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efining Quality of Care forreast Cancer: Clinical Challenges

rina Yermilov, MD, MS,*,† and Melinda A. Maggard, MD, MSHS†,‡

Breast cancer is the second most common oncologic diagnosis in women; however, thesepatients only receive 86% of the basic recommended care. Understanding how high-qualitybreast cancer care is defined and measured is the first step toward improving the care weprovide. In addition, regulatory agencies and some payers are requiring that certainmeasures of quality are reported and publicized. The Centers for Medicare and MedicaidServices offers higher payments to hospitals and providers with better quality care, ie,pay-for-performance. As the demands on physicians to measure quality grow, it is imper-ative that we are well informed on the topic and participate in the current debates and futurepolicy implications. In this article, we describe the methods used to measure the quality ofcare, as well as the challenges to measuring and providing high-quality breast cancer care.Semin Breast Dis 10:121-127 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS breast cancer, quality of care, structure, process, outcomes, administrative data

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here are 180,500 newly diagnosed cases of breast cancereach year, making it the most common cancer diagnosis

n women, with the exclusion of skin cancer. The death raterom breast cancer is 25 per 100,000.1 The majority of inter-entions for this disease, from screening to local and systemicontrol, are well-established. However, even for this preva-ent and well-studied cancer, many disparities in receipt ofherapy are found. To improve care and correct these treat-ent disparities, we must first measure the quality of care.nd whereas this task sounds simple on the surface, mosthysicians who care for these patients are unable to produceata on the treatments they provide, and thus are unaware ofhe level of quality they provide. For example, how manyhysicians who treat breast cancer can report the number ofheir patients prescribed Tamoxifen that either stopped tak-ng it within 5 years or never began taking it at all? As muchocus has been placed on quality of health care, the medicalommunity must learn to accurately report the quality ofare. This paper describes the measurement of the quality ofare for breast cancer and its challenges in four parts: (1)

Department of Surgery, Greater West Los Angeles Veterans Affairs MedicalCenter, Los Angeles, CA.

Department of Surgery, David Geffen School of Medicine at University ofCalifornia, Los Angeles, CA.

Department of Surgery, UCLA-Olive View Medical Center, Sylmar, CA.ddress reprint requests to Irina Yermilov, MD, MS, Department of General

Surgery, David Geffen School of Medicine at UCLA, 16-155 CHS, 10833

pLe Conte Avenue, Los Angeles, CA 90095. E-mail: iyermilov@gmail.com

092-4450/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1053/j.sembd.2007.10.011

hat is quality of care, (2) Current status of the quality ofare for these patients, (3) How to measure quality care, and4) Challenges of both measuring and providing high-qualityreast cancer care.

hat Is Quality of Carend How Is It Measured?ost physicians would state that they provide high “quality

f care” for their patients. Although we can recognize it inther physicians, it can be a challenge to articulate whatonstitutes good quality of care. A formal definition stateshat high quality care is “timely access to efficacious and safereatments.”2 In other words, this can be thought of as givinghe “right treatment for the right patient at the right time.”3

Physicians have been attempting to measure the quality ofhe care for nearly a hundred years; as early as 1911, Ernestodman, a surgeon, was tracking outcomes of patient treat-ents in an effort to identify errors and the reasons why they

ccurred. As he walked through the hospital, he would writeomplications on small note cards. Dr. Codman was so dis-atisfied with the lack of outcomes evaluation by surgeonshat he resigned his staff position at Massachusetts Generalospital and started his own hospital that he named the “Endesults Hospital.” Unfortunately, he proved to be a surgeonell ahead of his time and was ostracized by the medical

ommunity for his work linking errors to outcomes to im-

rove the quality of care.4 What is most striking now is that

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e have not progressed much beyond Codman’s efforts inerms of collecting our outcomes, outside of results withinlinical trials and research studies. In fact, very few surgeonsan report their personal rates for important complications,uch as wound infection, readmission, or lymphedema.

tructure, Process, and Outcomespproximately 50 years after Dr. Codman began tracking hisutcomes, a lasting framework for quality measurement wasreated by Avedis Donabedian. His structure, process, andutcomes model focused on creating a system of quality as-essment and monitoring (Fig. 1).5 “Structure” refers to theesources or backbone of our medical care system. Examplesnclude the number of beds in the hospital, the Registeredurse (RN) to Licensed Vocational Nurse (LVN) ratio, or theresence of a CT scanner on-site. “Processes” of care are whatoctors and nurses do to provide treatment in their one-on-ne relationships with patients.6 For example, a “process” ofare would be ordering mammography or providing antibi-tics an hour before surgery. Lastly, “outcomes” refers to thend result of the care provided (ie, 5-year mortality, disease-ree interval, recurrence rate, wound infection, etc.). Thesehree measures are linked in that “structure” and “process”an both directly impact the “outcomes” for our patientsFig. 1). In other words, if mammography is available on-site“structure”), patients might be more likely to receive theirtudy in a timely fashion (“process”). By increasing screeningammography rates (“process”), early detection and, there-

ore, survival (“outcome”) improves.7,8

It is common to track quality of care through outcomes;owever, it is important to choose the most critical or rele-ant outcomes for a particular disease. For example, although-year mortality is a gold standard outcome in the field ofncology, the value of using it is narrow in patients witharly-stage breast cancer who undergo breast-conserving sur-ery and have exceedingly low mortality rates.9 Therefore, toeasure quality and identify variations in care, it would beore appropriate to evaluate disease-free interval, recurrence

Figure 1 Improved adherence to both structure

ate, or quality of life as appropriate outcome measures.

Since improved outcomes are what we are interested in wheneasuring the quality of care, why measure structure or pro-

esses of care? When looking only at outcomes, we cannot iden-ify the reasons for the variation in care between providers. In-tead, identifying a specific process of care that is linked to betterutcomes will suggest possible reasons for the poor outcomesnd areas to target improvement efforts. Examples of both pro-ess and outcome measures are provided in Table 1. The use ofrocess measures has increased in recent years.Improvement of structure or process measures should, in

eneral, be associated with better outcomes. Process mea-ures tend to be relatively easier to implement and change asompared with altering structural components of care.hanging the nurse-to-patient ratio, a structural measure, is aaunting task compared with increasing compliance to a pro-ess measure, such as postoperative Tamoxifen therapy inreast cancer patients. Ideally, with improved compliance toprocess measure, better outcomes should be apparent.10,11

A widely accepted group of process measures is the Surgi-al Care Improvement Program (SCIP), created in April 2003ith the goal of reducing surgical complications and mortal-

ty. An example of one of these process measures is: prophy-

ocess measures can positively affect outcome.

able 1 Examples of Process and Outcome Measures

Process Measures Outcome Measures

f a palpable breast mass hasbeen detected, at least oneof the following proceduresshould be completed within3 months: fine-needleaspiration, mammography,ultrasound, biopsy, and/or afollow-up visit.

5-year survivalfollowing breastcancer diagnosis.

adiation therapy isadministered within 1 yearof diagnosis for womenunder age 70 receivingbreast-conserving surgery

Average disease-freesurvival followingbreast cancertreatment.

for breast cancer.

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Defining quality of care for breast cancer 123

actic antibiotic within 1 hour before surgical incision.12 Theenters for Medicare and Medicaid Services (CMS) estimates

hat 13,000 lives potentially can be saved in the Medicareopulation alone with strict adherence to the SCIP processeasures. This improved mortality demonstrates a link be-

ween process and outcome. There is currently required re-orting of selected measures to Medicare in order for hospi-als to be eligible for full reimbursement.13

ractice Guidelinesiffer from Quality Measures

here are many practice guidelines available to physicians toecommend and guide how care is provided. However, it ismportant to understand how practice guidelines differ fromuality measures. Practice guidelines are less specific in howhey are written and structured; they are statements that as-ist the practitioner regarding health care decisions, but theyre not so detailed as to allow for reliable quality measure-ent.14 Guidelines may be developed by government agen-

ies at any level, institutions, professional societies, govern-ng boards, or by the convening of expert panels, and theyorm a basis for the evaluation of all aspects of health care andelivery.15

An example of a guideline for breast cancer treatment is:xillary surgery should be performed in all patients with in-asive breast cancer.16 In comparison, an example of a Na-ional Initiative for Cancer Care Quality (NICCQ) qualityeasure is: if a patient with a new diagnosis of stage I to III

reast cancer and the patient is �70 years, tumor size is �1m, there is no evidence of metastatic disease within 3onths of diagnosis, and there is no documentation in theedical record that axillary lymph node sampling would not

hange treatment, then the patient should undergo that pro-edure.17 By comparing the guideline to the quality measure,t is clear that the guideline is more general, leaves room fornterpretation, and tends to lack specificity needed to mea-ure quality. The quality measure describes how care shoulde administered and which patients are exceptions to theeasure. In other words, quality measures define the most

asic aspects of care, identifying the population for whichhis care is recommended, which allows for quality and per-ormance measurement based on these measures (Table 2).

able 2 Comparison of Guidelines and Quality/Performance

Guidelines

efinition Less specific; not enough detail to allow for reliquality measurement.

xample Sentinel lymph node biopsy is the preferred meof axillary lymph node staging (NCCN*).

National Comprehensive Cancer Network. http://www.nccn.org/prNational Quality Forum. http://www.facs.org/cancer/qualitymeasu

oth practice guidelines and quality measures have their i

lace in the treatment of breast cancer; however, it is impor-ant to differentiate that, whereas a guideline recommendsreatment, a quality measure explicitly states the appropriateourse of care.

urrent Quality ofare: All Patients Do Noteceive Recommended Care

he nationwide movement to improve quality of care haseen supported by studies demonstrating inconsistent qual-

ty of care in both breast cancer care and overall health care.study by McGlynn and coworkers demonstrated that pa-

ients across the nation received only 55% of recommendedare for a diverse group of conditions. This study examinedatient medical records to assess the actual care provided by

ooking at 439 quality indicators (also known as processeasures), representing recommended care.18 Breast canceras one of the medical conditions they assessed. These pa-

ients were found to receive about 75% of recommendedare.18 Although the quality of breast cancer care exceededhat of overall health care, a 25% discrepancy remained be-ween actual care received and what was recommended. Ashis is the most basic of care, like receiving annual mammog-aphy or appropriately prescribing Tamoxifen, the fact thatne-quarter of patients did not receive this treatment is un-cceptable.

There are many breast cancer quality measures currentlyvailable; however, most are not formally developed and val-dated.2 The RAND Appropriateness method is an example offormal approach for developing quality indicators, which

ombines the evidence in the literature with expert opinion.he NICCQ studied the quality of both breast and colonancer care in 5 regions across the United States with thentention of creating validated quality indicators for theseiseases. Using a total of 36 indicators developed for thetudy, the NICCQ found that patients with breast cancereceived 86% of recommended care for individual measures,nd adherence to quality measures was less than 85% for halff the quality measures. These findings demonstrate room formprovement in breast cancer treatment.17 Examples of these

res

Quality/Performance Measures

Created with the purpose of quality measurement, explicitdescription of relevant patient population.

Combination chemotherapy is considered or administeredwithin 4 months of diagnosis for women under 70 withhormone receptor-negative breast cancer that is eitherlarger than 1 cm with no nodal or distant organmetastasis, or has spread to involve regional lymphnodes but has not metastasized to organs outside thebreast (NQF).†

nals/physician_gls/PDF/breast.Pdf.l.

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ndicators can be seen in Table 3.

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In addition to breast cancer patients as a whole not receiv-ng recommended care, there is marked variability in breastancer treatment among specific patient groups. For exam-le, studies have shown disparities between racial and ethnicroups in breast cancer treatment and mortality.19 Minorityomen with early-stage breast cancer have twice the risk ofhite women of not receiving appropriate adjuvant therapy,espite similar rates of oncology referral.20 This differenceay be attributable to financial barriers to care, but Issell and

oworkers demonstrated no significant differences in breastancer care between racial or ethnic groups in Hawaii, wherehere is nearly universal health insurance. Interestingly, inhis study, 25% of women with breast cancer did not receivereatment according to guidelines, illustrating that access toare does not guarantee high-quality care.21 Older patientsave also been found to suffer from treatment disparities inhat they receive less postsurgical radiation and adjuvantherapy.22,23 Only 75% of elderly breast cancer patients areeferred to a medical oncologist. Since referral to a medicalncologist is associated with receipt of Tamoxifen therapy,hose patients without referral may not have received neces-ary care, including Tamoxifen therapy.24 It is clear that theres a need for improvement in the quality of breast cancer care.he first step in this process is to accurately measure theuality of our care and identify areas for improvement.

ow to Measure theuality of Breast Cancer Care

he accurate measurement of quality is particularly complexor breast cancer due to the multidisciplinary nature of thereatment, variety of treatment options, and patient prefer-nces, to name a few. First, we must select the source fromhich to collect data on the care provided, which, in general,

ncludes two categories: primary data collection (chart ab-traction and self-report) or secondary databases (cancer reg-

able 3 Examples of NICCQ Indicators

F a patient has a sentinel lymph node biopsy that ispositive, THEN the patient should undergo axillary lymphnode dissection.

F a patient with stage I to III breast cancer undergoesmastectomy, THEN before undergoing mastectomy, thepatient should be informed about the option of breastreconstruction after mastectomy.

F a patient has stage I to III breast cancer and had abreast tumor removed, THEN the pathology reportshould state the status of the margins.

F a patient with stage I to III breast cancer initiatestreatment with tamoxifen and there is no evidence ofdisease progression, THEN the patient should receive 5years of tamoxifen 20 mg/day.

F a patient has been diagnosed with stage I to III breastcancer and has not had bilateral mastectomies, THENthe patient should have a mammogram in the last 12months.

stry or administrative claims data). There has been signifi- r

ant research comparing the different methods to collect dataor measuring the quality of breast cancer care, and each hasts strengths and weaknesses.

Collecting data directly from the chart, ie, chart abstrac-ion, is a commonly used method, which requires that a staffember, nurse, or chart abstractor reviews the medical

ecord to determine whether or not the quality measure waset and to collect and report the data. Data collected directly

rom the chart can provide a high degree of detail, such as theiming to receipt of chemotherapy from diagnosis or surgery.owever, considerable time and cost are incurred with this

pproach, as someone with a significant amount of medicalraining must evaluate the records by hand. In addition, tonsure accuracy of the data collection, random audits typi-ally are necessary. As more hospitals and physicians areoving away from paper records and using electronic med-

cal records, future data collection from medical records wille likely be simplified.Self-reported data are those which the patient provides. A

tudy by Thompson demonstrated no difference betweenelf-reported and administrative data when examining theate of mammography.25 On comparing self-reported dataith that of medical records, self-reported data were found toe accurate for information regarding initial treatment andecurrence, but less so for stage of disease at diagnosis.26

atients may answer certain questions inaccurately due toack of knowledge; for example, in the study above, the pa-ients that incorrectly listed their stage at diagnosis becausehey often did not differentiate between local and metastaticpread of the disease. Additionally, patient bias should al-ays be considered with the use of self-reported data. Lastly,

here is the question of how to capture patients when usingelf-reported data (ie, consecutive clinic patients, telephoneontact following search of hospital records, etc.). As withhart abstraction, the self-reported data also have bothtrengths and weaknesses that differ from those of secondaryata sources like cancer registries.Cancer registries contain considerable detail on the spe-

ific tumor characteristics, procedures, and treatments; how-ver, they are not without shortcomings. When cancer regis-ry data were compared with the medical record, the dataere significantly more accurate for hospital-based services

ie, type of surgical procedure), than for care provided in thembulatory setting (ie, radiation).27 Data from outpatient vis-ts are often not recorded into cancer registries. This lack ofutpatient information may stem from the large number ofources that a tumor registrar must abstract (ie, radiationncologist, medical oncologist, etc.). Considering that ob-aining these data sometimes involves sending form letters tohysicians, it is not surprising that documentation is poor.herefore, although it is feasible to use cancer registries forssessment of quality of some inpatient care processes, itypically is not comprehensive enough, especially for outpa-ient measures.28

The National Cancer Data Base (NCDB), a joint project byhe American College of Surgeons and the American Cancerociety, is the largest cancer registry in the United States,

eporting on approximately 75% of incident cancer cases

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Defining quality of care for breast cancer 125

ationwide.29 Despite the large number of cases included inhis database, it relies on voluntary reporting, and, therefore,s not population-based. Additionally, as is an issue for manyancer registries, there is a significant time delay from diag-osis to availability of data for analysis, often 16 to 18onths. This delay is a limiting factor for the use of cancer

egistry data for quality improvement projects, which requireimely feedback.30,31

Cancer registries, claims data, and administrative data-ases tend to lack detailed data that are necessary to measurehe quality of care. Researchers are often left without impor-ant data, such as the sidedness of the tumor (right versuseft), tumor receptor status, breast size, and the mix of inva-ive versus ductal carcinoma in situ (DCIS). Additionally,ith both the rising cost of health care as well as technolog-

cal advances, many procedures that once required an inpa-ient stay can now be performed in an outpatient setting,here they often are not recorded in an administrative data-ase. Tracking outpatient receipt of treatment, such as che-otherapy or radiation, is often not available or not accurate

n many of the cancer registries. For example, SEER, one ofhe more frequently used databases for investigating popula-ion-based outcomes for cancer that collects data on 14% ofhe cancers diagnosed in the United States, currently lacksata on receipt of chemotherapy, which is critical to assessingutcomes for breast cancer.Given the limitations of each data source, which method

ill be the best and most feasible for nationwide measure-ent of quality of care? A recent study evaluated mammog-

aphy rates in the elderly using both local and Medicareecords and showed that neither record was complete, sug-esting that accurate assessment of quality may require pool-ng of data.32 Ideally, a large network of centralized electronic

edical records which includes key processes of care woulde a good method for measuring quality. The future of qualityeasurement will likely involve assessing outcome as well asrocess measures through centralized electronic medicalecords and/or by integrating cancer registry data with ad-inistrative data.

hallenges to Providingigh-Quality Breast Cancer Care

s there are obstacles in measuring the quality of care, in-luding the lack of a combined inpatient and outpatient da-abase and the resources required to collect the data, there arelso challenges to providing high-quality breast cancer care.igh-quality breast cancer care requires a multidisciplinary

pproach, involving surgery, oncology, radiation oncology,athology, and radiology. With the participation of so manyroviders, communication is paramount; for example, it isot uncommon for a chemotherapy note to only be availableo the oncology clinic, or for radiation therapy to be admin-stered off-site. It is easy to see how coordination of care isssential in ensuring that the patient receives all recommendedare without repetition of procedures or examinations. Addi-

ionally, guidelines, despite being evidence-based, are slow p

o be adopted in clinical practice. Lastly, there should be aystem in place to deal with situations in which the patientakes an informed decision to pursue treatment against

uidelines.The knowledge attained through systematic breast cancer

esearch does not automatically transfer to the efficaciouselivery of treatment to patients; national guidelines con-inue to slowly translate to clinical practice. When the med-cal records of women with breast cancer were comparedith National Comprehensive Cancer Network (NCCN)uidelines and evidence from meta-analysis from 1995 to999, fewer than half of the women received the recom-ended treatment (Bloom). More recent studies, like theICCQ study, have demonstrated improved guideline com-liance rates.17,33 Poor dissemination of guidelines is seen asne reason for the slow adoption of guidelines to clinicalractice.34-36

To improve compliance, we should investigate the reasonshy guidelines are not being followed. Explanations for non-

ompliance, other than slow dissemination, include patientefusal, system failure, or physician belief that treatmenthould not occur, for example, due to comorbidities or goodrognosis based on histology.37 When a physician has a

engthy conversation with the patient recommending a ther-py that the patient refuses, the physician should not beenalized for guideline noncompliance. Additionally, if ahysician purposefully chooses not to follow a guideline,here should be a way in which to document the reason in theata collection tool for quality measurement. Through aore complete understanding of the causes for guidelineoncompliance, we can modify the quality measurement sys-em and more effectively measure quality.

ay-for-Performanceeveloped indicators are beginning to be used as measures

or pay-for-performance mechanisms. A growing number ofealth plans are implementing pay-for-performance mecha-isms not only to encourage high-quality care, but also torovide transparency by publishing results for health con-umers. A study by Rosenthal and coworkers compared twohysician groups, one using pay-for-performance and thether serving as a control group. Mammography screeningncreased by 1.9% in the pay-for-performance group, but thishange was not significant. Overall, the intervention groupnly showed improved performance on one of the three mea-ures, and physician groups with performance above or at thehreshold for receipt of bonus improved the least, but re-eived the greatest share of the payments.38 In a recent reviewf the first year of the pay-for-performance program in familyractices in the United Kingdom, there were high levels ofchievement; however, a few practices attained high scoresy excluding large numbers of patients.39

The increasing popularity of pay-for-performance mea-ures and increasing costs in the Medicare system haverompted CMS to oversee a large pilot pay-for-performance

nitiative in selected physician groups nationwide, where

erformance on certain measures, including breast cancer

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creening, is being tracked and rewarded.40 With this wide-pread adoption of pay-for-performance measures by largeayers such as CMS, they appear to be “here to stay.” Givenhe potential impact of these measures on clinical practice,hysicians must participate in their development and imple-entation.

here We Are Today in Measuringhe Quality of Breast Cancer Carese Both Process and Outcome Quality Measureslthough there is a strong focus on the use of process mea-ures to evaluate the quality of care, it is essential to use aombination of process and outcome measures to completelynd accurately determine the quality of breast cancer care.sing an example of mammography screening, if all physi-ians order mammography on their patients, they will beeen as having equivalent quality of care for that processeasure. Alternatively, if the outcome measure of survivalere used instead, a physician with a practice consisting ofatients of a higher stage would have worse survival and,herefore, worse outcomes. Screening mammography haseen linked to improved survival, which demonstrates that it

s important not only to use process measures, but also tonsure that they are strongly linked to desired outcomes.

now the Limits of Your Data Sourcet this time, to accurately evaluate quality of care, a combi-ation of data sources may be needed. A possible solution tohis issue may be a population-based national cancer registry,ontaining all aspects of patient care. For example, combin-ng a cancer registry, to obtain detailed tumor characteristics,ith the local medical record, to capture outpatient events

nd processes of care. Additionally, use of a centralized, elec-ronic medical record system may provide certain types ofata characteristically missing from usual data sources. It is

mportant to be aware of the contents of the selected dataource to obtain a comprehensive picture of the quality ofare.

hemotherapy Treatment Plan and Summarys cancer treatment has improved over the past decades,

here are increasingly large numbers of cancer survivors. Aecent report by the Institute of Medicine, titled “From Can-er Patient to Cancer Survivor,” focused on the specializedare of cancer survivors.41 In a move to improve the quality,he American Society of Clinical Oncology has developed ahemotherapy treatment plan and summary, which is avail-ble on their Web site.42 Currently, tumor registries sendorm letters to physicians to obtain follow-up information,uch as type of adjuvant therapy, with varying responseates28; the treatment summary will provide reliable source tobtain this information. This document provides a history ofancer treatment, including comorbidities, surgeries, radia-ion, and chemotherapy. Following treatment, the patient’sancer therapy is summarized, including chemotherapy typend dose, toxicities, response, and relevant follow-up. Hav-ng this information in one place, with all the inpatient and

utpatient treatments, allows all providers to be well-in-

ormed and provide efficient and well-informed care. Thehemotherapy treatment plan and summary is available forolon cancer and is currently being developed for breast can-er. These treatment plans will likely be a required compo-ent of the cancer patient’s chart in the future.

onclusionreast cancer patients do not receive all recommended basicare, and, as such, there remains room for improvement inoth measurement and provision of high-quality health care.e must strive for advancement through multiple ap-

roaches, including the dissemination of evidence-baseduidelines to physicians through both the literature and morective campaigns, the identification of validated and reliableuality measures, and the use of a data source which providesll information necessary to measure quality. Additionally,ith the widespread adoption of pay-for-performance mea-

ures by major payers, there has never been a time when it isore imperative for physicians to participate in both theevelopment and implementation of a feasible and econom-

cally sound approach to measuring and improving quality.

eferences1. Jemal A, Siegel R, Ward E, et al: Cancer statistics, 2007. CA Cancer

J Clin 57:43-66, 20072. Schachter HM, Mamaladze V, Lewin G, et al: Many quality measure-

ments, but few quality measures assessing the quality of breast cancercare in women: a systematic review. BMC Cancer 6:291, 2006

3. Ko C, Parikh J, Yermilov I, et al: The surgeon’s role in the quality ofoncologic care. J Natl Comp Cancer Netw 5:565-567, 2007

4. Neuhauser D: Ernest Amory Codman MD. Quality Safety Health Care11:104-105, 2002

5. Donabedian A: Evaluating the quality of medical care. Milbank MemFund Q 44:166-206, 1966 (suppl)

6. Kahn KL, Malin JL, Adams J, et al: Developing a reliable, valid, andfeasible plan for quality-of-care measurement for cancer: how shouldwe measure? Med Care 40:III73-III85, 2002

7. Donabedian A: The quality of care. How can it be assessed? J Am MedAssoc 260:1743-1748, 1988

8. Gotzsche PC, Nielsen M: Screening for breast cancer with mammogra-phy. Cochrane Database Systematic Rev (Online) CD001877, 2006

9. El-Tamer MB, Ward BM, Schifftner T, et al: Morbidity and MortalityFollowing Breast Cancer Surgery in Women: National Benchmarks forStandards of Care 245:665-671, 2007

0. Malin JL, Asch SM, Kerr EA, et al: Evaluating the quality of cancer care:development of cancer quality indicators for a global quality assessmenttool. Cancer 88:701-707, 2000

1. Eddy DM: Performance measurement: problems and solutions. HealthAffairs (Project Hope) 17:7-25, 1998

2. MedQIC, Examples of Surgical Care Improvement Project measures. Avail-able at: http://www.medqic.org/dcs/ContentServer?cid�1107196776637&pagename�Medqic%2FMeasure%2FMeasureTemplate&c�Measure

3. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/HospitalQualityInits/downloads/HospitalRHQDAPU200602.pdf

4. Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/fund/ngcguidl.htm

5. National Library of Medicine. Available at: http://www.nlm.nih.gov/cgi/mesh/2007/MB_cgi

6. National Guideline Clearinghouse. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id�8510&nbr�004745&string�

breast�AND�cancer

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1

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2

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Defining quality of care for breast cancer 127

7. Malin JL, Schneider EC, Epstein AM, et al: Results of the NationalInitiative for Cancer Care Quality: how can we improve the quality ofcancer care in the United States? J Clin Oncol 24:626-634, 2006

8. McGlynn EA, Asch SM, Adams J, et al: The quality of health caredelivered to adults in the United States. New Engl J Med 348:2635-2645, 2003

9. Masi CM, Olopade OI: Racial and ethnic disparities in breast cancer: amultilevel perspective. Med Clin North Am 89:753-770, 2005

0. Bickell NA, Wang JJ, Oluwole S, et al: Missed opportunities: racial dispar-ities in adjuvant breast cancer treatment. J Clin Oncol 24:1357-1362, 2006

1. Issell BF, Maskarinec G, Pagano I, et al: Breast cancer treatment amongwomen of different ethnicity in Hawaii. Cancer Invest 23:497-504,2005

2. Mor V, Laliberte LL, Petrisek AC, et al: Impact of breast cancer treat-ment guidelines on surgeon practice patterns: results of a hospital-based intervention. Surgery 128:847-861, 2000

3. Enger SM, Thwin SS, Buist DS, et al: Breast cancer treatment of olderwomen in integrated health care settings. J Clin Oncol 24:4377-4383,2006

4. Thwin SS, Fink AK, Lash TL, et al: Predictors and outcomes of sur-geons’ referral of older breast cancer patients to medical oncologists.Cancer 104:936-942, 2005

5. Thompson BL, O’Connor P, Boyle R, et al: Measuring clinical perfor-mance: comparison and validity of telephone survey and administrativedata. Health Serv Res 36:813-825, 2001

6. Phillips KA, Milne RL, Buys S, et al: Agreement between self-reportedbreast cancer treatment and medical records in a population-basedBreast Cancer Family Registry. J Clin Oncol 23:4679-4686, 2005

7. Malin JL, Kahn KL, Adams J, et al: Validity of cancer registry data formeasuring the quality of breast cancer care. J Natl Cancer Inst 94:835-844, 2002

8. Bickell NA, Chassin MR: Determining the quality of breast cancer care:do tumor registries measure up? Ann Intern Med 132:705-710, 2000

9. National Cancer Data Base. Available at: http://www.facs.org/cancer/ncdb/index.html

0. Winchester DP, Stewart AK, Bura C, et al: The National Cancer DataBase: a clinical surveillance and quality improvement tool. J Surg Oncol

85:1-3, 2004

1. Pearson ML, Ganz PA, McGuigan K, et al: The case identification chal-lenge in measuring quality of cancer care. J Clin Oncol 20:4353-4360,2002

2. Weiner M, Quwatli Z, Perkins AJ, et al: Limitation of a single clinicaldata source for measuring physicians’ performance on quality indica-tors. J Am Geriatr Soc 54:1256-1260, 2006

3. Landercasper J, Dietrich LL, Johnson JM: A breast center review ofcompliance with National Comprehensive Cancer Network BreastCancer guidelines. Am J Surg 192:525-527, 2006

4. Grunfeld E: Canadian breast cancer guidelines are as effective as pos-sible under the circumstances. CMAJ 176:785-786, 2007

5. Mannion R, Goddard M: Public disclosure of comparative clinical per-formance data: lessons from the Scottish experience. J Eval Clin Pract9:277-286, 2003

6. Wilkinson NW, Shahryarinejad A, Winston JS, et al: Concordance withbreast cancer pathology reporting practice guidelines. J Am Coll Surg196:38-43, 2003

7. Bickell NA, McEvoy MD: Physicians’ reasons for failing to deliver effec-tive breast cancer care: a framework for underuse. Med Care 41:442-446, 2003

8. Rosenthal MB, Frank RG, Li Z, et al: Early experience with pay-for-performance: from concept to practice. J Am Med Assoc 294:1788-1793, 2005

9. Doran T, Fullwood C, Gravelle H, et al: Pay-for-performance programsin family practices in the United Kingdom. New Engl J Med 355:375-384, 2006

0. Centers for Medicare and Medicaid Services: Performance-basedpayments. Available at: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter�1341

1. Hewitt ME, Greenfield S, Stovall E: National Cancer Policy Board(U.S.). Committee on Cancer Survivorship: Improving Care and Qual-ity of Life. From cancer patient to cancer survivor lost in transition.Washington DC, National Academies Press, 2006

2. American Society of Clinical Oncology: Chemotherapy treat-ment summary. Available at: http://www.asco.org/portal/site/ASCO/menuitem.5d1b4bae73a9104ce277e89a320041a0/?vgnextoid�

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