National Quality Assurance Programme Research Articles

Development and Validation of a HER2-Low Focused Immunohistochemical Scoring System With High-Interobserver Concordance: The Australian HER2-Low Breast Cancer Concordance Study

The DESTINY Breast-04 trial revealed survival advantages of trastuzumab deruxtecan for women with metastatic HER2-low breast cancer (1+ or 2+ immunohistochemistry [IHC], without amplification). Although this trial applied the 2018 Americal Society of Clinial Oncology (ASCO)/College of American Pathologists (CAP) HER2 IHC scoring criteria, the subjectivity and imprecision in IHC scoring have raised concerns that patients’ treatment may be misaligned. Our group of 9 experienced breast pathologists collated a deidentified set of 60 breast cancer core biopsies from 3 laboratories, evaluated with the Ventana 4B5 HER2 assay and mostly scored locally as HER2 0 or 1+. Based on ASCO/CAP 2018 criteria and our extensive experience of reporting HER2 IHC, we specified scoring conventions for cancers with low levels of HER2 protein expression, articulating specific scoring pitfalls. Each pathologist then reviewed digitized whole slide images of the IHC slides and scored the HER2 expression for each case. At a subsequent consensus workshop, we reviewed the cases jointly to establish consensus scores for each case and determine the percentage of HER2 expressing tumor cells. Consensus was reached on all cases, with 40 classified as 1+ and 3 as 2+ (not amplified), totaling 43 (71.7%) HER2-low cancers. The remaining cases were HER2 0. In 93.3% of cases (56/60), the consensus score matched with the majority opinion of pathologists’ independent scores. Seven (41.2%) of the 17 cases reported locally as HER2 0 were classified as HER2 low. Conversely, among 32 cases with local scores of 1+, 7 (21.8%) were reclassified as ultralow or null. Individual pathologists’ accuracy in matching the consensus scores ranged from 73.3% to 91.67% (mean, 80.74%). Among HER2-low cancers those in which <20% of the tumor cells expressed HER2 had the lowest concordance levels. Observers Cohen’s κ coefficients for concordance were excellent for 4, good in 1, and moderate in the 4 observers. This reference set of cases with expert consensus HER2 scores will be invaluable for peer training and development of our national external quality assurance program for HER2-low cancers. For assessing breast cancers at the low end of HER2 protein expression, our targeted scoring criteria and explicit instruction on pitfalls improved pathologists’ accuracy and concordance.

Current Methods of Newborn Screening Follow-Up for Sickle Cell Disease Are Highly Variable and without Quality Assurance: Results from the ENHANCE Study.

Newborn screening (NBS) for sickle cell disease (SCD) has significantly improved childhood survival but there are still gaps resulting in delayed care for affected infants. As a state-run program, there are no national quality assurance programs to ensure each state achieves consistent, reliable outcomes. We performed this qualitative study of NBS follow-up practices to better evaluate and understand the multi-level, state-specific processes of how each state's public health department delivers the NBS results to families, how/if they ensure affected infants are seen quickly by sickle cell specialists, and to determine the close-out processes used in each state. This project used semi-structured interviews conducted with 29 participants across eight states to explore these NBS follow-up processes in each state. Participants included SCD providers, NBS coordinators, or personnel associated with state health departments and community-based SCD organizations (CBO). Our results show significant state-dependent variations in the NBS processes of information delivery and patient management. Specifically, programs differed in how they communicated results to affected families and which other organizations were informed of the diagnosis. There was also state-based (and intrastate) variation in who should assume responsibility for ensuring that infants receive confirmatory testing and are promptly started on penicillin prophylaxis. Case closure was also highly variable and poorly validated. Our results also yielded identifiable challenges and facilitators to NBS which were highly variable by state but potentially addressable in the future. This information suggests opportunities for systematic improvement in NBS follow-up processes.

An Overview of Blood Transfusion Services in Palestine

Blood transfusion is a vital component of the health-care system, especially considering the ongoing violent Palestinian-Israeli conflict that increases the need to maintain sufficient availability of safe blood for medical emergencies. We assessed the elements of blood transfusion services (BTS) against the guidelines of the World Health Organization guidelines to identify the achievements and gaps of the Palestinian BTS. Before the provision of the Palestinian Authority in 1994, BTS was provided by one blood bank and lacked any legislative or regulatory framework. Currently, BTS is overseen by the Palestinian Ministry of Health (MoH). There are 32 functional blood banks in the West Bank. Fourteen functional blood banks are overseen by MoH including the Central Blood Bank, which takes the role of a reference blood bank and 13 hospital-based blood banks. BTS in Palestine still lacks some of the major components required for a good national effective and safe BTS such as legislative and regulatory frameworks that are integrated within the national health system, defined standards and national guidelines on the clinical use of blood components, a national comprehensive quality assurance program for BTS, and a hemovigilance system to capture data on adverse events. In addition, there are no national blood donor programs or educational programs for staff in place.

Strengthening antimicrobial stewardship activities in secondary and primary public healthcare facilities in India: Insights from a qualitative study with stakeholders

PurposeExamining the existing federal and state policies in place that could strengthen antimicrobial stewardship (AMS) activities in district and sub-district hospitals in India. MethodsIn-depth interviews were conducted with national and state level policy makers and various stakeholders at a district hospital. For national level, officials from the National Health Systems Resource Centre (NHSRC) were approached. The state of Haryana was selected and officials from Haryana State Health Systems Resource Centre (HSHRC), a state-level counterpart of the NHSRC, along with officials from the Health Department and relevant stakeholders from one of the district hospitals of the Haryana state were selected as participants. The recorded interviews were transcribed verbatim and thematic analysis was done. ResultsSeveral measurable elements within the existing policies such as National Quality Assurance Program (NQAP) and Kayakalp program, could be leveraged to strengthen AMS activities in district and sub-district hospitals, were identified. These cover aspects such as infection control, standard treatment guidelines (STGs), prescription auditing, essential medicine list (EML), availability of antimicrobials and incentives for meeting quality standards. Revising the EML based on WHO AWaRe classification, incorporating the STGs for common clinical infections from the WHO AWaRe antibiotic book and Indian Council of Medical Research (ICMR), program mandated requirements for dedicated staff/standards for AMS activities and antimicrobial-specific prescription audits as per WHO AMS tool-kit and ICMR AMS guidelines are identified as opportunities for strengthening AMS activities. Further, hindrances in executing existing policies were also identified such as shortage of human resources, reluctance to follow STGs, and limited availability of diagnostic microbiology laboratory services. ConclusionImplementing NQAS and Kayakalp program in public healthcare facilities are identified as existing well working key programs that aid in improving AMS activities with incorporation of WHO and ICMR recommended practices.

Assessment of National External Quality Assurance Programme of Pakistan as a tool for improving quality of lab results among participating laboratories.

To assess the impact of the National External Quality Assessment Programme of Pakistan NEQAPP in improving the quality of laboratory results among the participating laboratories. The cross-sectional observational study was conducted from July to December 2020 at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, in association with the National Quality Assurance Programme of Pakistan. A survey questionnaire was developed and sent to the participating laboratories via email. Frequencies of their responses were calculated and data was analysed using SPSS 21. Of the 150 laboratories approached, 145(96.6%) responded. Among them, 140 (96.6%) laboratories were satisfied by the information provided on the programme's portal, 123(84.8%s) were pleased with the responsiveness of the programme manager, 140(96.6%) reported quality of services had improved after participation in the programme, 129(89%) indicated that the clinician's confidence had enhanced, and 122(84%) said the participation in the programme had improved the credibility of their respective of laboratories. The National External Quality Assessment Programme of Pakistan was found to have significantly contributed in improving the quality of laboratory results among the participating laboratories.

Detection of subarachnoid haemorrhage with spectrophotometry of cerebrospinal fluid- a comparison of two methods.

Spectrophotometric absorption curve analysis of cerebrospinal fluid (CSF) for oxyhaemoglobin and bilirubin is necessary to accurately diagnose subarachnoid haemorrhage (SAH) in patients with typical symptoms but with negative findings on X-ray examinations. In this study, we evaluated the performance of two methods for interpreting absorption curves; one method from the United Kingdom National External Quality Assessment Service (UK-NEQAS) and the other from the national quality assurance programme in Sweden (Equalis). Consecutive absorbance curves (n=336) were interpreted with two different methods, and their performance was compared to the diagnosis as stated in the patient records. The UK-NEQAS method displayed equal sensitivity to the Equalis method, but the specificity of the UK-NEQAS method was significantly higher than the Equalis method resulting in fewer false positive results. For UK-NEQAS, a positive predictive value (PPV) of 84.6% and a negative predictive value (NPV) of 99.7% were observed, whereas the Equalis method had a PPV of 27.5% and an NPV of 99.7%. The semi-automated method based on the guidelines from UK-NEQAS provides an efficient and correct interpretation of absorbance curves with short turn-around times. We propose using this method for the routine interpretation of CSF spectrophotometric curves.

Improvement of Standardization of Molecular Analyses in Hematology: The 10-year GBMHM French Experience.

Molecular tests have become an indispensable tool for the diagnosis and prognosis of hematological malignancies and are subject to accreditation according to the International Standard ISO 15189. National standardization of these techniques is essential to ensure that patients throughout France benefit from the same care. We report here on the experience of the GBMHM (Groupe des Biologistes Moléculaires des Hémopathies Malignes). By organizing External Evaluation of Quality (EEQ) programs and training meetings, the GBMHM has contributed to improvement and standardization of molecular tests in 64 French laboratories. A retrospective analysis of the quality-control results of 11 national campaigns spanning 10 years was performed for the 3 most frequently prescribed tests: BCR-ABL1, JAK2 V617F, and lymphoid clonality. For each test, particular attention was placed on comparing methodologies and their evolution throughout the period. The establishment of the BCR-ABL1, JAK2 V617F, and lymphoid clonality EEQ programs and the associated training meetings have initiated a process of collective standardization concerning the methods of implementation (JAK2 V617F) and the interpretation and formulation of results (lymphoid clonality). In addition, it resulted in objective improvement in technical performance (BCR-ABL1). Our evaluation of the impact of these EEQ programs demonstrates that it is possible to obtain reproducible values across different laboratories in France by applying national recommendations. To our knowledge, this is the first publication that evaluates the impact of a national quality assurance program on improving molecular results in hematology.

P0800PROFILING HYPOKALAEMIC AND HYPERKALAEMIC STATES IN THE IRISH HEALTH SYSTEM: TESTING RATES, INCIDENCE AND DETERMINANTS

Abstract Background and Aims Hypo- and hyperkalaemia are potentially life-threatening electrolyte abnormalities often associated with severe adverse clinical outcomes. Real-world incidence and determinants of hypo- and hyperkalaemia in clinical settings are poorly characterised. We studied incidence and determinants of these abnormalities in the Irish healthcare system Method Data from the Irish National Kidney Disease Surveillance and Quality Assurance Programme were used to construct a retrospective observational study. We identified all adult individuals (age &amp;gt; 18 years) who accessed health care from 2006 and 2010 in a regional health system (n = 205,334). Cumulative incidence of hypokalaemia (K+ &amp;lt; 3.5 mmol/L), hyperkalaemia (K+&amp;gt; 5 mmol/L), and moderate/severe hyperkalaemia (K+&amp;gt; 5.5 mmol/L) was estimated over a 3-year period. Kidney function was assessed by estimated glomerular filtration rate (eGFR). Multinomial logistic regression explored associations of baseline patient characteristics with dyskalaemia states. Results Of 205,334 participants, 85.2% had 1–2 potassium tests, 5.8% had 2–3 tests, 2.7% had 3-4 tests and the remaining 6.4% had &amp;gt; 4 potassium tests/year. Hypokalaemia occurred in 17,145 (8.35%) individuals, of these 43.8% had recurrent hypokalaemia (&amp;gt;1 event). Hyperkalaemia occurred in 44,283 (21.6%) individuals, with 29.7% recurrence. Moderate/severe hyperkalaemia occurred in 9,672 (4.71%) with 18.0% recurrence. The frequency of potassium testing was an important determinant of dyskalaemia risk. In adjusted analyses, advancing age profile, women, inpatients, outpatients and emergency department patients (vs general practice), and frequency of tests had significantly higher risks of hypokalaemia. Additionally, advancing age, men, poorer kidney function, and frequency of potassium testing, and general practice were associated with significantly higher risk of hyperkalaemia. Conclusion Both hypo- and hyperkalaemic states are common in the Irish healthcare system with high rates of recurrence. Surveillance strategies should be put in place to allow timely detection and treatment of potassium disturbances in these high-risk groups.

Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation

ObjectivesThis study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.DesignWe adopted the realist evaluation...

Inter-Observer Variability in Target Volume Delineations of Benign and Metastatic Brain Tumours for Stereotactic Radiosurgery: Results of a National Quality Assurance Programme

AimsTo quantify inter-observer variation between all the intracranial stereotactic radiosurgery (SRS) providers in England in delineating the target volumes of four brain tumour cases. Materials and methodsTwenty-two, cross-platform SRS providers in England were instructed during a national commissioning assessment to contour the gross tumour volume (GTV) of six brain metastases, one cavernous sinus meningioma, one vestibular schwannoma and one pituitary adenoma. An expert reference group provided feedback if submitted contours were considered to be outliers and those centres were instructed to resubmit their contours. All contours were analysed in Python. The target volume contour (observed volume; VOBS), encompassing volume, 50% agreement volume (AV50), 100% agreement volume (AV100), concordance index (CCI) and discordance index (DCI) were calculated. ResultsTwenty-one centres participated using five different treatment platforms (CyberKnife, Gamma Knife, Varian Linac, Elekta Linac, Tomotherapy) and seven different treatment planning systems (GammaPlan, iPlan, Multiplan, Pinnacle, Eclipse, CMS Focal). The greatest variability was observed in the smallest brain metastases (GTV5 AV50 0.0 cm3, CCI 0.28–0.84, DCI 0.00–0.70) and pituitary case (AV50 1.1 cm3, CCI 0.42–0.82, DCI 0.01–0.40). The greatest agreement was observed with the vestibular schwannoma (AV50 2.8 cm3, CCI 0.77–0.94, DCI 0.00–0.17). There were four resubmissions for the cavernous sinus meningioma and three resubmissions for the pituitary adenoma. ConclusionsInter-observer variability was most evident with the smallest brain metastases and pituitary case. Several additional outliers and one acceptable contour were suggested using the metric-based analysis of AV50, CCI and DCI. Comparing contours using these metrics is an effective way to identify whether individual contours are similar to the ‘true’ target and to flag potentially significant deviations.

Maternal Mortality in Malaysia

Maternal health and well-being have extended to international consideration since the global launching of WHO’s Safe Motherhood Initiative in 1987. In 1990, Malaysia set itself an ambitious vision to achieve high income and developed status by 2020. A relatively low maternal mortality rate (23.2 in 2012), noteworthy increase in the proportion of safe deliveries and antenatal coverage have been achieved. Introduction of Confidential Enquiries into Maternal Deaths (CEMD) in 1991 was an important step towards a full-fledged audit taking into consideration the identification of shortfalls in the care of pregnant mothers and taking cognizance of the remedial measures set forth, thus improving standards of care. The High-Risk Approach system, the introduction of a colour coding system for identification of pregnancies that were at greater risk than average risk, the strengthening of referral systems, and home based maternity assessment cards kept by the patient present at any level of antenatal care were used as additional tools. Swift development of rural infrastructure, increase in skilled personnel to attend deliveries, and recruitment of traditional birth attendants (TBAs) as a short-gap measure was undertaken. In addition, midwives in rural areas were allowed to administer heparin as thromboprophylaxis, antenatal steroids to mothers with preterm labour and intramuscular magnesium sulphate to mothers with hypertension. These drugs are given under guidance by the Ministry of Health protocols and given before transfer to tertiary centres. In addition, partograph use, protocol development and creation of a “red alert system” in hospitals to mobilize specialists and other healthcare personnel were deployed to reinforce existing measures. In 1985, MOH initiated a national quality assurance programme (QAP). This programme was used as a managerial tool to justify the needs for further resources in terms of money, manpower, machinery and materials. Malaysia’s significant decline in maternal mortality has been as a result of development of rural health services (introduction of maternal and child health programmes and TBAs) , adopting specific approaches (strengthening of referral system and colour coding system), assuring quality of care by tracking progress (outcome), providing standardize care, and identifying outliers that needed further improvement.

Infection prevention and control practice for Crimean-Congo hemorrhagic fever-A multi-center cross-sectional survey in Eurasia.

BackgroundCrimean Congo Hemorrhagic Fever (CCHF) is a life threatening acute viral infection that presents significant risk of nosocomial transmission to healthcare workers.AimEvaluation of CCHF infection prevention and control (IP&C) practices in healthcare facilities that routinely manage CCHF cases in Eurasia.MethodsA cross-sectional CCHF IP&C survey was designed and distributed to CCHF centers in 10 endemic Eurasian countries in 2016.ResultsTwenty-three responses were received from centers in Turkey, Pakistan, Russia, Georgia, Kosovo, Bulgaria, Oman, Iran, India and Kazakhstan. All units had dedicated isolation rooms for CCHF, with cohorting of confirmed cases in 15/23 centers and cohorting of suspect and confirmed cases in 9/23 centers. There was adequate personal protective equipment (PPE) in 22/23 facilities, with 21/23 facilities reporting routine use of PPE for CCHF patients. Adequate staffing levels to provide care reported in 14/23 locations. All centers reported having a high risk CCHFV nosocomial exposure in last five years, with 5 centers reporting more than 5 exposures. Education was provided annually in most centers (13/23), with additional training requested in PPE use (11/23), PPE donning/doffing (12/23), environmental disinfection (12/23) and waste management (14/23).ConclusionsStaff and patient safety must be improved and healthcare associated CCHF exposure and transmission eliminated. Improvements are recommended in isolation capacity in healthcare facilities, use of PPE and maintenance of adequate staffing levels. We recommend further audit of IP&C practice at individual units in endemic areas, as part of national quality assurance programs.

Challenges in the delivery of public HIV testing and counselling (HTC) in Douala, Cameroon: providers perspectives and implications on quality of HTC services

BackgroundThe Cameroon government has made HIV testing and counselling (HTC) a priority in its HIV/AIDS strategic plan. However, there is a dearth of literature on the perspectives of providers on the quality of HTC services. The aim of this study was to explore challenges in the provision of HTC services and their implications on quality of HTC services in Douala’s district hospitals.MethodsTwo primary data collection methods supported by the Donabedian’s model of healthcare were used to explain the challenges in the provision of HTC services and their implications on quality of HTC services. This consisted of semi-structured individual interviews with 6 nurses and 16 lay counsellors and a non-participant observation of the physical environment for HTC by site. The study sites were the prevention and voluntary testing and counselling centre (PVTCC) of the six district hospitals of the city of Douala.ResultsThe study reveals concerns about confidentiality and privacy during the counselling sessions due to inadequate and limited space. An absence of consent, even verbal, was reported in one PVTCC. There is no specific accredited training curriculum that leads to a formal registration as a PVTCC staff, and some lay counsellors work without training. Lay counsellors carry the burden of HIV counselling, but the majority of them work for many years without remuneration and recognition. Another quality challenge is the high workload in the district hospitals’ lab, which leads to long waiting times for HIV test results, thus contributing to failure to return for results.ConclusionThe findings of this study highlighted some issues such as lack of adequate space and equipment for HIV testing and counselling that hinder the quality of HTC services and should challenge the health authorities of Cameroon on the need to reorganize HTC services and create a national HIV quality assurance program.

Practice, science and governance in interaction: European effort for the system-wide implementation of the International Classification of Functioning, Disability and Health (ICF) in Physical and Rehabilitation Medicine.

Since its launch in 2001, relevant international, regional and national PRM bodies have aimed to implement the International Classification of Functioning, Disability and Health (ICF) in Physical and Rehabilitation Medicine (PRM), whereby contributing to the development of suitable practical tools. These tools are available for implementing the ICF in day-to-day clinical practice, standardized reporting of functioning outcomes in quality management and research, and guiding evidence-informed policy. Educational efforts have reinforced PRM physicians' and other rehabilitation professionals' ICF knowledge, and numerous implementation projects have explored how the ICF is applied in clinical practice, research and policy. Largely lacking though is the system-wide implementation of ICF in day-to-day practice across all rehabilitation services of national health systems. In Europe, system-wide implementation of ICF requires the interaction between practice, science and governance. Considering its mandate, the UEMS PRM Section and Board have decided to lead a European effort towards system-wide ICF implementation in PRM, rehabilitation and health care at large, in interaction with governments, non-governmental actors and the private sector, and aligned with ISPRM's collaboration plan with WHO. In this paper we present the current PRM internal and external policy agenda towards system-wide ICF implementation and the corresponding implementation action plan, while highlighting priority action steps - promotion of ICF-based standardized reporting in national quality management and assurance programs, development of unambiguous rehabilitation service descriptions using the International Classification System for Service Organization in Health-related Rehabilitation, development of Clinical Assessment Schedules, qualitative linkage and quantitative mapping of data to the ICF, and the cultural adaptation of the ICF Clinical Data Collection Tool in European languages.

A national quality assurance programme for point-of-care testing in Malawi.

No abstract available.

Implementing Laboratory Quality Management Systems in Mozambique: The Becton Dickinson-US President's Emergency Plan for AIDS Relief Public-Private Partnership Initiative.

Mozambique's ministry of health (MOH) recognized the need to establish a national laboratory quality assurance (NLQA) program to improve the reliability and accuracy of laboratory testing. The Becton Dickinson-US President's Emergency Plan for AIDS Relief Public-Private Partnership (PPP) was used to garner MOH commitment and train a cadre of local auditors and managers to support sustainability and country ownership of a NLQA program. From January 2011 to April 2012, the World Health Organization Regional Office for Africa Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist and the Strengthening Laboratory Management Towards Accreditation (SLMTA) curriculum were used in 6 MOH laboratories. PPP volunteers provided training and mentorship to build the capacity of local auditors and program managers to promote institutionalization and sustainability of the program within the MOH. SLIPTA was launched in 6 MOH laboratories, and final audits demonstrated improvements across the 13 quality system essentials, compared with baseline. Training and mentorship of MOH staff by PPP volunteers resulted in 18 qualified auditors and 28 managers/quality officers capacitated to manage the improvement process in their laboratories. SLIPTA helps laboratories improve the quality and reliability of their service even in the absence of full accreditation. Local capacity building ensures sustainability by creating country buy-in, reducing costs of audits, and institutionalizing program management.

Task-Shifting and Quality of HIV Testing Services: Experiences from a National Reference Hospital in Zambia.

BackgroundWith new testing technologies, task-shifting and rapid scale-up of HIV testing services in high HIV prevalence countries, assuring quality of HIV testing is paramount. This study aimed to explore various cadres of providers’ experiences in providing HIV testing services and their understanding of elements that impact on quality of service in Zambia.MethodsSixteen in-depth interviews and two focus group discussions were conducted with HIV testing service providers including lay counselors, nurses and laboratory personnel at purposively selected HIV testing sites at a national reference hospital in Lusaka. Qualitative content analysis was adopted for data analysis.ResultsLay counselors and nurses reported confidentiality and privacy to be greatly compromised due to limited space in both in- and out-patient settings. Difficulties in upholding consent were reported in provider-initiated testing in in-patient settings. The providers identified non-adherence to testing procedures, high workload and inadequate training and supervision as key elements impacting on quality of testing. Difficulties related to testing varied by sub-groups of providers: lay counselors, in finger pricking and obtaining adequate volumes of specimen; non-laboratory providers in general, in interpreting invalid, false-negative and false-positive results. The providers had been participating in a recently established national HIV quality assurance program, i.e. proficiency testing, but rarely received site supervisory visits.ConclusionTask-shifting coupled with policy shifts in service provision has seriously challenged HIV testing quality, protection of confidentiality and the process of informed consent. Ways to better protect confidentiality and informed consent need careful attention. Training, supervision and quality assurance need strengthening tailored to the needs of the different cadres of providers.

Reduced Circumferential Resection Margin Involvement in Rectal Cancer Surgery: Results of the Dutch Surgical Colorectal Audit.

The circumferential resection margin (CRM) is a significant prognostic factor for local recurrence, distant metastasis, and survival after rectal cancer surgery. Therefore, availability of this parameter is essential. Although the Dutch total mesorectal excision trial raised awareness about CRM in the late 1990s, quality assurance on pathologic reporting was not available until the Dutch Surgical Colorectal Audit (DSCA) started in 2009. The present study describes the rates of CRM reporting and involvement since the start of the DSCA and analyzes whether improvement of these parameters can be attributed to the audit. Data from the DSCA (2009-2013) were analyzed. Reporting of CRM and CRM involvement was plotted for successive years, and variations of these parameters were analyzed in a funnelplot. Predictors of CRM involvement were determined in univariable analysis and the independent influence of year of registration on CRM involvement was analyzed in multivariable analysis. A total of 12,669 patients were included for analysis. The mean percentage of patients with a reported CRM increased from 52.7% to 94.2% (2009-2013) and interhospital variation decreased. The percentage of patients with CRM involvement decreased from 14.2% to 5.6%. In multivariable analysis, the year of DSCA registration remained a significant predictor of CRM involvement. After the introduction of the DSCA, a dramatic improvement in CRM reporting and a major decrease of CRM involvement after rectal cancer surgery have occurred. This study suggests that a national quality assurance program has been the driving force behind these achievements.

Forceps versus snare polypectomies in colorectal cancer screening: are we adhering to the guidelines?

European guidelines for quality assurance in colorectal cancer screening recommend snare resection for polyps > 5 mm. The aim of this study was to investigate polypectomy technique according to lesion size and shape, and to assess adherence of endoscopists enrolled in the national quality assurance program to the European guidelines. This cohort study included screening colonoscopies performed between 2007 and 2013 within a quality assurance program in Austria. Resection technique was analyzed according to lesion characteristics and endoscopy facility (private practices, hospitals, outpatient clinics) before publication of the EU guidelines (2007 - 2010) and adherence to the guidelines after publication (2011 - 2013). All surveillance colonoscopies and examinations with missing data were excluded. A total of 128 969 screening colonoscopies performed by 278 endoscopy units were included. The polyp detection rate was 39.6 % (n = 47 797) and 95.6 % of polyps were resected. Of polyps ≥ 5 mm, 46.0 % were resected using forceps and were therefore not treated in accordance with the guidelines. Forceps polypectomy of lesions 5 - 10 mm and > 10 mm decreased significantly in hospitals after implementation of the guidelines (both P < 0.0001). In private practices, there was no difference in forceps usage for polyps of 5 - 10 mm (P = 0.41) before and after the guidelines, and for polyps > 10 mm forceps usage even increased (P < 0.0001). Endoscopists' forceps removal rates for polyps ≥ 5 mm correlated significantly with respective adenoma detection rates (P = 0.0007, r p - 0.187) and cecal intubation rates (P = 0.0001, r p - 0.303). Among endoscopists in private practices, internists had slightly lower forceps removal rates for polyps ≥ 5 mm than surgeons, both before (47.2 % vs. 50.7 %; P = 0.014) and after publication of the guidelines (51.9 % vs. 53.5 %; P = 0.161). This study confirmed the importance of the European guidelines. The inclusion of adequate resection technique as a quality indicator in colorectal cancer screening programs is recommended.

Measuring Institutional Quality in Argentina: The Devil Is in the Details

More than a decade after launching a national quality assurance program, Argentina may be pursuing a worthy cause on the wrong path. The country has adopted schemes in use elsewhere without accommodating conditions that make higher education in Argentina very different. Measuring itself by the evaluation criteria applied elsewhere, Argentine universities are diverting attention and resources from improving their primary activity—teaching.