Using the Delphi technique to improve clinical outcomes through the development of quality indicators in renal cell carcinoma

Generation of Indicators to Assess Quality of Health Care in Hospital at Home Through e-Delphi

BACKGROUND AND OBJECTIVES

The quality of health care in hospital at home (HaH) has been measured in different countries using simple indicators and clinical results that only contribute to some dimensions of the quality of health care. We sought to generate indicators to comprehensively evaluate the quality of health care provided to HaH users through the e-Delphi technique.

METHODS

The e-Delphi technique was performed with the participation of 17 HaH experts. The methodological strategy applied in this study was divided into the following 3 phases: a preparatory phase; consultation phase; and consensus phase. Three rounds of consultations were conducted with experts. In round 1, they were asked to identify which aspects of HaH they believed should be evaluated using an indicator for each of the following 6 dimensions of health care quality: effectiveness; efficiency; timeliness; patient-centered care; equity; and safety. In round 2, they were asked to rate each indicator using a 5-point Likert-type scale with the following values: (1) Totally disagree; (2) Disagree; (3) Moderately agree; (4) Agree; and (5) Totally agree. The criteria for evaluating each indicator were as follows: (1) The indicator is a useful measure for assessing the quality of health care provided to HaH users. (2) The indicator is clearly and specifically written and does not require modification. (3) The indicator is essential and incorporates information that can be extracted from HaH program records. An indicator was considered approved if it received at least 65% approval from the expert panel for each evaluation criterion. In round 3, experts were asked to reassess their ratings, taking into account the opinions of the other experts. The reliability of this technique was ensured through credibility, reliability, and confirmability. We obtained ethical approval of the corresponding institutions and informed consent from the participating experts.

RESULTS

Nine unpublished and reliable indicators were generated. In addition, 13 indicators were incorporated that evaluate aspects previously analyzed by other authors and/or national and international institutions, which were adapted to be used in HaH. The total indicators generated (n = 22) represented all dimensions of the quality of health care: safety; opportunity; effectiveness; efficiency; equity; and patient-centered care.

CONCLUSIONS

The 22 indicators generated through the e-Delphi technique permit a comprehensive evaluation of the quality of health care provided to HaH users.

Perspectives on the representation of frailty in the electronic frailty index

BACKGROUND

Frailty is a state of increased vulnerability from physical, social, and cognitive factors resulting in greater risk of negative health-related outcomes and increased healthcare expenditure. A 36-factor electronic frailty index (eFI) developed in the United Kingdom calculates frailty scores using electronic medical record data. There is currently no standardization of frailty screening in Canadian primary care. In order to implement the eFI in a Canadian context, adaptation of the tool is necessary because frailty is represented by different clinical terminologies in the UK and Canada. In considering the promise of implementing an eFI in British Columbia, Canada, we first looked at the content validation of the 36-factor eFI. Our research question was: Does the eFI represent frailty from the perspectives of primary care clinicians and older adults in British Columbia?

METHODS

A modified Delphi using three rounds of questionnaires with a panel of 23 experts (five family physicians, five nurse practitioners, five nurses, four allied health professionals, four older adults) reviewed and provided feedback on the 36-factor eFI. These professional groups were chosen because they closely work as interprofessional teams within primary care settings with older adults. Older adults provide real life context and experiences. Questionnaires involved rating the importance of each frailty factor on a 0-10 scale and providing rationale for ratings. Panelists were also given the opportunity to suggest additional factors that ought to be included in the screening tool. Suggested factors were similarly rated in two Delphi rounds.

RESULTS

Thirty-three of the 36 eFI factors achieved consensus (> 80% of panelists provided a rating of ≥ 8). Factors that did not achieve consensus were hypertension, thyroid disorder and peptic ulcer. These factors were perceived as easily treatable or manageable and/or not considered reflective of frailty on their own. Additional factors suggested by panelists that achieved consensus included: cancer, challenges to healthcare access, chronic pain, communication challenges, fecal incontinence, food insecurity, liver failure/cirrhosis, mental health challenges, medication noncompliance, poverty/financial difficulties, race/ethnic disparity, sedentary/low activity levels, and substance use/misuse. There was a 100% retention rate in each of the three Delphi rounds.

CONCLUSIONS AND NEXT STEPS

Three key findings emerged from this study: the conceptualization of frailty varied across participants, identification of frailty in community/primary care remains challenging, and social determinants of health affect clinicians' assessments and perceptions of frailty status. This study will inform the next phase of a broader mixed-method sequential study to build a frailty screening tool that could ultimately become a standard of practice for frailty screening in Canadian primary care. Early detection of frailty can help tailor decision making, frame discussions about goals of care, prevent advancement on the frailty trajectory, and ultimately decrease health expenditures, leading to improved patient and system level outcomes.

Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis

OBJECTIVE

To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association.

METHODS

We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data. Hospitals were divided into quartiles based on their total nephrectomy volume for the study period. We investigated 6 quality metrics as potential mediators of the association between hospital volume and mortality using a mediation model.

RESULTS

At the highest volume centers, survival was higher at 1-, 3-, 5-, and 10-year time intervals, respectively (91% vs 89%, 80% vs 76%, 70% vs 66%, 45% vs 38%, P < .001) compared to the lowest quartile nephrectomy centers. Receipt of partial nephrectomy for stage ≤T1a tumors explains 52.3% of the total association between hospital nephrectomy volume and mortality. Additionally, patients at the highest-volume centers were more likely to be younger (20% vs 26% 80≤ years old, P < .001), white (82% vs 78%, P < .001), reside in more densely populated counties (≥1 million residents, 62% vs 42%, P > .001), have a shorter mean length of stay (5.03 vs 5.88days, P < .001) when compared to those in the lowest-volume quartile.

CONCLUSION

This analysis of SEER-Medicare data is the first to suggest that partial nephrectomy in the setting of T1a tumors mediates the association between hospital volume and mortality. Quality metrics that reduce mortality should be harnessed to develop more efficient and higher-quality health systems.

Evidence-based consensus guidelines for ALS genetic testing and counseling

OBJECTIVE

Advances in amyotrophic lateral sclerosis (ALS) gene discovery, ongoing gene therapy trials, and patient demand have driven increased use of ALS genetic testing. Despite this progress, the offer of genetic testing to persons with ALS is not yet "standard of care." Our primary goal is to develop clinical ALS genetic counseling and testing guidelines to improve and standardize genetic counseling and testing practice among neurologists, genetic counselors or any provider caring for persons with ALS.

METHODS

Core clinical questions were identified and a rapid review performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P) 2015 method. Guideline recommendations were drafted and the strength of evidence for each recommendation was assessed by combining two systems: the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) System and the Evaluation of Genomic Applications in Practice and Prevention (EGAPP). A modified Delphi approach was used to reach consensus among a group of content experts for each guideline statement.

RESULTS

A total of 35 guideline statements were developed. In summary, all persons with ALS should be offered single-step genetic testing, consisting of a C9orf72 assay, along with sequencing of SOD1, FUS, and TARDBP, at a minimum. The key education and genetic risk assessments that should be provided before and after testing are delineated. Specific guidance regarding testing methods and reporting for C9orf72 and other genes is provided for commercial laboratories.

INTERPRETATION

These evidence-based, consensus guidelines will support all stakeholders in the ALS community in navigating benefits and challenges of genetic testing.

Development of a research mentorship guide and consensus statement for low- and middle-income countries: Results of a modified Delphi process

BACKGROUND

Institutional research mentorship is a form of mentorship whereby institutions foster mentor-mentee relationships. Research mentorship improves research effectiveness and supports relationships. However, resources are needed in order to institutionalize research mentorship tailored to low- and middle- income countries (LMICs). The aim of this study was to develop a consensus document on institutionalizing research mentorship through a modified Delphi process as part of the practical guide development process.

METHODS

This study used a two-round modified Delphi process, which is an iterative, structured approach of consensus decision making. Each participant was asked about a series of items related to research mentorship using Likert scale questions. Agreement for each item was pre-defined as ≥80% of participants rating the item as "agree" or "strongly agree." The items that reached agreement, were then discussed during round two at an in-person conference in Ethiopia. A separate group of individuals only participated virtually. For the final consensus survey, response rates and commenting rates (participants who wrote two or more comments) were compared among conference and non-conference participants.

RESULTS

The Delphi process led to the inception of three main themes in terms of developing research mentorship: leveraging existing resources, measuring and evaluating institutional mentorship, and encouraging a research mentorship life cycle. During the virtual first round, 59% (36/61) participants who were emailed completed the survey. In the second round, conference participants had a response rate of 79% (11/14) compared to non-conference participants with a response rate of 45% (21/47). Conference participants had a 100% (11/11) commenting rate whereas non-conference participants had a 38% (8/21) commenting rate. This study achieved consensus in both survey rounds for all 35 items on the consensus document.

CONCLUSIONS

The data suggest that an in-person conference may increase participant engagement. The consensus developed through a modified Delphi method directly informed a practical guide on institutionalizing research mentorship in LMICs.

U-CHANGE Project: a multidimensional consensus on how clinicians, patients and caregivers may approach together the new urothelial cancer scenario

Introduction

Advanced urothelial carcinoma remains aggressive and very hard to cure, while new treatments will pose a challenge for clinicians and healthcare funding policymakers alike. The U-CHANGE Project aimed to redesign the current model of care for advanced urothelial carcinoma patients to identify limitations ("as is" scenario) and recommend future actions ("to be" scenario).

Methods

Twenty-three subject-matter experts, divided into three groups, analyzed the two scenarios as part of a multidimensional consensus process, developing statements for specific domains of the disease, and a simplified Delphi methodology was used to establish consensus among the experts.

Results

Recommended actions included increasing awareness of the disease, increased training of healthcare professionals, improvement of screening strategies and care pathways, increased support for patients and caregivers and relevant recommendations from molecular tumor boards when comprehensive genomic profiling has to be provided for appropriate patient selection to ad hoc targeted therapies.

Discussion

While the innovative new targeted agents have the potential to significantly alter the clinical approach to this highly aggressive disease, the U-CHANGE Project experience shows that the use of these new agents will require a radical shift in the entire model of care, implementing sustainable changes which anticipate the benefits of future treatments, capable of targeting the right patient with the right agent at different stages of the disease.

Surgeon-level versus hospital-level quality variance in kidney cancer surgery

PURPOSE

To determine whether variance in kidney cancer surgery quality indicators (QIs) is most impacted by surgeon-level or hospital-level factors in order to inform quality improvement initiatives.

MATERIALS AND METHODS

The ICES and Veterans Affairs (VA) databases were queried for patients undergoing surgery for localized kidney cancer. Kidney cancer surgery QIs were defined within each cohort. Quality of care was benchmarked at a surgeon- vs. hospital-level to identify statistical outliers, using available clinicopathological data to adjust for differences in case-mix. Variance between surgeons and hospitals was calculated for each QI using a random-effects model.

RESULTS

The QI with the greatest amount of variance explained by hospital and surgeon-level factors was proportion of cases performed with minimally invasive surgery (MIS). The majority of this variance was due to surgeon-level factors for both the VA and ICES cohorts. The proportion of cases performed using an MIS approach was also the QI with the greatest number of outlier hospitals and surgeons compared to the average performance. The proportion of partial nephrectomies performed for patients at risk of chronic kidney disease was the QI with the greatest amount of variance due to hospital-level factors for the ICES cohort.

CONCLUSIONS

The proportion of localized kidney cancer cases performed using an MIS approach is the QI requiring the greatest attention. Quality improvement initiatives should focus on surgeon-level factors to increase the number of MIS cases being performed for patients with localized renal masses.

A modified Delphi study to identify strategies to promote health literacy in parents of children with cancer

BACKGROUND

Parents play a key role in the care, monitoring, management of symptoms experienced in children with cancer, the support, and follow-up of treatment. However, there is a paucity of research as how to improve the health literacy of parents with cancer. The aim of this study was to identify the best and most important strategies to promote health literacy in parents of children with cancer.

MATERIALS AND METHODS

A two-step modified Delphi method was used to establish consensus in Iran in 2021. Fourteen experts representing oncology, clinical nursing, and faculty members of nursing were selected by purposive sampling. In round one, 90 strategies to promote health literacy obtained in the qualitative study were distributed to the experts, which were scored from 1 to 5. In order to discuss statements without consensus in the first round, round two was held in a face-to-face meeting. Descriptive statistics such as mean, standard deviation, and percentage of response frequency were used to calculate agreement levels between experts.

RESULTS

In round one, 57 statements reached a consensus. In round two, 21 statements reached a consensus. Finally, 78 statements reached consensus representing four domains including functional health literacy, interactive health literacy, critical health literacy, and care health literacy.

CONCLUSION

Delphi method helps to identify the best and most important strategies to use in health literacy promotion programs for parents of children with cancer. Identifying these strategies will help health officials, planners, and policymakers.

The value of disease-free survival (DFS) and osimertinib in adjuvant non-small-cell lung cancer (NSCLC): an international Delphi consensus report

Background

Rates of disease recurrence and death following surgery remain high in early-stage non-small-cell lung cancer (NSCLC), despite adjuvant treatment and curative intent. Recently, osimertinib showed overwhelming evidence for disease-free survival (DFS), as demonstrated by an overall reduction in the risk of disease recurrence or death in the adjuvant setting of 80% versus control in the ADAURA study (stage IB-IIIA; hazard ratio 0.20; 99.12% confidence interval 0.14-0.30; P < 0.001). However, due to the early unblinding of ADAURA and lack of mature overall survival data, there is a need to qualitatively confirm consensus on the clinical and patient relevance of DFS.

Materials and methods

We conducted a modified Delphi panel study consisting of two rounds of surveys, followed by a consensus meeting. An international panel of experts in the field of NSCLC and epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) (n = 13) was asked to rate agreement and comment on a list of pre-defined statements covering key consensus gaps. Statements were eliminated or updated between surveys, depending on the level of agreement. A final list of agreed-upon statements was drafted in the consensus meeting.

Results

Consensus was reached on 32 qualitative statements, with topics including unmet needs in early-stage NSCLC, the value of DFS, and the value of osimertinib. Crucially, DFS was agreed to be a clinically and patient-relevant endpoint in adjuvant NSCLC. The relevance of DFS was found to relate to the ability of an adjuvant therapy, such as osimertinib, to keep patients in the clinically valuable curative intent setting, while preventing the burden associated with distant and locoregional recurrence, and progressive disease.

Conclusions

Addressing the need for measures that reflect clinical benefit is essential to continue improving outcomes for NSCLC patients. To that end, this work provides a qualitative framework for clinicians to consider the clinical and patient relevance of DFS in adjuvant NSCLC and the benefit demonstrated in ADAURA thus far.

•

There is a need for qualitative consensus assessment of the clinical and patient relevance of DFS in the adjuvant setting.

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An international panel of experts viewed DFS as a clinically and patient-relevant endpoint in adjuvant NSCLC.

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DFS relevance in adjuvant therapy, e.g. osimertinib, relates to keeping early-stage patients in a curative intent setting.

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Curative intent prevents or significantly delays locoregional and distant (CNS) recurrence burden and progressive disease.

Using the Delphi Method to Elucidate Patient and Caregiver Experiences of Cancer Care

Objective: Identify the most salient elements of the head and neck cancer (HNC) care experience described by patients and caregivers in focus group interviews. Methods: Three focus groups of patients and caregivers were facilitated by research assistants and clinicians. Open-ended guiding questions captured/elicited aspects of care that were appreciated, warranted improvement, or enhanced communication and information. A four-step Delphi process derived consensus among focus group facilitators (n = 5) regarding salient discussion points from focus group conversations. Results: Seven salient themes were identified: (1) information provision, (2) burden related to symptoms and treatment side effects, (3) importance of social support, (4) quality of care at both hospital and provider levels, (5) caring for the person, not just treating cancer, (6) social and emotional impact of HNC, and (7) stigma and insufficient information regarding human papillomavirus-related HNC. Conclusion: Participants reported varying needs and support preferences, a desire for individualized communication, and to feel cared for as both a person and a patient. Findings illuminate the intricate details underlying high-quality, compassionate, person-centered HNC cancer care.

What matters for people with brain cancer? Selecting clinical quality indicators for an Australian Brain Cancer Registry

BACKGROUND

The goal of a clinical quality registry is to deliver immediate gains in survival and quality of life by delivering timely feedback to practitioners, thereby ensuring every patient receives the best existing treatment. We are developing an Australian Brain Cancer Registry (ABCR) to identify, describe, and measure the impact of the variation and gaps in brain cancer care from the time of diagnosis to the end of life.

METHODS

To determine a set of clinical quality indicators (CQIs) for the ABCR, a database and internet search were used to identify relevant guidelines, which were then assessed for quality using the AGREE II Global Rating Scale. Potential indicators were extracted from 21 clinical guidelines, ranked using a modified Delphi process completed in 2 rounds by a panel of experts and other stakeholders, and refined by a multidisciplinary Working Group.

RESULTS

Nineteen key quality reporting domains were chosen, specified by 57 CQIs detailing the specific inclusion and outcome characteristics to be reported.

CONCLUSION

The selected CQIs will form the basis for the ABCR, provide a framework for achievable data collection, and specify best practices for patients and health care providers, with a view to improving care for brain cancer patients. To our knowledge, the systematic and comprehensive approach we have taken is a world first in selecting the reporting specifications for a brain cancer clinical registry.

Identifying patient characteristics associated with potentially redirectable paramedic transported emergency department visits in Ontario, Canada: a population-based cohort study

OBJECTIVE

Paramedic redirection from emergency department (ED) to subacute centres may be more beneficial for some patients, though little is known about which patients are potentially appropriate. We examined whether patient characteristics were associated with ED visits when the main intervention was suitable to be performed in a subacute centre.

METHODS

We conducted a retrospective observational study using the National Ambulatory Care Reporting System from 2014 to 2018 in Ontario, Canada. We included all adult patients transported by paramedics and had a main physician intervention recorded. We used results of a RAND/UCLA modified Delphi study to categorise patients into either ED or a subacute care (urgent care and/or general practice centre) based on their main intervention. An independent logistic regression model was analysed for each subacute centre.

RESULTS

A total of 2 394 072 ED visits were included; 59% of ED interventions were categorised as 'urgent care', 27% 'ED only', 9% either 'urgent care' or 'general practice' and 5% had an intervention not previously classified. ED visits suitable for 'general practice' had the highest percentage of patients discharged, while 'ED only' had the lowest. Lower medical acuity, younger age, time of triage in evening and overnight, and discharged from ED were independently associated with both subacute centres. 'Urgent care' visits/interventions were associated with an ED main diagnosis of the respiratory system (OR 3.49), while 'general practice' visits were associated with mental health disorders (OR 9.85) and injury/poison/consequences of external causes (OR 3.38).

CONCLUSIONS

The majority of ED visits had a main intervention that could have potentially been conducted in a subacute centre. We identified characteristics and diagnostic patterns associated with ED visits when the main intervention was categorised as a subacute centre intervention. This study contributes knowledge to inform which patients are potentially appropriate for paramedic redirection.

Treatment of MRSA infections in India: Clinical insights from a Delphi analysis

PURPOSE

International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India.

METHODS

We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance.

RESULTS

Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections.

CONCLUSIONS

This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.

A Delphi Consensus Approach for Difficult-to-Treat Patients with Severe Hemophilia A without Inhibitors

Introduction

Over the past decade, there has been an increase in novel therapeutic options to treat hemophilia A. It is still unclear how these novel treatments are used in the management of patients with hemophilia A, particularly those with challenging clinical scenarios who are typically excluded in clinical trials.

Purpose

This study aimed to understand the areas of consensus and disagreement among hematologists regarding the preferences toward therapeutic approaches for difficult-to-treat patients with severe hemophilia A without inhibitors.

Patients and Methods

During February-June 2020, a three-round modified Delphi study was conducted to generate consensus among 13 US experts in the field of hemophilia. Experts were asked about their preferences toward therapeutic options for patients with challenging clinical situations, including age-related morbidities (eg, myocardial infarction, joint arthropathy), increasing demand for high-impact physical activities, early onset osteoporosis, and newborns with hemophilia A. Consensus was defined as ≥75% agreement between the panelists.

Results

Consensus was reached on many, but not all cases, leaving uncertainty about appropriateness of therapeutic approaches for some patients where clinical evidence is not available or driven by physicians' or patients' preferences toward therapeutic options. A majority of panelists preferred FVIII replacement therapy rather than emicizumab prophylaxis for the challenging cases presented due to established evidence on safety, efficacy, and level of bleed protection for FVIII treatment.

Conclusion

Recommendations emerging from this study may help guide practicing hematologists in the management of challenging hemophilia A cases. Future studies are needed to address treatment options in the clinical cases where no consensus was reached.

The Use of Intraoperative Transit Time Flow Measurement for Coronary Artery Bypass Surgery: Systematic Review of the Evidence and Expert Opinion Statements

Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making.

Measures to evaluate quality of care in renal cancer: results of a Delphi study in Spain

PURPOSE

To review current measures for renal cancer care and develop a comprehensive and updated list of measures for their practical use in Spain.

METHODS

The study was developed by Fundación ECO, a Spanish foundation aiming to improve oncology quality of care. A systematic literature review was carried out to identify measures and knowledge gaps. A scientific committee composed of nine experts reviewed the literature findings and added measures. A preliminary list of 42 measures was evaluated with the Delphi method to gather feedback from 47 medical oncology experts in Spain. Experts scored the appropriateness of the measures and ranked their priority in two consecutive online surveys. The scientific committee reviewed the Delphi results and developed the measures. A technical group from Universidad Francisco de Vitoria conducted and oversaw the Delphi method.

RESULTS

The Delphi method led to consensus on all 42 measures. The scientific committee used a prioritisation matrix to select 25 of these measures for evaluating quality of care in renal cancer. These measures regarded structure, process, and outcome and covered general management, diagnosis, treatment, follow-up, and evaluation of health outcomes. Easy-to-use index cards were developed for all 25 measures, including their definition, formula, acceptable level of attainment, and rationale.

CONCLUSIONS

This manuscript aims to provide healthcare professionals with expert- and evidence-based measures that are useful for evaluating quality of care in renal cancer in Spain and cover all aspects and stages.

Quality Indicators in Surgical Palliative Care: A Systematic Review

CONTEXT

Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs.

OBJECTIVES

To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality.

METHODS

A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality.

RESULTS

There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators.

CONCLUSION

This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

Strategies for Successful Clinical Trial Recruitment of People Living with HIV in Low- and Middle-Income Countries: Lessons Learned and Implementation Implications from the Nigeria Renal Risk Reduction (R3) Trial

PURPOSE OF REVIEW

Clinical trials represent a bedrock for measuring efficacy of interventions in biomedical research, but recruitment into clinical trials remains a challenge. Few data have focused on recruitment strategies from the perspective of clinical trial teams, especially in low- and middle-income countries (LMIC), where HIV is most prevalent.

RECENT FINDINGS

We summarized data from the literature and our experience with recruitment for the Renal Risk Reduction trial, aimed at reducing risk of kidney complications among people living with HIV in Nigeria. Using an implementation science framework, we identified strategies that contributed to successful clinical trial recruitment. For strategies that could not be categorized by this framework, we summarized key features according to selected action, actor, target, context, and time. We identified how these identified strategies could map to subsequent implementation outcomes at the patient and provider/health system level, as well as capacity-building efforts to meet needs identified by LMIC partners, which is a priority for success. Our experience highlights the importance of considering implementation outcomes, and the strategies necessary to achieve those outcomes early, in the planning and execution of clinical trials. Clinical trial recruitment can be optimized via methodologies grounded in implementation science.

Establishing Research Priorities for the Emergency Severity Index Using a Modified Delphi Approach

INTRODUCTION

The accuracy of an initial ED triage decision has been reported to drive the clinical trajectory for ED patients, and, therefore, this assessment is critical to patient safety. The Emergency Severity Index-a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use-is used both in the United States and internationally. In the US, the Emergency Severity Index is used by up to 94% of the academic medical center emergency departments. In 2020, the Emergency Nurses Association acquired the intellectual property rights to the Emergency Severity Index and is responsible for its maintenance and improvement.

OBJECTIVE

The purpose of this study was to establish a research agenda for the improvement of individual and institutional understanding and use of the Emergency Severity Index.

METHODS

Modified Delphi process was used with 3 rounds of data collection.

RESULTS

Round 1 yielded 112 issues, which were collapsed into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). These questions were used in round 2 to establish importance. Round 3 yielded a rank ordering of both categories and research questions.

DISCUSSION

The research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses' triage decisions and accuracy of Emergency Severity Index assignments.

Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement

Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.

Guideline-based indicators for adult patients with myelodysplastic syndromes

Myelodysplastic syndromes (MDSs) represent a heterogeneous group of hematological stem cell disorders with an increasing burden on health care systems. Evidence-based MDS guidelines and recommendations (G/Rs) are published but do not necessarily translate into better quality of care if adherence is not maintained in daily clinical practice. Guideline-based indicators (GBIs) are measurable elements for the standardized assessment of quality of care and, thus far, have not been developed for adult MDS patients. To this end, we screened relevant G/Rs published between 1999 and 2018 and aggregated all available information as candidate GBIs into a formalized handbook as the basis for the subsequent consensus rating procedure. An international multidisciplinary expert panel group (EPG) of acknowledged MDS experts (n = 17), health professionals (n = 7), and patient advocates (n = 5) was appointed. The EPG feedback rates for the first and second round were 82% (23 of 28) and 96% (26 of 27), respectively. A final set of 29 GBIs for the 3 domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7) achieved the predefined agreement score for selection (>70%). We identified shortcomings in standardization of patient-reported outcomes, toxicity, and geriatric assessments that need to be optimized in the future. Our GBIs represent the first comprehensive consensus on measurable elements addressing best practice performance, outcomes, and structural resources. They can be used as a standardized instrument with the goal of assessing, comparing, and fostering good quality of care within clinical development cycles in the daily care of adult MDS patients.

The value of the polypill in cardiovascular disease: an Italian multidisciplinary Delphi panel consensus

The purpose of this work was to reach the consensus of a multidisciplinary and multistakeholder Italian panel on the value of polypill in cardiovascular disease, with respect to the clinical, technological, economic and organizational dimension. A three-step modified Delphi method was used to establish consensus. Eleven experts in the area of cardiology, pharmaceutical technology, general practice, hospital pharmacy, pharmacology, and health economics participated in the expert panel. To identify existing evidence concerning the value of polypill in the prevention of patients with cardiovascular disease, a systematic literature review was carried out according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. In the first round, 22 statements were distributed to the panel. Panel members were asked to mark 'agree' or 'disagree' for each statement and provide any comments. The same voting method was again used for the second round. In the first round nine statements met consensus. In the second round, 10 statements reached consensus. Overall, consensus was reached for 19 statements representing five value polypill domains: clinical, technological, economic and organizational. During a final web meeting with all panel members consensus document open points were discussed. Panel members agreed to recognize polypill as effective in reducing cardiovascular events, blood pressure and lipids, cardiovascular risk and the weight of therapy, in therapeutic adherence improvement, in the absence of differences in bioavailability between drugs administered in fixed or free combinations and the better cost-effectiveness profile compared with standard care. This document represents a knowledge framework to inform decision makers of the value of polypill in cardiovascular prevention.

Optimizing outcomes for patients with metastatic prostate cancer: insights from South East Asia Expert Panel

AIMS

Clinical decision making is challenging in men with metastatic prostate cancer (mPC), as heterogeneity in treatment options and patient characteristics have resulted in multiple scenarios with little or no evidence. The South East Asia Expert Panel 2019 addressed some of these challenges.

METHODS

Based on evidence in the literature and expert interviews, 19 statements were formulated for key challenges in the treatment of men with castration-sensitive and -resistant prostate cancer in clinical practice. A modified Delphi process was used to reach consensus among experts in the panel and develop clinical practice recommendations.

RESULTS

The majority of the panel preferred a risk-based stratification and recommended abiraterone or enzalutamide as first-line therapy for symptomatic chemotherapy naïve patients. Abiraterone is preferred over enzalutamide as a first-line treatment in these patients. However, the panel did not support the use of abiraterone in high risk lymph-node positive only (N+M0) or in non-metastatic (N0M0) patients. In select patients, low dose abiraterone with food may be used to optimize clinical outcomes. Androgen receptor gene splice variant status may be a useful guide to therapy. In addition, generic versions of approved therapies may improve access to treatment to a broader patient population. The choice of treatment, as well as sequencing are guided by both patient and disease characteristics, preferences, drug access, cost, and compliance.

CONCLUSION

Expert recommendations are key to guidance for the optimal management of mPC. Appropriate choice, timing, and sequence of treatment options can help to tailor therapy to maximize outcomes in men with mPC.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy

INTRODUCTION

Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes.

METHODS

A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting.

RESULTS

An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles).

CONCLUSIONS

Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Maintenance Therapies for Hodgkin and Non-Hodgkin Lymphomas After Autologous Transplantation: A Consensus Project of ASBMT, CIBMTR, and the Lymphoma Working Party of EBMT

Importance

Maintenance therapies are often considered as a therapeutic strategy in patients with lymphoma following autologous hematopoietic cell transplantation (auto-HCT) to mitigate the risk of disease relapse. With an evolving therapeutic landscape, where novel drugs are moving earlier in therapy lines, evidence relevant to contemporary practice is increasingly limited. The American Society for Blood and Marrow Transplantation (ASBMT), Center for International Blood and Marrow Transplant Research (CIBMTR), and European Society for Blood and Marrow Transplantation (EBMT) jointly convened an expert panel with diverse expertise and geographical representation to formulate consensus recommendations regarding the use of maintenance and/or consolidation therapies after auto-HCT in patients with lymphoma.

Observations

The RAND-modified Delphi method was used to generate consensus statements where at least 75% vote in favor of a recommendation was considered as consensus. The process included 3 online surveys moderated by an independent methodological expert to ensure anonymity and an in-person meeting. The panel recommended restricting the histologic categories covered in this project to Hodgkin lymphoma (HL), mantle cell lymphoma (MCL), diffuse large B-cell lymphoma (DLBCL), and follicular lymphoma. On completion of the voting process, the panel generated 22 consensus statements regarding post auto-HCT maintenance and/or consolidation therapies. The grade A recommendations included endorsement of: (1) brentuximab vedotin (BV) maintenance and/or consolidation in BV-naïve high-risk HL, (2) rituximab maintenance in MCL undergoing auto-HCT after first-line therapy, (3) rituximab maintenance in rituximab-naïve FL, and (4) No post auto-HCT maintenance was recommended in DLBCL. The panel also developed consensus statements for important real-world clinical scenarios, where randomized data are lacking to guide clinical practice.

Conclusions and Relevance

In the absence of contemporary evidence-based data, the panel found RAND-modified Delphi methodology effective in providing a rigorous framework for developing consensus recommendations for post auto-HCT maintenance and/or consolidation therapies in lymphoma.

Causal variance decompositions for institutional comparisons in healthcare

There is increasing interest in comparing institutions delivering healthcare in terms of disease-specific quality indicators (QIs) that capture processes or outcomes showing variations in the care provided. Such comparisons can be framed in terms of causal models, where adjusting for patient case-mix is analogous to controlling for confounding, and exposure is being treated in a given hospital, for instance. Our goal here is to help identify good QIs rather than comparing hospitals in terms of an already chosen QI, and so we focus on the presence and magnitude of overall variation in care between the hospitals rather than the pairwise differences between any two hospitals. We consider how the observed variation in care received at patient level can be decomposed into that causally explained by the hospital performance adjusting for the case-mix, the case-mix itself, and residual variation. For this purpose, we derive a three-way variance decomposition, with particular attention to its causal interpretation in terms of potential outcome variables. We propose model-based estimators for the decomposition, accommodating different link functions and either fixed or random effect models. We evaluate their performance in a simulation study and demonstrate their use in a real data application.

Development and Implementation of a Continuing Medical Education Program in Canada: Knowledge Translation for Renal Cell Carcinoma (KT4RCC)

An in-person multidisciplinary continuing medical education (CME) program was designed to address previously identified knowledge gaps regarding quality indicators of care in kidney cancer. The objective of this study was to develop a CME program and determine if the program was effective for improving participant knowledge. CME programs for clinicians were delivered by local experts (uro-oncologist and medical oncologist) in four Canadian cities. Participants completed knowledge assessment tests pre-CME, immediately post-CME, and 3-month post-CME. Test questions were related to topics covered in the CME program including prognostic factors for advanced disease, surgery for advanced disease, indications for hereditary screening, systemic therapy, and management of small renal masses. Fifty-two participants attended the CME program and completed the pre- and immediate post-CME tests. Participants attended in Ottawa (14; 27%), Toronto (13; 25%), Québec City (18; 35%), and Montréal (7; 13%) and were staff urologists (21; 40%), staff medical oncologists (9; 17%), fellows (5; 10%), residents (16; 31%), and oncology nurses (1; 2%). The mean pre-CME test score was 61% and the mean post-CME test score was 70% (p = 0.003). Twenty-one participants (40%) completed the 3-month post-CME test. Of those that completed the post-test, scores remained 10% higher than the pre-test (p value 0.01). Variability in test scores was observed across sites and between French and English test versions. Urologists had the largest specialty-specific increase in knowledge at 13.8% (SD 24.2, p value 0.02). The kidney cancer CME program was moderately effective in improving provider knowledge regarding quality indicators of kidney cancer care. These findings support continued use of this CME program at other sites.

Benchmarking quality for renal cancer surgery: Canadian Kidney Cancer information system (CKCis) perspective

INTRODUCTION

There is a lack of validated quality metrics to evaluate the care of patients receiving surgery for renal cell carcinoma (RCC). To address this, the Kidney Cancer Research Network of Canada defined a list of quality indicators (QI) to assess hospital-level performance. We have case-mix adjusted these QIs to benchmark RCC surgical care at Canadian academic centres.

METHODS

The Canadian Kidney Cancer information system (CKCis) was used to measure six QIs: laparoscopic approach proportion (LA), partial nephrectomy proportion (PN), partial nephrectomy in patients with chronic kidney disease (CKDPN), positive margin rate (PMR), partial nephrectomy complication rate (PNCx), and warm ischemia time (WIT). To benchmark performance, indirect standardization (observed-to-expected ratio) methodology was employed using multivariate regression models.

RESULTS

Multivariate models for LA, PN, and CKDPN demonstrated good discrimination and were used for benchmarking. National averages of 74% (70-78%), 73% (70-75%), and 70% (67-74%) for the LA, PN, and CKDPN QIs, respectively, were determined and used to benchmark individual hospital performance. Overall, three (23%), two (15%), and two (15%) hospitals performed below expected for LA, PN, and CKDPN, respectively. Hospital identity was an independent predictor of LA, PN, and CKDPN (p<0.001).

CONCLUSIONS

Significant variability between CKCis hospitals for three RCC surgical QIs exists. Using the CKCis infrastructure may provide a framework for institution-level audit feedback for quality improvement. Greater CKCis capture rates and further data supporting the construct validity of these QIs are required to extend the use of this dataset to real-world quality initiatives.

Population-based Cancer Screening: Measurement of Coordination and Continuity of Care

BACKGROUND

European guidelines for the quality of screening programs for breast and colorectal cancer describe process, structure, and outcome indicators. However, none of them specifically evaluate coordination and continuity of care during the cancer screening process.

OBJECTIVES

The aim of this study was to identify and adapt care quality indicators related to the coordination and continuity of the cancer screening process to assess nursing care in cancer screening programs.

METHODS

The indicators proposed in this study were selected in 2 phases. The first consisted of a literature review, and the second was made by consensus of an expert group. An electronic literature search was conducted, through June 2016. From a total of 225 articles retrieved, 14 studies met inclusion criteria, and these 14 documents were delivered to the group of experts for evaluation and to propose a final list of agreed-upon indicators.

RESULTS

The group of experts selected 7 indicators: adequacy and waiting time derivation of participants, delivery and availability of the report of the process, understanding professionals involved in the process, and satisfaction and understanding of participants.

CONCLUSIONS

These indicators should help identify areas for improvement and measure the outcome of coordination and continuity of care.

IMPLICATIONS FOR PRACTICE

The results provided a common set of indicators to evaluate the coordination and continuity of care for cancer screening and to consequently assess the contribution of nursing care in cancer screening programs. The identification and adaptation of these quality indicators will help to identify areas for improvement and measure the effect of coordination and continuity of care.

Needs Assessment Survey for the Management of Kidney Cancer

INTRODUCTION

In this study we determined self-perceived knowledge gaps and continuing medical education preferences among Canadian urologists and medical oncologists related to the treatment of patients with kidney cancer.

METHODS

A needs assessment survey was created by the Quality Initiative group of the Kidney Cancer Research Network of Canada using an iterative feedback process. The survey determined knowledge gaps and continuing medical education preferences pertaining to 23 previously validated quality indicators of kidney cancer care. Topics included screening, diagnosis, prognosis, surgical management, systemic therapies and followup care. The survey was distributed via e-mail to Canadian urologists and medical oncologists.

RESULTS

Among the 164 respondents 121 (74%) were urologists and 43 (26%) were medical oncologists. The majority of respondents practice in academic (72, 57%) or large urban community centers (40, 32%). Of the 23 quality indicators examined 14 were designated as priority continuing medical education topics based on perceived inadequate knowledge or high interest in the topic. Priority topics were similar for urologists and medical oncologists, and covered the spectrum of kidney cancer care with an emphasis on hereditary kidney cancer and management of advanced disease. Most respondents preferred that continuing medical education be delivered through in person, case based group discussions.

CONCLUSIONS

Canadian urologists and medical oncologists report similar knowledge gaps and continuing medical education preferences regarding kidney cancer care. Priority topics include screening for hereditary kidney cancer and management of advanced disease.

Measuring quality care in localized renal cell cancer: use of appropriate preoperative investigations in a population-based cohort

INTRODUCTION

Obtaining appropriate preoperative risk-specific staging investigations for localized renal cell carcinoma (rcc) is a recognized quality indicator. The goal of the present work was to determine the use and appropriateness of preoperative investigations in patients undergoing curative surgery for rcc.

METHODS

This population-based retrospective study of patients having surgery for localized rcc recorded the use of preoperative imaging and laboratory investigations within 6 months of surgery. "Appropriate" stage-specific investigations were determined using recognized published guidelines.

RESULTS

The study cohort consisted of 544 patients with 72.8% being stage i, 18.4% being stage ii, and 8.8% being stage iii by clinical TNM (2002) criteria. In 61.6%, chest imaging was obtained by chest radiography or computed tomography (ct) within 3 months preoperatively; in 75.6%, such imaging was obtained within 6 months. Abdominal ct imaging was obtained in 97.1% of patients before surgery, with 77.5% of patients receiving such imaging within 3 months of surgery. Complete blood count, electrolytes, and creatinine were measured in 99.1% of patients, but those tests plus other recommended blood tests including calcium, alkaline phosphatase, and liver function were measured in only 17.7%.

CONCLUSIONS

In this study, most patients received appropriate abdominal imaging, but chest imaging was underutilized in the overall cohort. Despite being recommended, blood tests such as liver function, alkaline phosphatase, and calcium were completed in fewer than 2 of 10 patients. This analysis provides the groundwork for quality improvement initiatives directed to the use of preoperative investigations in localized rcc.

Quality indicators in the management of bladder cancer: A modified Delphi study

BACKGROUND

Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement.

OBJECTIVE

To produce an evidence- and consensus-based list of QIs for the management of bladder cancer.

METHODS

A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed.

RESULTS

A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed.

CONCLUSIONS

This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology

Background

Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm.

Methods

A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting.

Results

In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic.

Conclusion

This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0165-8) contains supplementary material, which is available to authorized users.

Surgical management of stage T1 renal tumours at Canadian academic centres

INTRODUCTION

The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours.

METHODS

The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined.

RESULTS

From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05).

CONCLUSION

Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.