Assurance de qualité pour le cancer rectal – phase 2 ...

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4 PROCARE – phase 2 KCE reports 811 INTRODUCTIONIn 2004, the Belgian Section for Colorectal Surgery, a section of the Royal BelgianSociety for Surgery, decided to start PROCARE (PROject on CAncer of the REctum) asa multidisciplinary, profession-driven and decentralized project(www.belgiancancerregistry.be). All medical specialties involved in the care of rectalcancer established a multidisciplinary steering group in 2005. Delegates from therespective scientific societies as well as from the Belgian Professional Association wereincluded from the start, as it was evident that the project should not only have ascientific backbone, but should be driven by the professionals. In a questionnaire morethan 80 % of the Belgian hospitals expressed their willingness to participate in theproject.The main objective of this multidisciplinary project is to reduce diagnostic andtherapeutic variability and to improve outcome in patients with rectal cancer by meansof:• standardization through guidelines;• implementation of these guidelines (workshops, meetings, training forTME, pathology, radiotherapy and radiology);• quality assurance through registration and feedback.Multidisciplinary guidelines on the management of rectal cancer were discussed and afirst draft was written in 2005. This first version of the PROCARE guidelines was madeavailable by the respective scientific societies. In the context of a study assigned by theKCE to PROCARE (summer 2006), the guidelines were updated with recently publishedevidence (part I of the study) [1].During the years 2005 – 2008, several workshops, postgraduate courses and seminarson rectal cancer were organised in the context of the PROCARE project. Specificdocuments (e.g. an atlas on Clinical Target Volume [CTV] during radiotherapy for rectalcancer, a handbook on histopathologic examination of a TME specimen) werecomposed and discussed during discipline-specific workshops.Central registration of credible and high-quality data is a key issue in a national projectlike this. Fortunately, PROCARE found a partner at the Belgian Cancer Registry (BCR).In 2005, a multidisciplinary dataset was elaborated for registration in a rectal cancerspecific database at the BCR. Registration started in October 2005.In 2007, the RIZIV/INAMI decided to financially support the project for 5 years. Abouthalf of the budget is dedicated to registration with feedback, while the other half isreserved for (re)training in order to foster implementation of the guidelines. The latterwill be done by means of peer-review of radiological pre-treatment staging results,planned CTV and TME specimens, and by ‘TME training’ by peers or candidate TMEtrainers who fulfilled predefined criteria.In order to allow individual feedback and national/international benchmarking, it wasdecided to set up a quality indicator (QI) system. For this cause, the conceptualflowchart provided in a previous KCE report on clinical QI [2] was consulted andadapted to the specific oncologic context. In general, some important steps need to betaken when developing and instauring a QI system in oncology (Figure 1). First, amultidisciplinary group should be composed, including all relevant specialties involved inthe work-up of the tumour of interest. Specific to the Belgian situation, the College ofOncology(https://portal.health.fgov.be/portal/page?_pageid=56,512693&_dad=portal&_schema=PORTAL) – which is in charge of organizing the external evaluation in all domains ofoncology – should be represented. For the present study, all relevant specialties arerepresented in the multidisciplinary working group and the PROCARE steering group.Above this, the College of Oncology is represented in the PROCARE steering group.Next, the multidisciplinary group should decide on the scope of the QI system (Figure1).
KCE Reports 81 PROCARE – phase 2 5This not only involves the decision on which phases of the clinical work-up to include inthe quality assessment, but also the decision on the quality of care dimensions ofinterest [2].The present project aims at measuring the quality of care during the entire clinicalcourse of patients with primary rectal cancer, including diagnosis and staging, treatment(neoadjuvant treatment, surgery, adjuvant treatment, palliative treatment), pathologyand follow-up. This project focuses on the primary treatment of rectal cancer, but noton the treatment of recurrent or progressive disease. The quality of care dimensions‘effectiveness’, ‘efficiency’, ‘safety’, ‘timeliness’ and ‘continuity’ are the focus of thePROCARE QI system.Once the scope is defined, a literature search (including grey literature and clinicalpractice guidelines) should identify existing QI (Figure 1). Based on predefined criteria, aselection of QI should be made ensuring the coverage of all predefined treatmentphases and quality of care dimensions. In case the identified QI do not cover allimportant aspects, the selection should be complemented by additional QI,preferentially based on recent clinical practice guidelines. The methodology used for thepresent project is described in chapter 2.1.For the selected QI the specifications should be written (Figure 1), including a definition,in- and exclusion criteria, data sources and data collection specifications. Based on thisinformation, the selected QI should be piloted in order to detect potential problemsand to modify the QI set accordingly. Finally, the QI system should be disseminated,implemented and evaluated.An important aim of the present project is to identify QI for the management of rectalcancer and to construct a QI set for the quality assessment of rectal cancer care inBelgium (chapter 2). Furthermore, the feasibility of measuring the selected QI will betested on 2 different databases: the prospective PROCARE database and anadministrative database (chapter 3). This feasibility test will allow a fine-tuning and/oradaptation of the selected QI. Consequently, it cannot be the intention of the authorsto measure the quality already. Therefore, no judgement about quality or target valueswill be provided in this report or can be deduced from this report.To construct and pilot test the QI set, the following questions will be addressed:1. Which of the selected quality indicators can be measured using a) the prospectivePROCARE database and b) administrative databases?2. If the quality indicators are measurable, at what level are they (national, hospital,individual care provider)?3. Which data are needed at the minimum to measure and interpret these qualityindicators? Can the PROCARE database and the administrative databases complementeach other?4. How will results of the quality measurement be presented?In addition, an attempt will be made to project the results of this exercise to othercancers, in order to have a generic methodology to measure oncologic qualityindicators in Belgium.Finally, an overview will be given of international experiences with measuring the qualityof rectal cancer care (chapter 4). This will allow a judgment on how the present projectcan connect to similar international projects.
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35. Etude relative aux coûts poten
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