P5-23-06: Monitoring of Quality Indicators Should Lead to Quality Measures. A Dynamic Clinical Pathway for the Treatment of Patients with Early Breast Cancer Is a Tool for Better Cancer Care: Implementation and Prospective Analysis between 2002–2010.
Authors: van Dam PA , Verheyden G , Trinh BX , VanderMussele H , Wuyts H , Verkinderen L , Hauspy J , Vermeulen P , Dirix LY 
Published: June 2012

Aim: To describe the effects of the development, implementation and prospective systematic evaluation and adaptation of a clinical care pathway for the management of patients with early breast cancer between 2002 and 2010) in a single breast unit.

Materials and methods: In 2002 a clinical pathway was developed by the multidisciplinary breast team of the Sint Augustinus Hospital for de diagnosis and treatment of patients with operable breast cancer. Performance measurements were documented systematically by care providers using an order communication, planning and result reporting system. Annual analysis of predefined clinical outcome measures and indicators was performed. Based on these data and evidence based guidelines the pathway was regularly adapted to improve patient care. Results: The annual number of patients included in the pathway (289 vs 390, p 0.01) ), proportion of patients with Tis-T1 tumors (42% vs 58 %, p 0.01), negative lymph nodes (44% vs 58%, p &lt; 0.01)) and no metastases at diagnosis (91.5% vs 95.9%) has risen significantly between 2002 and 2010. Histological subtypes remained the same. The average length of hospital stay (7.0 days vs 4.1 days, p 0.01) nearly halved and the proportion of breast conserving surgery (BCS) (43% vs 57%), preoperative guide wire localization (14% vs 27%) for impalpable lesions and use of sentinel node biopsy (0% vs 49%) increased significantly (p 0.01). Evolution of quality indicators defined by Eusoma (www.eusomadb.org/indicators.htm) between 2002 and 2010 shows a significant improvement of cancer care: proportion of positive of preoperative histologic diagnosis (59.7% vs 88.4%, p 0.001), more then 9 lymph nodes removed when axillary clearance performed (85.6 vs 91.4%, p&lt; 0.04), BCS for invasive carcinoma up to 3 cm (62.0% vs 82.6%, p 0.016), BCS for DCIS up to 20 mm (43.8% vs 78.6%, p 0.016), hormone therapy in endocrine sensitive tumor (84.8% vs 97.4%, p 0.002), adjuvant chemotherapy in ER negative (PT1c or N+) invasive carcinoma (72% vs 95.6% p 0.028), proportion of second surgery (25% vs 10%, p 0.001) and clear margins after last operation (95% vs 99%, p 0.02). All mandatory EUSOMA requirements were fulfilled in 2010. Patient satisfaction improved significantly over the years (13/19 measured parameters p &lt;0.05 between 2002–2010). Progression free 4 year survival was significantly higher for all patients, for T1 tumors only and for T2-T4 tumors only, treated in 2006–2008 compared to 1999–2002 and 2003–2005 (respectively p 0.006, p 0.05, p 0.06). Overall 4 year survival of the entire M0 population treated in 2006–2008 was significantly better (p 0.05)

Conclusion: Although the patient characteristics changed over the years due to better screening, this clinical pathway for the treatment of patients operable breast cancer proved to be an important tool to improve the quality of patient care and patient satisfaction. Better adherence to guidelines and constant feedback of treatment data to the breast team contributes to a superior patient outcome. Measuring quality indicators proved useful to develop quality measures improving patient care.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-23-06.