Variations In Patterns Of Care Research Articles

Different Patterns of Care and Survival Outcomes in Transplant-Centre Managed Patients with Early-Stage HCC: Real-World Data from an Australian Multi-Centre Cohort Study.

The management of early-stage hepatocellular carcinoma (HCC) is complex, with multiple treatment strategies available. There is a paucity of literature regarding variations in the patterns of care and outcomes between transplant and non-transplant centres. We conducted this real-world multi-centre cohort study in two liver cancer referral centres with an integrated liver transplant program and an additional eight non-transplant HCC referral centres across Australia to identify variation in patterns of care and key survival outcomes. Patients with stage Barcelona Clinic Liver Cancer (BCLC) 0/A HCC, first diagnosed between 1 January 2016 and 31 December 2020, who were managed at a participating site, were included in the study. Patients were excluded if they had a history of prior HCC or if they received upfront liver transplantation. A total of 887 patients were included in the study, with 433 patients managed at a liver cancer centre with a transplant program (LTC) and 454 patients managed at a non-transplant centre (NTC). Management at an LTC did not significantly predict allocation to resection (adjusted OR 0.75, 95% CI 0.50 to 1.11, p = 0.148). However, in those not receiving resection, LTC and NTC patients were systematically managed differently, with LTC patients five times less likely to receive upfront ablation than NTC patients (adjusted OR 0.19, 95% CI 0.13 to 0.28, p < 0.001), even after adjusting for tumour burden, as well as for age, gender, liver disease aetiology, liver disease severity, and medical comorbidities. LTCs exhibited significantly higher proportions of patients undergoing TACE for every tumour burden category, including those with a single tumour measuring 2 cm or less (p < 0.001). Using multivariable Cox proportional hazards analysis, management at a transplant centre was associated with reduced all-cause mortality (adjusted HR 0.71, 95% CI 0.51 to 0.98, p = 0.036), and competing-risk regression analysis, considering liver transplant as a competing event, demonstrated a similar reduction in risk (adjusted HR 0.70, 95% CI 0.50 to 0.99, p = 0.041), suggesting that the reduced risk of death is not fully explained by higher rates of transplantation. Our study highlights systematic differences in HCC care between large volume liver transplant centres and other sites, which has not previously been well-described. Further work is needed to better define the reasons for differences in treatment allocation and to aim to minimise unwarranted treatment variation to maximise patient outcomes across Australia.

Variations in Patterns of Care of Rectal Cancer Patients in South Australia According to Sociodemographic Characteristics:A Registry Study

Objective. To explore variations in patterns of care over three decades for a subgroup of rectal cancer patients in South Australia according to sociodemographic characteristics. Methods. This study evaluated three decades of retrospective data from the South Australian Clinical Cancer Registry. A total of 4,131 patients diagnosed with rectal cancer between 1982 and 2015 and treated in South Australian public hospitals were included. Study outcomes were age at diagnosis, area of primary residence, cancer stage, and primary treatment (surgery, chemotherapy, or radiotherapy). Results. There was a significantly lower likelihood of conventional therapy for the elderly. Adjusted odds of receiving surgery or radiotherapy decreased by 70% and those of receiving chemotherapy by 90% in the 80+ age group, compared to the 50–59 age group. No significant variation was detected according to area-level socioeconomic status or remoteness. Conclusion. Socioeconomic factors showed little impact on the receipt of therapies for rectal cancer patients in South Australia. Variation in treatment by age, irrespective of disease stage or period of diagnosis, requires further investigation.

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Synthea™ Novel coronavirus (COVID-19) model and synthetic data set

March through May 2020, a model of novel coronavirus (COVID-19) disease progression and treatment was constructed for the open-source Synthea patient simulation. The model was constructed using three peer-reviewed publications published in the early stages of the global pandemic, when less was known, along with emerging resources, data, publications, and clinical knowledge. The simulation outputs synthetic Electronic Health Records (EHR), including the daily consumption of Personal Protective Equipment (PPE) and other medical devices and supplies.For this simulation, we generated 124,150 synthetic patients, with 88,166 infections and 18,177 hospitalized patients. Patient symptoms, disease severity, and morbidity outcomes were calibrated using clinical data from the peer-reviewed publications. 4.1% of all simulated infected patients died and 20.6% were hospitalized. At peak observation, 548 dialysis machines and 209 mechanical ventilators were needed. This simulation and the resulting data have been used for the development of algorithms and prototypes designed to address the current or future pandemics, and the model can continue to be refined to incorporate emerging COVID-19 knowledge, variations in patterns of care, and improvement in clinical outcomes. The resulting model, data, and analysis are available as open-source code on GitHub and an open-access data set is available for download.

Variations in patterns of care across neonatal units and their associations with outcomes in very preterm infants: the French EPIPAGE-2 cohort study

ObjectivesTo describe patterns of care for very preterm (VP) babies across neonatal intensive care units (NICUs) and associations with outcomes.DesignProspective cohort study, EPIPAGE-2.SettingFrance, 2011.Participants53 (NICUs); 2135 VP neonates born at...

Economic variations in patterns of care and outcomes of patients receiving invasive mechanical ventilation in China: a national cross-sectional survey.

Ventilation practice may be affected by economic variations, which might result in different outcomes to mechanically ventilated patients. We aimed to investigate the important effect of economic variations in patients with mechanical ventilation (MV) in China. We carried out a national prospective multicentre cross-sectional observational study over 1 month of all patients receiving invasive MV for more than 24 hours in 20 intensive care units (ICUs), including patient characteristics, practice of MV, weaning modalities and outcomes, including probability of weaning and survival. Based on the 2012 World Bank classification of counties, patients were divided into high-income and middle-income groups according to gross domestic product per capita in their province of origin. Of the 483 patients enrolled, 291 (60.2%) were from high-income provinces and 192 (39.8%) were from middle-income provinces. Tidal volume, peak pressure, plateau and driving pressure were significantly lower, and the proportion of patients receiving protective ventilation (71.1% vs. 59.9%, P=0.014) was significantly higher in the high-income group than in the middle-income group. The probability of weaning within 28 days was significantly greater in the high-income group than in the middle-income group (P=0.046). Patients in the high-income group had significantly higher median numbers of ventilator-free days within 14 and 28 days than those in the middle-income group (P<0.05). Although the patients did not differ in terms of their demographics, survival within 28 days was significantly higher in the high-income group than in the middle-income group (P=0.025). Driving pressure, positive end-expiratory pressure and spontaneous breathing trial were independently associated with hospital mortality. Important economic differences exist in the management of MV and patient outcomes. Higher income is associated with a higher proportion of protective ventilation, lower driving pressure, shorter weaning and better survival in mechanically ventilated patients in China.

Trends on Axillary Surgery in Nondistant Metastatic Breast Cancer Patients Treated Between 2011 and 2015: A Dutch Population-based Study in the ACOSOG-Z0011 and AMAROS Era.

To evaluate patterns of care in axillary surgery for Dutch clinical T1-4N0M0 (cT1-4N0M0) breast cancer patients and to assess the effect of the American College for Surgeons Oncology Group (ACOSOG)-Z0011 and After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) trial on axillary surgery patterns in Dutch cT1-2N0M0 sentinel node positive breast cancer patients. Since publication of the ACOSOG-Z0011 and AMAROS trial, omitting a completion axillary lymph node dissection (cALND) in sentinel node positive breast cancer patients is proposed in selected patients. Data were obtained from the nationwide Nationaal Borstkanker Overleg Nederland breast cancer audit. Descriptive analyses were used to demonstrate trends in axillary surgery. Multivariable logistic regression analyses were used to identify factors associated with the omission of cALND in cT1-2N0M0 sentinel node-positive breast cancer patients. Between 2011 and 2015 in cT1-4N0M0 breast cancer patients, the use of sentinel lymph node biopsy as definitive axillary staging increased from 72% to 93%, and (c)ALND as definitive axillary staging decreased from 24% to 6% (P < 0.001). The use of cALND decreased from 75% to 17% in cT1-2N0 sentinel node-positive patients (P < 0.001). Earlier year of diagnosis, lower age, primary mastectomy, invasive lobular subtype, increasing tumor grade, and treatment in a nonteaching hospital were associated with a lower probability of omitting cALND (P < 0.001). This study shows a trend towards less extensive axillary surgery in Dutch cT1-T4N0M0 breast cancer patients; illustrated by an overall increase of sentinel lymph node biopsy and decrease in cALND. Despite this trend, particularly noticed in cT1-2N0 sentinel node-positive patients after publication of the ACOSOG-Z0011 and AMAROS trial, variations in patterns of care in axillary surgery are still present.

Inclusion of Unstructured Clinical Text Improves Early Prediction of Death or Prolonged ICU Stay.

Early prediction of undesired outcomes among newly hospitalized patients could improve patient triage and prompt conversations about patients' goals of care. We evaluated the performance of logistic regression, gradient boosting machine, random forest, and elastic net regression models, with and without unstructured clinical text data, to predict a binary composite outcome of in-hospital death or ICU length of stay greater than or equal to 7 days using data from the first 48 hours of hospitalization. Retrospective cohort study with split sampling for model training and testing. A single urban academic hospital. All hospitalized patients who required ICU care at the Beth Israel Deaconess Medical Center in Boston, MA, from 2001 to 2012. None. Among eligible 25,947 hospital admissions, we observed 5,504 (21.2%) in which patients died or had ICU length of stay greater than or equal to 7 days. The gradient boosting machine model had the highest discrimination without (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.81-0.84) and with (area under the receiver operating characteristic curve, 0.89; 95% CI, 0.88-0.90) text-derived variables. Both gradient boosting machines and random forests outperformed logistic regression without text data (p < 0.001), whereas all models outperformed logistic regression with text data (p < 0.02). The inclusion of text data increased the discrimination of all four model types (p < 0.001). Among those models using text data, the increasing presence of terms "intubated" and "poor prognosis" were positively associated with mortality and ICU length of stay, whereas the term "extubated" was inversely associated with them. Variables extracted from unstructured clinical text from the first 48 hours of hospital admission using natural language processing techniques significantly improved the abilities of logistic regression and other machine learning models to predict which patients died or had long ICU stays. Learning health systems may adapt such models using open-source approaches to capture local variation in care patterns.

Influence of age on variation in patterns of care in patients with rectal cancer in Catalonia (Spain).

Population ageing is a relevant concern in people diagnosed with rectal cancer. This study evaluates the adherence to clinical practice guidelines (CPGs) and patient outcomes in rectal cancer, with a particular focus on variation according to age. This is a multicentre retrospective cohort study of all patients surgically treated for the first time for primary rectal cancer with curative intent in public hospitals in Catalonia during two study periods: first, with data from 2005 to 2007, and then with data from 2011 to 2012. We obtained the study data through a comprehensive review of patients' clinical records. Information on diagnosis, treatment and follow-up was collected and then compared with the relevant CPGs. We then performed a descriptive analysis of the categorical variables followed by a univariate and multivariate logistic regression analysis to calculate the odds ratio. Finally, we calculated the recurrence and death rates per person-year at 2years' follow-up. In total, 3770 people were included in this study. The participants aged 70 and under were more likely to receive neoadjuvant therapy than those aged over 80 (2005/2007, 63 vs 17.4% p < 0.001; 2011/2012, 72 vs 41.1% p < 0.001); however, in the second study period there was less imbalance between the two groups in this regard, showing improved administration of neoadjuvant therapy in the elderly. The quality of surgery was suboptimal in a larger proportion of the elderly population, and the choice of surgical technique was dependent to some extent on the age of the participant. Recurrence and survival rates were significantly better in the second study period. Compared to younger patients, the most elderly were less likely to receive the recommended adjuvant treatment, laparoscopy and total mesorectal excision. However, we observed improved adherence to the recommended treatment regimen in the most elderly participants, resulting in decreased recurrence and increased survival rates in this population.

Patterns of Care Among Patients Referred to Rheumatologists in Ontario, Canada.

Our aim was to characterize referrals to rheumatologists, the early care management of patients with rheumatic diseases, and timeliness of care and treatment. We conducted a retrospective observational study involving patients with first-time rheumatology referrals between 2000 and 2013 in the primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Referrals were characterized in terms of diagnoses, patient demographics, diagnostic tests, treatment initiated by family physicians and rheumatologists, and other specialists seen prior to rheumatology consultation. Timeliness of referrals, rheumatologist consultations, and treatment were determined overall and for each diagnostic category. Among 2,430 patients referred to a rheumatologist, 69% were female, with an average age of 53 years. The principal diagnosis associated with the referral included osteoarthritis (32%), systemic inflammatory rheumatic diseases (31%), regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), and other/miscellaneous (5%). Family physicians most frequently prescribed nonsteroidal antiinflammatory drugs/cyclooxygenase 2 inhibitors (38%), and their pre-referral diagnostic testing practice varied considerably. The duration of time from symptom onset to rheumatology consultation varied by diagnoses, with the shortest being for patients with systemic rheumatic diseases; for rheumatoid arthritis (RA), the median time to consultation was 327 days. Most of the delay occurred prior to referral; 36% of RA patients initiated a disease-modifying antirheumatic drug within 6 months of symptom onset. Approximately 1 in 3 referrals to rheumatologists were for a systemic inflammatory rheumatic disease. We observed substantial delays to rheumatology consultations and variations in patterns of care that could be amenable to quality improvement interventions.

Demographics, management and survival of patients with malignant pleural mesothelioma in the National Lung Cancer Audit in England and Wales.

Malignant pleural mesothelioma (MPM) is an uncommon cancer with poor survival. We have used data collected for the UK National Lung Cancer Audit to assess current practice and to highlight regional variation in the management of mesothelioma patients, as well as to describe survival patterns in subgroups. Our data on 8740 cases seen in hospitals in England and Wales is the largest cohort of MPM in the literature and represents approximately 80% of the total incident cases. 83% are male and median age is 73 years. Performance status is recorded in 81% and of these approximately 70% are PS 0-2. Stage is poorly recorded and unreliable in this dataset. The patient pathway is similar to lung cancer with approximately one-fifth having a non-elective referral to secondary care. A histo-cytological diagnosis is made in 87% and varies across organisations. Only 67% have anti-cancer treatment, and this also varies across organisations, but there has been an annual increase in the proportion receiving chemotherapy. Overall median survival was 9.5 months, with a 1YS of 41.4% and 3YS of 12.0%, but was strongly linked to performance status and histological subtype. Median survival also varied by cancer network from 209 days to 349 days, but appeared to increase from of 9.2 months in 2008 to 10.5 months in 2012. Our data provide a large scale, detailed assessment of MPM epidemiology, treatment choices and outcomes. Incidence is increasing in line with predictions and uptake of treatments has generally mirrored publication of key MPM treatment trials, in particular increasing use of chemotherapy but low uptake of radical surgery. However, there is significant variation in care patterns and outcomes that may reflect limited expertise in area with low incidence. Initiatives to improve outcomes should include improved recording of clinical stage.

Variation in Patterns of Care in the United States for Clinical Stage I Seminoma: Results From the National Cancer Data Base (1998-2011)

Variation in Patterns of Care in the United States for Clinical Stage I Seminoma: Results From the National Cancer Data Base (1998-2011) C.J. Beard, C. Jeldres, K. Odem-Davis, K.E. Hoffman, N.E. Martin, P.L. Nguyen, C.R. Porter, C.J. Sweeney, C. Kollmannsberger, and C.R. Nichols; Brigham and Women’s Hospital, Boston, MA, Virginia Mason Medical Center, Seattle, WA, MD Anderson Cancer Center, Houston, TX, Dana-Farber Cancer Institute, Boston, MA, BC Cancer Agency, Vancouver, BC, Canada

A167: Variations in Patterns of Care Across Pediatric Rheumatic Diseases in the Childhood Arthritis &amp; Rheumatology Alliance Network Registry

Background/Purpose:In 2009, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) established a longitudinal multi‐center, multiple disease U.S. national registry (CARRA Registry) for pediatric rheumatology with the intent of providing a new framework to drive observational clinical research and best practices, evidence‐based care. Simultaneously, recognizing that widely variable therapeutic approaches hinder the ability to conduct meaningful comparative effectiveness studies and pragmatic trials in pediatric rheumatic diseases, CARRA investigators convened expert groups to formulate new consensus‐based treatment plans (CTPs) in 5 major pediatric rheumatic disease areas. As the CTP approaches are adopted, it is important to establish baseline treatment variability across pediatric rheumatic diseases and clinical sites in the CARRA network. Using longitudinal data from the CARRA Registry, we provide a first description of variability of care across the network.Methods:We examine variations of medication usage across 55 clinical sites in the treatment of 8 rheumatic conditions, including juvenile idiopathic arthritis (JIA), SLE and mixed connective tissue disease (MCTD), juvenile dermatomyositis (JDM), localized scleroderma, systemic sclerosis, juvenile primary fibromyalgia syndrome (JPFS), sarcoidosis, and vasculitis. Management of uveitis in JIA patients was also assessed. Study participants include all CARRA registry subjects enrolled in May 2010 through December 2013. Medications were categorized into 4 major classes: biologics, DMARDs, steroids and NSAIDs. We compare the percentage of patients exposed to each medication class at each; care variations were quantified using dispersion measures of standard deviation and range. A subgroup analysis was conducted to assess care variations among the largest group of subjects with similar characteristics of and low disease activity (JIA subjects with an average active joint count of 0 to 1 averaged over the enrolment period), where treatment were hypothesized to be most similar.Results:8,869 subjects were included in data analysis. Therapeutic approaches were highly variable for all 8 rheumatic diseases (Table 1, Fig 1). Subgroup analysis for JIA showed persistence of variability (Fig 2). imageConclusion:We quantify a substantial degree of therapeutic practice variability across sites, persisting across disease‐severity‐matched cohorts. Although enrollment bias is a significant limitation, the magnitude of the variability for the largest cohort (JIA) and persistence across multiple diseases and subtypes supports a widespread effect. This baseline quantification and methods developed for assessing variability will support ongoing efforts to monitor new consensus treatment protocol‐based standardization efforts across the CARRA network.

Patterns of Colorectal Cancer Care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Variations in Patterns of Care Activities for Nursing Home Residents with Heart Failure

Early clues of change in heart failure (HF) status, such as weight gain or reduced exercise tolerance, may be missed by caregivers in nursing homes (NHs) since daily weight measurement and functional assessments may not be performed routinely. These factors are likely to contribute to a delay in non-emergent care for the resident. The purpose of this study was to examine patterns of care activities provided in the NH setting to residents with HF and document variations in these care patterns across a random national sample of NHs. Care activities performed daily within a large proportion of NHs for residents with HF were assessment for changes in HF symptoms (94%), changes in mental status (91%), and changes in swelling/edema (85%). There was wide variation in care patterns. Not all evidence-based guidelines for HF care and monitoring were followed in the NH setting, which could affect hospitalizations and other outcomes.

Racial differences in the use of adjuvant chemotherapy for breast cancer in a large urban integrated health system.

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02–1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26–1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73–1.43), or timing of chemotherapy (OR 1.18, 95 CI, 0.8–1.74). Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer.

Stigma and other barriers to health and social care services among youth in Greater London

Background/Objectives : Despite the evidence supporting early intervention as a means of mitigating onset of more severe psychopathology, most children in the United Kingdom do not receive treatment for their mental illness. Delays to service use are common and often only occur once the youth has already experienced significant impairment, clinical symptoms and stigma, the effects of which can be difficult to reverse. Stigma may directly impact access to mental health care and indirectly influence mental health problems. Stigma, however, may influence access in different ways for youth with various presentations of clinical symptoms and socio-demographic characteristics and may be greater for those youth with the highest level of risk. This study describes the patterns of formal and informal care utilised by youth and identifies facilitators and barriers to receiving services and treatments among youth. Additionally, we examine the relationship between variations in patterns of care and barriers to mental health care, specifically stigma, by clinical profile, socio-demographic and community characteristics. Methods : This study used a retrospective longitudinal design, nested within an ongoing prospective study to recruit a community sample of youth from Greater London over-representing youth from deprived inner-London areas. Clinical profile was determined via psychotic like experiences (PLEs), internalising/externalising mental health problems and early developmental delays. The „Services Assessment for Children and Adolescents“ was used to ascertain type, nature, frequency and duration of services used, treatments received, setting in which the service occurred (including a range of informal and formal care), reasons for service use, and referrals via phone interview with the parent. The interview also inquired about social cohesion, social capital, parental awareness of symptoms, availability of services, and socio-demographic variables which might facilitate access to care or mediate or moderate the effects of stigma. Multivariable regression models were used to examine the independent effects of stigma and other barriers on pattern of care. Models tested for confounding, interaction and moderation effects. Results : Initial findings will be presented based on interviews with 100 parents. Specifically, we will describe findings on the prevalence of care patterns and reported barriers to care by clinical profile. Predictors of care patterns and impact of stigma will be presented. Discussion/Conclusions : This study sheds new light on the potential effects of stigma on access to mental health care and social support. This study overcomes limitations associated with previous ‘pathways to care’ studies by examining a wide range of service systems, assessing service use among a community sample in a naturalistic way (rather than recruiting from a service setting), and by incorporating a dimensional perspective rather than a categorical perspective by assessing risk of schizophrenia. Future research should continue to investigate and implement strategies which reduce stigma and other barriers which impede access to services and to work toward the development of a service system which better meets the needs of youth and their families.

Patterns of care in Dutch postmenopausal patients with hormone-sensitive early breast cancer participating in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial

Background: The Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial investigates the efficacy and safety of adjuvant exemestane alone and in sequence after tamoxifen in postmenopausal women with hormone-sensitive early breast cancer. As there was a nationwide participation in The Netherlands, we studied the variations in patterns of care in the Comprehensive Cancer Centre Regions (CCCRs) and compliance with national guidelines.Methods: Clinicopathological characteristics, carried out local treatment strategies and adjuvant chemotherapy data were collected.Results: From 2001 to January 2006, 2754 Dutch patients were randomised to the study. Mean age of patients was 65 years (standard deviation 9). Tumours were ≤2cm in 46% (within CCCRs 39%–50%), node-negative disease varied from 25% to 45%, and PgR status was determined in 75%–100% of patients. Mastectomy was carried out in 55% (45%–70%), sentinel lymph node procedure in 68% (42%–79%) and axillary lymph node dissections in 77% (67%–83%) of patients, all different between CCCRs (P<0.0001). Adjuvant chemotherapy was given in 15%–70% of eligible patients (P<0.001).Discussion: In spite of national guidelines, breast cancer treatment on specific issues widely varied between the various Dutch regions. These data provide valuable information for breast cancer organisations indicating (lack of) guideline adherence and areas for breast cancer care improvement.

Quality of care indicators for prostate cancer: Progress toward consensus

Previously-documented variations in patterns of care and patient outcomes suggest differences in the quality of care provided to men with prostate cancer. Herein we describe ongoing efforts to measure the quality of prostate cancer care, including the development and pilot-testing of the RAND prostate cancer quality indicators and the selection of the consensus-based Physician Performance Measurement Set for Prostate Cancer. We also summarize current payer-led initiatives aimed at measuring quality of care for men with prostate cancer. We conclude that currently-available prostate cancer quality indicators are derived from valid, consensus-based methodologies and capture clinical practices that are necessary for high-quality care in early-stage prostate cancer. Despite this promise, however, the currently available measures have several limitations that should be considered during their implementation in prostate cancer quality assessment and improvement activities.

The Pen and the Scalpel

As information is disseminated about best practices, variations in patterns of care should diminish over time. To test the hypotheses that differences in rates of a surgical procedure are associated with type of insurance in an era of evolving practice guidelines and that insurance and site differences diminish with time as consensus guidelines disseminate among the medical community. We use lymph node dissection among women with ductal carcinoma in situ (DCIS) as an example of a procedure with uncertain benefit. Using a sample of 1051 women diagnosed from 1985 through 2000 at 2 geographic sites, we collected detailed demographic, clinical, pathologic, and treatment information through abstraction of multiple medical records. We specified multivariate logistic models with flexible functions of time and time interactions with insurance and treatment site to test hypotheses. Lymph node dissection rates varied significantly according to site of treatment and insurance status after controlling for clinical, pathologic, treatment, and demographic characteristics. Rates of lymph node dissection decreased over time, and differences in lymph node dissection rates according to site and generosity of insurance were no longer significant by the end of the study period. We have demonstrated that rates of a discretionary surgical procedure differ according to nonclinical factors, such as treatment site and type of insurance, and that such unwarranted variation decreases over time with diminishing uncertainty and in an era of diffusion of clinical guidelines.