ABSTRACT
BACKGROUND: Studies on quality of care for oesophageal cancer patients usually include only traditional outcome parameters. The aim of the study was to address quality of care in a broader perspective. METHODS: Between 2003 and 2008, 821 oesophageal cancer patients were referred to our institute. Indicators to measure quality of care (i.e., process and outcome measures) were defined and comparisons between two time periods were made. RESULTS: 335 patients came for a second opinion only, 382 patients received palliative treatment and 104 (13%) patients underwent potentially curative treatment. The median time between the first hospital visit and start of treatment decreased from 24 days in period I to 18 days in period II (P = 0.03). Of patients who underwent potentially curative treatment, 81% in period I and 86% in period II were discussed during a weekly multidisciplinary meeting (P = 0.54). Compliance with the national guideline was comparable in both periods (84% vs. 80%, P = 0.27). There were non-significant improvements in completion of chemoradiation (85% vs. 91%), postoperative complication rates (57% vs. 33%) and 3-year survival (40% vs. 46%). CONCLUSION: By evaluating different dimensions of health care quality, we have identified which steps in the multidisciplinary care path need more attention in order to raise the whole level of care. Efforts for improvement should focus primarily on process measures rather than on outcome measures for which high-quality standards are already met.
Subject(s)
Esophageal Neoplasms/mortality , Esophageal Neoplasms/therapy , Quality Indicators, Health Care , Referral and Consultation/statistics & numerical data , Chemoradiotherapy/methods , Cohort Studies , Combined Modality Therapy , Disease-Free Survival , Esophageal Neoplasms/pathology , Esophagectomy/methods , Female , Hospitals, Special , Humans , Male , Neoplasm Invasiveness/pathology , Neoplasm Staging , Netherlands , Palliative Care/methods , Prognosis , Quality of Health Care , Retrospective Studies , Risk Assessment , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Quality-of-care indicators are measurable elements of practice performance that can assess the (change in) quality of the care provided. To date, the literature on quality-of-care indicators for oesophageal cancer surgery has not been reviewed. METHODS: We performed a review of the literature on quality-of-care indicators for oesophageal cancer surgery. The indicators were classified by their nature of care provision (structural, process, or outcome). RESULTS: One hundred thirty articles were included. For structural measures, most evidence was found for the inverse relationship between hospital or surgeon volume and post-operative mortality. Few articles described the required infrastructural and organisational elements for oesophageal cancer surgery. Regarding process measures, the most common indicators were determinants of patient selection for surgery. Other process indicators with considerable evidence were found (e.g., multidisciplinary team management), though the number of studies was small. For outcome indicators, the level of evidence for pathological outcome measures was strong. Data on post-operative complications as outcome indicators varied widely. CONCLUSION: Since there is considerable variation in the evaluation of quality of care, the uniform use of well-defined quality-of-care indicators to measure and document practice performance holds the promise of improving outcome in patients who undergo oesophageal cancer surgery.
Subject(s)
Esophageal Neoplasms/diagnosis , Esophageal Neoplasms/surgery , Esophagectomy , Outcome and Process Assessment, Health Care , Quality of Health Care , Aged , Aged, 80 and over , Chemotherapy, Adjuvant , Esophageal Neoplasms/pathology , Esophagectomy/adverse effects , Esophagectomy/methods , Esophagectomy/standards , Esophagectomy/statistics & numerical data , Evidence-Based Medicine , Humans , Length of Stay , Neck Dissection , Neoplasm Staging , Netherlands , Observer Variation , Outcome Assessment, Health Care , Patient Care Team , Patient Selection , Radiotherapy, Adjuvant , Risk Assessment , Risk FactorsABSTRACT
BACKGROUND: Surgery alone for locally advanced oesophageal cancer is associated with low cure rates. The benefits and risks of neoadjuvant chemoradiation for patients with oesophageal cancer were evaluated. METHODS: A systematic review of publications between 2000 and 2008 on neoadjuvant chemoradiation for oesophageal cancer was undertaken. RESULTS: Thirty-eight papers comprising 3640 patients met the inclusion criteria. Chemoradiation regimens varied widely with a predominance of 5-fluorouracil/cisplatin chemotherapy. Chemoradiation-related toxicity was reported in only ten studies and consisted mainly of neutropenia. The chemoradiation-related mortality rate was 2.3 per cent. The mean R0 resection rate and pathological complete response (pCR) rate were 88.4 and 25.8 per cent respectively. Postoperative morbidity was not uniformly reported. The in-hospital mortality rate after oesophagectomy following chemoradiation was 5.2 per cent. Five-year survival rates varied from 16 to 59 per cent in all patients and from 34 to 62 per cent in those with a pCR. Chemoradiation had a temporary negative effect on quality of life. CONCLUSION: Neoadjuvant chemoradiation regimens for oesophageal cancer vary widely. Besides traditional outcome variables (such as survival), other parameters should be analysed (for example toxicity) to assess whether the risks of chemoradiation are sufficiently compensated for by the benefits.
