Compliance with clinical practice guidelines for breast cancer treatment: a population-based study of quality-of-care indicators in Italy

Abstract

BackgroundIt has been documented that variations exist in breast cancer treatment despite wide dissemination of clinical practice guidelines. The aim of this population-based study was to evaluate the impact of regional guidelines (Piedmont guidelines, PGL) for breast cancer diagnosis and treatment on quality-of-care indicators in the Northwestern Italian region of Piedmont.MethodsWe included two samples of women aged 50–69 years with incident breast cancer treated in Piedmont before and after the introduction of PGL: 600 in 2002 (pre-PGL) and 621 in 2004 (post-PGL). Patients were randomly selected among all incident breast cancer cases identified through the hospital discharge records database. We extracted clinical data on breast cancer cases from medical charts and ascertained vital status through linkage with town offices. We assessed compliance with 14 quality-of-care indicators from PGL recommendations, before and after their introduction in clinical practice.ResultsAmong patients with invasive lesions, 77.1% (N = 368) and 77.5% (N = 383) in the pre-PGL and post-PGL groups, respectively, received breast conservative surgery (BCS) as a first-line treatment. Following BCS, 87.7% received radiotherapy in 2002, compared to 87.9% in 2004. Of all patients at medium-to-high risk of distant metastasis, 65.5% (N = 268) and 63.6% (N = 252) received chemotherapy in 2002 and in 2004, respectively. Among the 117 patients with invasive lesions and negative estrogen receptor status in 2002, hormonal therapy was prescribed in 23 of them (19.6%). The incorrect prescription of hormonal therapy decreased to 10.8% (N = 10) among the 92 estrogen receptor-negative patients in 2004 (p < 0.01).Compliance with PGL recommendations was already high in the pre-PGL group, although some quality-of-care indicators did not reach the standard. In the pre/post analysis, 8 out of 14 quality-of-care indicators showed an improvement from 2002 to 2004, but only 4 out of 14 reached statistical significance. We did not find any change in the risk of mortality in the post-PGL versus the pre-PGL group (adjusted hazard ratio 0.94, 95%CI 0.56–1.56).ConclusionsThese results highlight the need to continue to improve breast cancer care and to measure adherence to PGL.

Absence of socioeconomic inequalities in access to good-quality breast cancer treatment within a population-wide screening programme in Turin (Italy)

“…Other indicators of quality treatment (such as performing a single operation, not performing axillary dissection or leaving clear margins) remained unchanged with time, possibly because they had already very high percentages of success (between 83 and 96%). The general improvement observed in quality indicators after the introduction of the regional guidelines on breast cancer diagnosis and treatment is in line with the literature (Sacerdote et al, 2013). This effect may be attributed not only to the implementation and diffusion of guidelines in themselves but also to the progressive increase in the coverage of the screening programme protocol, which ensured a strict adherence to recommendations and an optimal pathway of care to women diagnosed through the programme.…”

Clinical auditing as an instrument for quality improvement in breast cancer care in the Netherlands: The national NABON Breast Cancer Audit

“…The collection of data in all hospitals in the Netherlands resulted in 56,927 patients for whom detailed information regarding their work-up and treatment was available for analysis. Several initiatives have shown that improvement of quality of care can be established by measuring quality indicators over time [7][8][9][10][11][12]; however, to the best of our knowledge we are the first to report on a nationwide breast cancer audit with full participation of all hospitals. The use of quality indicators embedded in a national audit providing benchmark information to Fig.…”

Provision of breast cancer care and survival in Germany – results from a population-based high resolution study from Saarland

“…The extent of adherence to CPG and the observed trends during the study period corresponded to findings from previous population-based studies from other Western countries (e.g. proportion of patients with BCS receiving radiotherapy: Saarland 2004/05: 85%, region of Piedmont (Italy) 2004: 88%, Canadian regions 2000–2004: ranging between 77% and 83%; chemotherapy in nodal positive patients: Saarland: 73%, region of Piedmont: 64%, Canadian regions: between 53%-68%; antiestrogen treatment in HR positive or mixed patients: Saarland 2000/2001: 79%, Canadian regions: 79%-85%) [ 38 – 41 ].…”