National Accreditation Program Research Articles

Impact of National Accreditation Program for Rectal Cancer guidelines on surgical margin status

BackgroundThe American College of Surgeons established the National Accreditation Program for Rectal Cancer (NAPRC) to standardize rectal cancer care. We sought to assess the impact of NAPRC guidelines at a tertiary care center on surgical margin status. Materials and methodsThe Institutional NSQIP database was queried for patients with rectal adenocarcinoma undergoing surgery for curative intent two years prior to and following implementation of NAPRC guidelines. Primary outcome was surgical margin status before (pre-NAPRC) versus after (post-NAPRC) implementation of NAPRC guidelines. ResultsSurgical pathology in five (5%) pre-NAPRC and seven (8%) post-NAPRC patients had positive radial margins (p = 0.59); distal margins were positive in three (3%) post-NAPRC and six (7%) post-NAPRC patients (p = 0.37). Local recurrence was observed in seven (6%) pre-NAPRC patients, there were no recurrences to date in post-NAPRC patients (p = 0.15). Metastasis was observed in 18 (17%) pre-NAPRC patients and four (4%) post-NAPRC patients (p = 0.55). ConclusionNAPRC implementation was not associated with a change in surgical margin status for rectal cancer at our institution. However, the NAPRC guidelines formalize evidence-based rectal cancer care and we anticipate that improvements will be greatest in low-volume hospitals which may not utilize multidisciplinary collaboration.

Abstract P021: Association of social determinants of health and healthcare-related factors with delayed total neoadjuvant therapy among rectal cancer patients from the national cancer database

Abstract Total neoadjuvant therapy (TNT) is a treatment strategy for rectal cancer that includes a course of chemotherapy and a separate course of chemoradiation before definitive surgery. The use of TNT has increased in recent years and carries the potential for improved sphincter preservation and a significant risk reduction of locoregional recurrence. One criterion of the National Accreditation Program for Rectal Cancer is to begin definitive treatment within 60 days of a patient’s diagnosis of rectal cancer. The objective of this study was to evaluate the association of social determinants of health and healthcare-related factors with starting TNT 60 days or more after diagnosis using data from the National Cancer Database (NCDB). Patients aged 18 years and older diagnosed with primary rectal cancer between 2016 and 2019, who underwent NCCN recommended TNT regimen followed by definitive surgery at a Commission on Cancer (CoC)-accredited facility and did not die before receiving surgery were eligible for the current study. We included 3,210 patients in the analytic sample who did not have the following conditions: clinical stage IV, clinical stage T1N0 or lower, non-adenocarcinoma histology, and adjuvant therapy use. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for factors potentially associated with starting TNT more than 60 days after a cancer diagnosis. The median age of patients included in the study was 57 years old, with a majority of them starting TNT within 60 days (87.5%), were males (62.3%), and reported as Non-Hispanic White race and ethnicity (76.7%). Furthermore, 35.0% had a median household income of $63,333 or more, 57.7% had private insurance/managed care, 65.0% traveled within 30 miles to their treatment facility, and 49.1% lived in a zip code where less than 10.9% of adults age 25 or older did not graduate from high school. In multivariable models, factors positively associated with starting TNT after 60 days or more were uninsured status (OR 2.93, CI: 1.84, 4.67), living in a zip code with more than 10.8% of adults age 25 or older not graduating from high school (OR 1.66, CI: 1.22, 2.25), traveling more than 30 miles to the treatment facility (OR 1.63, CI: 1.20, 2.20), treatment with an academic/research program (OR 1.51, CI: 1.13, 2.02), Medicaid as primary insurance (OR 1.50, CI: 1.03, 2.19), Hispanic ethnicity (OR 1.44, CI: 1.00, 2.07), male (OR 1.28, CI: 1.00, 1.65) and age (1.02, CI: 1.01, 1.04). In conclusion, results from this study show that social determinants of health and other healthcare-related factors are significantly associated with those who started TNT more than 60 days after a rectal cancer diagnosis. Further investigation is ongoing to understand the impact of delays in TNT and other treatment regimens for rectal cancer. Citation Format: Megan T. Mai, Zheng Shi, Duke Appiah. Association of social determinants of health and healthcare-related factors with delayed total neoadjuvant therapy among rectal cancer patients from the national cancer database. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P021.

Benefits and Impacts of Public Health Accreditation for Small Local Health Departments.

This study sought to identify accreditation benefits and impacts among local health departments (LHDs) stratifying by size of population served to determine differences between small, medium, and large LHDs. The Public Health Accreditation Board operates the national accreditation program for public health departments, through which 306 LHDs have been accredited as of August 2022. Benefits of accreditation for LHDs are well documented, despite potential challenges and barriers to seeking accreditation. Research on the benefits of accreditation for small LHDs, specifically, is more limited. All health departments that completed the accreditation process between December 2013 and May 2022 were surveyed following receipt of the accreditation decision. The analytic sample included 266 LHDs (response rate of 93.7%). Data for LHDs were analyzed for specific variables related to experiences, challenges, and benefits, and stratified by size to compare small LHDs with medium and large LHDs. Bivariate analyses were conducted to identify statistical significance. Generally, small LHDs reported similar outcomes of accreditation to medium and large LHDs. These included improvements in staff competencies, capacity to provide high-quality services, and relationships with partners. Small LHDs were significantly more likely than medium and large LHDs to report that accreditation increased their use of evidence-based practices. LHDs of all sizes reported an increase in quality improvement activities due to accreditation. Challenges for small LHDs included limited staff time or staff turnover and limited funding. The public health accreditation program has offered numerous benefits to LHDs of all sizes, including small LHDs. These accreditation benefits may be particularly important for small LHDs because of their critical role in the public health system and the ongoing need to support performance improvement, strengthen infrastructure, and increase resilience.

LONG-TERM PATENCY AND NEED-FOR-REINTERVENTIONS OF EUS-GUIDED CHOLEDOCODUODENOSTOMY WITH ELECTROCAUTERY-ENHANCED LUMEN APPOSING METAL STENTS: A SINGLE-CENTRE PROSPECTIVE EVALUATION

National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis.This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality.A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively.This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days.

How can I Start an Multidisciplinary Team for Management of Rectal Cancer Patients? Analysis of the Feasibility of Using American National Accreditation Program for Rectal Cancer Patients Standards in a Low-Income Country Hospital

How can I Start an Multidisciplinary Team for Management of Rectal Cancer Patients? Analysis of the Feasibility of Using American National Accreditation Program for Rectal Cancer Patients Standards in a Low-Income Country Hospital

Barriers to breast reconstruction for socioeconomically disadvantaged women.

Socioeconomic disparities in post-mastectomy breast reconstruction exist. Key informants have suggested that finding providers who accept Medicaid insurance and longer travel time to a plastic surgeon are important barriers. Our objective was to assess the relationship between these factors and reconstruction for socioeconomically disadvantaged women in Wisconsin. We identified women < 75years of age with stage 0-III breast cancer who underwent mastectomy using the Wisconsin Cancer Reporting System. Women in the most disadvantaged state-based tertile of the Area Deprivation Index were included (n = 1809). Geocoding determined turn-by-turn drive time from women's address to the nearest accredited Commission on Cancer or National Accreditation Program for Breast Centers. Multivariable logistic regression determined the relationship between reconstruction, Medicaid, and travel time, controlling for patient factors known to impact reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated. Most patients had early-stage breast cancer (51% stage 0/I) and 15.2% had Medicaid. 37% of women underwent reconstruction. Socioeconomically disadvantaged women with Medicaid (OR = 0.62, 95% CI 0.46-0.84) and longer travel times (OR = 0.99, 95% CI 0.99-1.0) were less likely to receive reconstruction. Patients with the lowest predicted probability of reconstruction were those with Medicaid who lived furthest from a plastic surgeon. Among socioeconomically disadvantaged women, Medicaid and travel remained associated with lower rates of reconstruction. Further work will explore opportunities to improve access to reconstruction for women with Medicaid. This is particularly challenging as it may require socioeconomically disadvantaged women to travel further to receive care.

TH3.5 Completeness of operative reports for rectal cancer surgery

Abstract Introduction and Objectives Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation, which ultimate improves quality of care. We set out to assess whether post-operative reports, made at the JPUH, include the primary components recommended by the National Accreditation Program for Rectal Cancer. The JPUH does not currently use synoptic templates to guide post operative note making. Methods and materials We retrospectively looked at the post-operative reports for 71 patients who had undergone surgery for rectal cancer from March 2018 to October 2020 at the James Paget University Hospital. These reports were evaluated to establish how many of the primary components were included. Results Of the 71 reports assessed, none included all 23 components. The areas well documented included the nature of the operation (100%), completeness of resection (93%), the type of reconstruction (85%) and anastomosis testing method (97%). The areas that were poorly documented included en bloc resection (8%), metastectomy (0%), intra-operative complications (0%) and blood transfusion (0%). Overall there was 53% completeness of documentation. Conclusion Rectal cancer post-operative note making at the JPUH does not meet the standard expected by the NAPRC. Some points were documented well and others were infrequently documented. Plans are in place to introduce accessible templates to guide note making and re-audit will be completed.

SAR user guide to the rectal MR synoptic report (primary staging).

Rectal MR is the key diagnostic exam at initial presentation for rectal cancer patients. It is the primary determinant in establishing clinical stage for the patient and greatly impacts the clinical decision-making process. Consequently, structured reporting for MR is critically important to ensure that all required information is provided to the clinical care team. The SAR initial staging reporting template has been constructed to address these important items, including locoregional extent and factors impacting the surgical approach and management of the patient. Potential outputs to each item are defined, requiring the radiologist to commit to a result. This provides essential information to the surgeon or oncologist to make specific treatment deisions for the patient. The SAR Initial Staging MR reporting template has now been officially adopted by the NAPRC (National Accreditation Program for Rectal Cancer) under the American College of Surgery. With the recent revisions to the reporting template, this user guide has been revamped to improve its practicality and support to the radiologist to complete the structured report. Each line item of the report is supplemented with clinical perspectives, images, and illustrations to help the radiologist understand the potential implications for a given finding. Common errors and pitfalls to avoid are highlighted. Ideally, rectal MR interpretation should not occur in a vacuum but in the context of a multi-disciplinary tumor board to ensure that healthcare providers use common terminology and share a solid understanding of the strengths and weaknesses of MR.

Synchronous prostate and rectal cancers across a large distributed healthcare system: Implications for national accreditation program for rectal cancer (NAPRC) guidelines.

e15591 Background: Prostate and colorectal cancers are among the most common cancers in men. The prevalence of patients (pts) diagnosed with prostate and rectal cancers at the same time (synchronous) is unknown and guidelines for co-management are not well established despite implications on their co-management. This study aggregated data using several methods across New York’s largest healthcare system, studied the prevalence of synchronous diagnoses, and identified a potential need for prostate specific antigen (PSA) assessment in NAPRC guidelines. Methods: We conducted an IRB approved review of pts using 3 different cohorts from 2010-2021: Northwell Health NAPRC tumor boards, the Oncora radiation oncology database, and the Northwell Health clinical informatics tool Population Analyzer to access electronic health records across the entire Northwell Health System. Synchronous diagnosis was defined as prostate cancer diagnosed during the workup of rectal cancer. Results: Ten pts had synchronous prostate and rectal cancers. Workup of prostate cancer was prompted by elevated PSA alone (n = 3), prostate lesion on rectal cancer staging MRI alone (n = 3), or both (n = 4). Two pts declined recommended treatment (tx). Radiation (RT) volume for pts during neoadjuvant RT included the rectum and prostate. Patients received total neoadjuvant therapy (n = 6) or neoadjuvant chemoRT (n = 4) alone. Three pts had surgery for rectal cancer after neoadjuvant tx. Eight patients received androgen deprivation therapy (n = 8); after neoadjuvant tx pts also had prostate-specific RT (n = 6) or prostate brachytherapy (n = 2). Six pts completed neoadjuvant tx; after a median follow up of 25.9 months 4 pts have no evidence of prostate or rectal cancers. One pt has residual disease with plan for surgical resection; one pt developed new metastases. Median overall survival was 114 months with one death. Among 273 newly diagnosed rectal cancer pts presented at NAPRC tumor boards, there were 122 male pts age ≥ 40 years of which 70% (n = 81) did not have PSA screen at rectal cancer diagnosis. Medical oncologists ordered PSA in 72% (n = 13) of pts not evaluated by primary care. Conclusions: We aggregated data via several methods and performed system wide evaluation of electronic health records across New York State’s largest healthcare system. PSA was not evaluated in a majority of eligible pts. These results support PSA testing in NAPRC guidelines for new rectal cancer diagnosis as it is inexpensive, non-invasive, and may prompt prostate cancer workup. Additionally, 3 pts with prostate cancer did not have prostate lesions on rectal MRI imaging, suggesting a potential role for prostate-protocoled imaging during radiological workup of rectal cancer. Future studies are needed to develop best management of synchronous prostate and rectal cancers due to a lack of consensus guidelines.

Correlation of Tumor Response Between Flexible Sigmoidoscopy and Magnetic Resonance Imaging in Patients Undergoing Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Retrospective Review.

The National Accreditation Program for Rectal Cancer recommends a pelvic MRI to assess the response to neoadjuvant therapy for advanced rectal cancers. However, there is no single restaging modality that can identify all patients with complete tumor response. At our institution, we perform both a pelvic MRI and a flexible sigmoidoscopy (FS) after neoadjuvant therapy prior to surgical resection. The objective is to elucidate the correlation of tumor response between FS and MRI in patients undergoing neoadjuvant therapy for locally advanced rectal cancer. Single institution from 2010 to 2019. Retrospective cohort study comparing local tumor response on FS to MRI utilizing final pathology as the gold standard for comparison. Patients with confirmed locally advanced rectal adenocarcinoma (stage II or III) who underwent neoadjuvant therapy prior to surgical intervention and underwent flexible endoscopy and a standardized rectal cancer protocol MRI to evaluate tumor response. A total of 48 patients were evaluated. Seven (14%) patients had a complete pathological response. MRI adequately reported 1 (14%), while FS found 4 (57.14%) out of the 7 complete responders. Nevertheless, this did not reach statistical significance (P = .06). On logistic regression analysis, flexible sigmoidoscopy had a 5.5 higher likelihood to report an accurate complete response (OR 5.5, 95% CI: 1.02-29.64; P = .047). Flexible sigmoidoscopy should be used in conjunction with MRI in the work up of patients who have received neoadjuvant therapy for advanced rectal cancer prior to surgical resection.

Specialization improves outcomes in rectal cancer surgery

Scope of specialtyColorectal surgery encompasses any procedure performed on the colon and/or rectum. This section focuses on rectal surgery, specifically regarding surgery for rectal cancer and its technical complexity and disease complexity that often requires a multidisciplinary team-based approach. The emergence of rectal cancer surgical specialists exhibits improvements in rectal cancer outcomes.Colorectal surgery fellowships are available for general surgeons who desire specialization. Roughly 70 colorectal surgery fellowship programs exist, of which 39 are accredited by the National Accreditation Program for Rectal Cancer (NAPRC). Patient care and quality outcomesThe OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Consortium (OC) and NAPRC developed guidelines for a standardized pathway for rectal cancer care and outline standards for patient care and performance indicators. These efforts focus on the recognition of disparities in rectal cancer outcomes, a system for improvement, delivery of quality care, and optimizing patient results by minimizing morbidity and mortality. Regulatory requirementsIn the United States, Board certification for surgeons performing colorectal surgery is granted by the American Board of Colon and Rectal Surgery (ABCRS). While the United States lags behind its European counterparts in development of rectal cancer quality measures, significant changes have been made to close the gap. Improvement initiatives launched by the OC implemented a myriad of quality metrics for longitudinal outcome tracking; surgical site infection, positive circumferential margin rate, rate of colostomy creation, recurrence rate, to name a few.

Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer.

We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance. With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification. A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited. During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.

Does Adherence to National Accreditation Program for Rectal Cancer (NAPRC) Process Measures Lead to Better Outcomes in the Management of Rectal Cancer? Initial Experience From the First NAPRC Accredited Center in the Country

Does Adherence to National Accreditation Program for Rectal Cancer (NAPRC) Process Measures Lead to Better Outcomes in the Management of Rectal Cancer? Initial Experience From the First NAPRC Accredited Center in the Country

Does Accreditation Symbolise Quality in Public Healthcare Delivery? An Investigation of Hospitals in Kerala

Accreditation has become an important benchmark for healthcare organisations, and accordingly, many government hospitals in Kerala got accredited with national level (National Accreditation Board for Hospitals &amp; Healthcare Providers [NABH]) and state level (Kerala Accreditation Standards for Hospitals [KASH]) accreditation programmes. This study examined the quality of public healthcare delivery in these accredited hospitals while having a comparison with the non-accredited hospitals. It also compared the impact of national and state-level accreditation programmes in Kerala public healthcare settings. This cross-sectional study conducted between July 2017 and July 2018, employing a positivist approach using stratified random sampling. In total, 621 samples were collected from inpatients of both accredited (NABH and KASH) (312) and non-accredited (309) public healthcare institutions in Kerala. Nine constructs overarching the quality of healthcare delivery and patient satisfaction construct are used in the study. The study found that patient satisfaction is identical in both accredited and non-accredited hospitals ( M = 4.28). Patient satisfaction in NABH accredited hospital ( M = 4.27 ± 0.67874) is lower than that of KASH accredited hospital ( M = 4.30 ± 1.25417). The mean score of six constructs of quality healthcare delivery of KASH accredited hospitals is higher than NABH accredited. The study revealed that accreditation brings improvement in certain dimensions of healthcare delivery but does not bring a holistic change. The study concluded that if accreditation has to symbolize quality healthcare delivery, infrastructural and interpersonnel components of healthcare delivery must be improved.

What’s the magic number? Impact of time to initiation of treatment for rectal cancer

BackgroundNational guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis. MethodsThis was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality. ResultsA total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively. ConclusionThis study found no difference in oncologic outcomes with initiation of treatment beyond 60 days.

Impact of the Introduction of Accreditation Standards on the Satisfaction of Patients in Cardiology Departments.

Background: It can be presumed that introducing accreditation standards and obtaining national accreditation by a hospital should translate into increased patient satisfaction. The aim was to analyze the impact of introducing accreditation standards on patient satisfaction in cardiology departments. Methods: 1080 patients, who were hospitalized in four cardiological wards (W1–W4) between 2009–2015, were asked to complete a 22-item questionnaire that assessed the level of their satisfaction with their medical care. 58 questionnaires were excluded because of incomplete data. The hospital was accredited in 2013. Results: In 3 of the 4 wards, a statistically higher total score (the patient was more satisfied) in the period after the accreditation (2013–2015) compared to the period before the accreditation (2009–2012) was as follows: W1 (80.37 ± 6.54 vs. 83.85 ± 5.9; p = 0.0004), W2 (79.95 ± 7.62 vs. 81.46 ± 8.2: p = 0.0376), W4: (78.84 ± 7.94 vs. 84.91 ± 5.57; p = 0.0376); in one ward, there was no statistical difference: W3 (80.11 ± 8.42 vs. 81.07 ± 8.15; p = 0.3284). A significant difference was found in the number of points for the total assessment that were collected for all of the analyzed departments throughout the entire period (2009–2015)–W1: p = 0.0032; W2: p = 0.0176; W3: p = 0.0313 and W4: p < 0.0001). The medium-term rate of the change of the total score decreased after the accreditation. Conclusion: Preparing a hospital for a national accreditation program brought significant benefits for patients in a long-term observation.

Institutions Treating Breast Cancer Patients of a Low Socioeconomic Status Achieve Multidisciplinary Quality Standards at Lower Rates.

The National Accreditation Program of Breast Centers (NAPBC) certifies institutions that provide quality breast care. Whereas low socioeconomic status (SES) has a negative impact on patient outcomes, it is unknown whether an institution's patient SES mix is associated with meeting NAPBC standards. All institutions submitting at least 100 breast cancer patients to the National Cancer Database (2006-2017) were ranked based on the patients' insurance status, income, and education. The 10% treating the largest proportion of low-SES patients were termed low-SES institutions (LSES). Patient cohorts were created based on the 2018 NAPBC standards. Uni- and multivariate comparisons of patient, tumor, and treatment factors were made to calculate adjusted odds of meeting each standard between low- and non-low-SES institutions. The analysis included 1319 institutions. Both the LSES and non-LSES reached the benchmark rate of 50% lumpectomies (61.2 vs 62.9%; p < 0.001), but the unadjusted and adjusted rates of lumpectomy were lower in LSES. The rate for sentinel lymphadenectomy was lower for LSES (49.2 vs 53.7%; p < 0.001). Similarly, the unadjusted and adjusted rates of adjuvant chemotherapy and endocrine therapy were lower at LSES. Although the unadjusted rate of adjuvant radiation was higher at LSES, adjusted odds demonstrated that patients treated at LSES were less likely to undergo adjuvant radiation when appropriate. Small but significant differences in achieving multidisciplinary standards for quality breast cancer care exist between LSES and non-LSES and may exacerbate disparities already faced by patients of low SES.

Are we adequately reviewing confusion inducing drugs in patients referred to the memory assessment service?

AimsThe aim of this quality improvement evaluation project is to establish the standard of current practice in relation to reviewing confusion inducing drugs (CIDs) at the time of referral, as it has been hypothesised that these medications contribute to short term cognitive impairment. This is essential in order to establish the validity of the diagnostic processes of dementia syndrome in the memory assessment services.BackgroundIt has long been established that anti-cholinergic medications (ACMs) have contributed to short-term cognitive impairment in patients taking them. This is compounded with the fact that these medications may be continued without review, for longer than was originally intended. The impact of polypharmacy, subsequent anti-cholinergic burden, and the overlapping presence of delirium, may call into question the validity of a diagnosis of dementia in patients who have not been correctly vetted during the course of their assessment. This quality improvement evaluation aims to assess whether patients’ medications are being reviewed before diagnosing a memory disorder. This is in accordance with guidance set out by the NG97 NICE guidelines, The Royal College of Psychiatrists Memory Service National Accreditation Programme (MSNAP), and the National Institute on Ageing and Alzheimer's Association (NIA-AA).MethodAll new referrals to the memory assessment service during July and August 2019 were systematically reviewed and data extracted from the memory referral document and entries on RIO from first point of contact. The following data were recorded: patient ID, GPCOG/6CIT score, final diagnosis, CID prescriptions and CID review.ResultThe results were collated using a data-set of 216 patients (136 females and 80 males,) of which the mean age was 79 years. It was noted that 36% of patients had not had any sort of cognitive assessment before referral, which identifies an area for improvement. However the most substantial finding was that only 10 patients (5%) had a CID prescription review documented in the RIO notes.ConclusionOur data suggest that in our memory assessment service, only a small proportion of patients are having a documented review of their CIDs prior to diagnosis of dementia. In order to improve this and thus improve compliance with guidelines from the Royal College of Psychiatrists MSNAP and the NIA-AA, measures will be taken to issue each dementia support worker and nurse with a CID prescription review card, which will list those medications to consider and flag for review.

National accreditation programmes for hospitals in the Eastern Mediterranean Region: Case studies from Egypt, Jordan, and Lebanon

Many countries use external evaluation programmes such as accreditation in order to improve quality and safety in their healthcare settings. Hospital accreditation has developed in many low-and-middle-income countries (LMICs); however, the implementation and sustainability of these programmes vary in each country. This study addresses design and implementation issues of national hospital accreditation programmes. It identifies factors which may explain why programmes can be implemented successfully in one country but not in another and derives lessons for the design and implementation of national accreditation programmes in poor-resource settings. A multiple case study design was used, comprising three countries in the Eastern Mediterranean Region: Egypt, Lebanon and Jordan. In-depth semi-structured interviews were conducted with 27 key stakeholders in the three countries and experts from international organisations concerned with accreditation activities in LMICs. The hospital accreditation programme was successful and sustainable in Jordan but experienced some difficulties in Egypt and Lebanon. The premature end of external funding and devastating political instability after the Arab Spring were problematic for the programmes in Egypt and Lebanon, but continuous funding and strong political will supported the implementation and sustainability of the programme in Jordan. LMICs striving to improve their hospitals' performance through accreditation programmes should consider their vulnerability to a scarcity of financial resources and political instability. An important factor underpinning sustainability is recognising that the accreditation programme is an ongoing and developing quality improvement process that needs continuing and careful attention from funders and political systems if it is to survive and thrive.

The perceptions of healthcare professionals about accreditation and its impact on quality of healthcare in Kuwait: a qualitative study.

The accreditation of healthcare organizations has been applied as a quality assurance mechanism of healthcare services. Kuwait health authorities implemented a national healthcare accreditation program at the governmental healthcare system. This study aimed to explore the perceptions of healthcare professionals (HCPs) about healthcare accreditation, perceived challenges to implementing accreditation, and views on how to overcome these challenges. A phenomenological qualitative framework was adopted to conduct focus group interviews to explore perceptions of HCPs about accreditation in governmental healthcare system. Data were collected from 30 HCPs using seven focus group interviews. The verbatim transcripts of the interviews were analysed using the framework approach. The HCPs indicated that accreditation enhanced patient safety culture at their organizations through staff adherence to good practices, improved documentation and patient handover practices, and incident reporting. The facilitators to the implementation of accreditation that emerged from interviews included administrative support, staff training about accreditation, and expansion in application of electronic systems. Participants reported several challenges to implementing accreditation including challenges related to staff (eg, high workload, burdens imposed by accreditation requirements), challenges related to organizational system and resources (eg, poor teamwork among HCPs, inadequate infrastructure in some facilities), and challenges related to patients (eg, poor understanding about accreditation). However, most participants expressed positive attitudes towards accreditation and appreciated its impact on quality of healthcare. Participants suggested ways to support accreditation such as increasing staff numbers to reduce workload, enhancing staff motivation and education about accreditation, developing proactive leadership and staff teamwork, and improving patients' awareness about accreditation. HCPs in Kuwait expressed positive attitudes towards accreditation while also recognizing the challenges that may hinder its implementation. The collaboration between different stakeholders in this process is essential to overcome these challenges and support HCPs to meet accreditation standards and improve quality of healthcare services.