Timilshina Narhari, Finelli Antonio, Tomlinson George, Sander Beate, Alibhai Shabbir M H
1Department of Medicine, University Health Network, Toronto, Ontario, Canada.
2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
J Natl Compr Canc Netw. 2023 May;21(5):465-472.e9. doi: 10.6004/jnccn.2022.7256.
Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level.
QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume.
The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with ≥6 patients with AS annually).
This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and Qis related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.
尽管有一些研究报告了主动监测（AS）中医疗质量存在广泛差异，但缺乏使用经过验证的质量指标（QI）的研究。本研究的目的是应用循证质量指标来检查人群层面的AS医疗质量。
使用基于人群的回顾性队列研究来测量质量指标，该队列研究对象为2002年至2014年间诊断为低风险前列腺癌的患者。我们通过改良的德尔菲法与临床医生共同制定了20个质量指标，旨在针对人群层面的AS医疗质量。质量指标包括结构指标（n = 1）、医疗过程指标（n = 13）和结果指标（n = 6）。提取的病理数据与加拿大安大略省的癌症登记处和行政数据库相关联。根据行政数据库中的可用信息，20个质量指标中有17个可以应用。根据患者年龄、诊断年份和医生工作量探讨了质量指标表现的差异。
该队列包括33454名低风险前列腺癌男性患者，中位年龄为65岁（四分位间距，59 - 71岁），中位前列腺特异性抗原水平为6.2 ng/mL。10个医疗过程质量指标的依从性差异很大（范围为36.6% - 100.0%，其中6个[60%]质量指标>80%）。初始AS采用率为36.6%，且随时间增加。在结果指标中，观察到不同患者年龄组之间存在显著差异（65 - 74岁年龄组的10年无转移生存率为95.0%，<55岁年龄组为97.5%）以及医生年均AS工作量之间的差异（每年有1 - 2例AS患者的医生，其10年无转移生存率为94.5%，每年有≥6例AS患者的医生为95.8%）。
本研究为在人群层面实施AS期间的医疗质量评估和监测奠定了基础。与医生工作量相关的医疗过程质量指标以及与患者年龄组相关的结果质量指标存在相当大的差异。这些发现可能代表了有针对性的质量改进举措的领域。
