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.
Highlights
It has been documented that variations exist in breast cancer treatment despite wide dissemination of clinical practice guidelines
In the Piedmont Region (Northwestern Italy, population 4.25 million), clinical practice guidelines (PGL) for the treatment of breast cancer were first released in July 2002 and disseminated to all relevant clinicians and other stakeholders [2,3] as from 1996, the Piedmont Region has been covered by a breast screening program for all resident women aged 50–69 years
Several studies have examined the different surgical and medical breast cancer treatments employed following the publication of clinical practice guidelines, to our knowledge few reports have included a comparison with clinical practice prior to guideline publication, and even fewer have examined the impact of guidelines in clinical practice at a population level [6,7]
Summary
It 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. In the Piedmont Region (Northwestern Italy, population 4.25 million), clinical practice guidelines (PGL) for the treatment of breast cancer were first released in July 2002 and disseminated to all relevant clinicians and other stakeholders [2,3] as from 1996, the Piedmont Region has been covered by a breast screening program for all resident women aged 50–69 years. Several studies have examined the different surgical and medical breast cancer treatments employed following the publication of clinical practice guidelines, to our knowledge few reports have included a comparison with clinical practice prior to guideline publication, and even fewer have examined the impact of guidelines in clinical practice at a population level [6,7]
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