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

72 PROCARE – phase 2 KCE reports 81As already mentioned above, a possible threat for the PROCARE database is theselective inclusion of ‘good’ patients. Coupling with the administrative database to checkthe completeness of inclusion can be a solution.The advantage of administrative data is their efficiency. Since these data are alreadycollected for other reasons (e.g. epidemiology, financing, accreditation, etc.), the extraworkload for clinicians is negligible. Above this, in contrast to the PROCARE database,the administrative database (which is population-based) includes all Belgian patients withrectal cancer.However, administrative data lack specificity and detail. Indeed, the selected QI in thisreport were often not measurable using administrative data, because of the absence ofspecific administrative codes or clinical data. Although the MCD database offers theadvantage to link procedures to diagnoses (in contrast to the HIC database), the linkageof the 3 different administrative databases did not have much impact on themeasurability of the QI.Administrative data are only available 2 to 3 years after registration. The quality of careis therefore measured with an important delay. Above this, the request for theadministrative data and the coupling of the 3 databases turned out to be a longprocedure taking several months. Furthermore, many weeks were needed to gaininsight in the information available from this large database. Of course, the experiencefrom the present study can be used for future exercises.Importantly, since these administrative data are collected for (often financing) reasonsother than quality and are therefore associated with risks of up- or under-coding, theiruse for the measurement of the quality of care is at least questionable.3.3.5 High versus low performance on quality indicatorsMost individual QI show enough variation to allow a distinction between centresoffering high vs. less quality care. This is essential and very relevant, since it offerscentres the opportunity to act on specific procedures and outcomes.However, the QI set as a whole has less potential to distinguish overall high from lowperformance. While the variation in mean corrected rank is acceptable using thePROCARE database (with a high number of measurable QI, but a low number ofcentres) (Figure 15), the variation in mean QI result is less pronounced (Figure 16). Onthe contrary, the variation in both mean corrected rank and mean QI result increasesusing the administrative database (with a low number of measurable QI, but a highnumber of centres).It is difficult to give straightforward explanations for these results. One possible reasonis that most PROCARE centres are performing on a similar overall quality level. This issupported by the analysis of the mean QI result using the administrative databases,where the PROCARE centres tend to be on the right side of the graph (Figure 19), butrefuted by the analysis of the mean corrected rank using the administrative databases,where the PROCARE centres are represented on both sides of the graph (Figure 17and Figure 18).Another possible explanation is that this QI set is simply not balanced enough to allow adistinction between overall high and less quality care. Nevertheless, it is obvious thatmore centres and more patients per centre need to get involved in order to increasethe relevance of these results. This would also allow risk-adjustment (e.g. ASA score forpostoperative mortality, tumour level for type of resection, tumour stage for (y)pCRM,etc.), which is essential for the distinction between high and low performance.No correlation was shown between the mean corrected ranks of 24 PROCARE centresusing the prospective and administrative databases respectively. This can have severalreasons. First, for some hospitals the data in the PROCARE database are notrepresentative for their entire rectal cancer population because of the selection bias(see above). Above this, a time lag exists between the 2 databases, reflecting differentstandards of care. Finally, the mean corrected ranks are not calculated using the sameQI for both databases, and therefore may reflect other aspects of quality of care.