators can be used to assess their health condition. The health risk assessment index system was developed to improve the health level of the rural left-behind elderly. A two-round web-based Delphi process was used to organize the recommendations from fifteen Chinese experts in geriatrics, health management, social psychology who participated in this study. Meaningfulness, importance, modifiability, and comprehensive value of the health risk assessment indicators in the index system were evaluated. The effective recovery rates of the two-round Delphi were 86.67% and 92.31%, respectively. The judgement coefficient and the authority coefficient were 0.87 and 0.82, respectively. The expert familiarity was 0.76. Ultimately, the health risk assessment index system for the rural left-behind elderly consisted of five first-level indicators, thirteen second-level indicators, and sixty-six third-level indicators. The final indicators can be used to evaluate the health of the rural left-behind elderly and provide the basis for additional health risk interventions.

Defining success factors to describe coordinated care in cancer

Providing coordinated care remains a challenge for cancer services globally. There is a lack of consensus in the literature about what constitutes successful coordinated care. This study aimed to define and prioritize a set of consensus-driven success factors that can lead to coordinated care. A mixed-methods approach was used that included literature review, a broad call for submissions from relevant stakeholders, and a priority-setting process based on a modified nominal group technique. Thirty articles that related to success factors in coordinated care were identified in the literature. Twenty submissions were received from a broad range of stakeholders. From these sources, a set of 20 success factors was derived. Seventy stakeholders attended a series of workshops across New South Wales, Australia, to review and prioritize these 20 success factors against significance and measurability. Clear consensus was reached on prioritizing two success factors linked to improving coordinated care from first presentation to diagnosis and ensuring that patients are routinely screened for physical and supportive care needs. Other highly ranked factors included the need for a comprehensive care plan and the identification of patients at higher risk for disjointed care. This study defines and prioritizes a set of success factors related to coordinated care in cancer. These success factors will be used to guide the development of interventions that target improving coordinated care as well as supporting the development of new funding models based on performance indicators derived from these factors.

Quality indicators for ambulatory care for older adults with diabetes and comorbid conditions: A Delphi study

Background

An increasing number of people are living with multiple chronic conditions and it is unclear which quality indicators should be used to guide care for this population.

Objective

To critically appraise and select the most appropriate set of quality indicators for ambulatory care for older adults with five selected disease combinations.

Methods

A two-round web-based Delphi process was used to critically appraise and select quality of care indicators for older adults with diabetes and comorbidities. A fifteen-member Canadian expert panel with broad geographical and clinical representation participated in this study. The panel evaluated process indicators for meaningfulness, potential for improvements in clinical practice, and overall value of inclusion, while outcome indicators were evaluated for importance, modifiability and overall value of inclusion. A 70% agreement threshold was required for high consensus, and 60–69% for moderate consensus as measured on a 5-point Likert type scale.

Results

Twenty high-consensus and nineteen medium-consensus process and outcome indicators were selected for assessing care for older adults with selected disease combinations, including 1) concordant (conditions with a common management plan), 2) discordant (conditions with unrelated management plans), and 3) both types. Panelists reached rapid consensus on quality indicators for care for older adults with concordant comorbid conditions, but not for those with discordant conditions. All selected indicators assess clinical aspects of care. The feedback from the panelists emphasized the importance of developing indicators related to patient-centred aspects of care, including patient self-management, education, patient-physician relationships, and patient’s preferences.

Conclusions

The selected quality indicators are not intended to provide a comprehensive tool set for measuring quality of care for older adults with selected disease combinations. The recommended indicators address clinical aspects of care and can be used as a starting point for ambulatory care settings and development of additional quality indicators.

Adapting the nominal group technique for priority setting of evidence-practice gaps in implementation science

BACKGROUND

There are a variety of methods for priority setting in health research but few studies have addressed how to prioritise the gaps that exist between research evidence and clinical practice. This study aimed to build a suite of robust, evidence based techniques and tools for use in implementation science projects. We applied the priority setting methodology in lung cancer care as an example.

METHODS

We reviewed existing techniques and tools for priority setting in health research and the criteria used to prioritise items. An expert interdisciplinary consensus group comprised of health service, cancer and nursing researchers iteratively reviewed and adapted the techniques and tools. We tested these on evidence-practice gaps identified for lung cancer. The tools were pilot tested and finalised. A brief process evaluation was conducted.

RESULTS

We based our priority setting on the Nominal Group Technique (NGT). The adapted tools included a matrix for individuals to privately rate priority gaps; the same matrix was used for group discussion and reaching consensus. An investment exercise was used to validate allocation of priorities across the gaps. We describe the NGT process, criteria and tool adaptations and process evaluation results.

CONCLUSIONS

The modified NGT process, criteria and tools contribute to building a suite of methods that can be applied in prioritising evidence-practice gaps. These methods could be adapted for other health settings within the broader context of implementation science projects.

The Value of Continuity between Primary Care and Surgical Care in Colon Cancer

BACKGROUND

Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs.

METHODS

Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider's main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models.

RESULTS

Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746-$14,577), a 20% reduction in total median cost of care at 12 months.

CONCLUSIONS

Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.