Measuring the Quality of Breast Cancer Care in Women

Summary (continued)

Discussion

Of the 143 quality indicators identified by this review, only a small minority had received any attention as to development into formal quality measures either prior to or during the adherence studies in which they were employed. One can, as a result, have little confidence in the meaningfulness of the gaps in care suggested by the adherence rates produced by quality indicators other than patient-centered ones (i.e., QOL, satisfaction with care). Even the interpretability and generalizability of the results produced by McGlynn et al.'s rigorous effort² to establish the support for and clinical relevance of their breast cancer care quality indicators were limited.

Although based on a systematic review of the evidence and a peer consensus process, these results were limited by the small number of eligible breast cancer cases; the less than optimal level of evidence (observational evidence and expert opinion) supporting some standards, especially treatment standards; and the likelihood that their quality indicators had not been fully pilot tested as measures. It may be best to proceed with caution before allowing even minor policy decisions to be guided by any of the adherence data reviewed in this report.

The research implications of the present findings suggest the need to close the gap between existing ways of measuring the quality of breast cancer care and the ideal, scientific way required to highlight possible gaps in care. While more research is needed, employing principles by which any formal measure is derived, it may be wise to wait until the results of at least one important research project are reported before independently undertaking what ASCO may already be in the process of achieving.

At present, ASCO is developing a robust set of largely evidence-based quality measures relating to stage I-III breast cancer. Their goal is to produce a detailed profile of the reliability (e.g., inter-rater), feasibility, and validity of measures based on pilot testing using multiple data sources (e.g., patient survey, the National Cancer Database of the American College of Surgeons). The results of ASCO's project are widely anticipated, since it is possible that they will have developed the validated measures required to push forward the field of quality measurement with respect to breast cancer care. It remains to be seen whether ASCO's quality measures will cover the definitions of care (e.g., quality of delivery of care, structural factors) identified by the present review as mostly absent from the literature.

A number of limitations characterized the present systematic review. In having to narrow the review scope, UO-EPC lost the chance to go back to reference standards (e.g., clinical practice guidelines) and their evidence sources (empirical studies) to determine the clinical appropriateness of quality indicators in terms of the strength of the evidence linking these standards to improved outcomes. Eligibility criteria were predefined to include in the review only quality indicators that were evidence based. However, it was sometimes difficult to confirm either within or beyond a study report that the evidence authors noted as evidence based actually constituted empirical support. As a result, it is possible that some types of quality indicators included in the review could easily have been excluded. Finally, the "trajectory of scientific development" scheme was designed especially for this study without benefit of a validational process. The data obtained through its use are not likely to be overly reliable or valid. Nevertheless, almost none of the grades received by quality indicators suggested a history of scientific development, confirming what is likely the most unequivocal finding of this review: other than a few QOL or patient satisfaction instruments, no validated quality measures to quantify patterns of breast cancer care could be identified.

Some have asserted that the degree to which health care quality in the United States is consistent with quality standards is basically unknown and that the continuing failure to have a clear and comprehensive view of the level of quality care received by the average American will reinforce the belief that quality care is not a serious national problem.⁴⁴

In our view, the failure to have reliable and valid quality measures with which to confidently point to possible gaps in breast cancer care—and to afford accountability, improvement, and research⁴⁵—is a situation that does nothing to help resolve this important dilemma. Some promise is attached to ASCO's ongoing enterprise, although it will be some time before the results are known. Until validated quality measures are established, it will likely be impossible to derive a meaningful overview of gaps in breast cancer care that can inform the public about the quality of its health care choices.⁴⁶

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Availability of Full Report

The full evidence report from which this summary was taken was prepared for the Agency for Healthcare Research and Quality (AHRQ) by the University of Ottawa Evidence-based Practice Center under Contract No. 290-02-0021. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 105, Measuring the Quality of Breast Cancer Care in Women.

The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a PDF File (1.4 MB). PDF Help.

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AHRQ Publication Number 04-E030-1
Current as of September 2004