Improving breast cancer care through a regional quality collaborative

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<ul><li><p>Improving breast cana regional quality co</p><p>, Jane, M</p><p>provtes aality</p><p>ithin a regional breast cancer quality collaborative.</p><p>IMPROVcenterDespitmentsthereEfforts</p><p>n theout-stitu-</p><p>ensivetionalandSM),ualityThis</p><p>g andre at</p><p>Accepte</p><p>ReprintMichigaAnn Arb0039-6060/$ - see front matter 2011doi:10.1Methods. Established in 2006, the Michigan Breast Oncology Quality Initiative (MiBOQI) consists of18 hospitals collecting data on breast cancer care using the National Comprehensive Cancer CentersNetwork (NCCN) Oncology Outcomes Database Project platform to analyze and compare breast cancerpractices and outcomes amongst member institutions. Institutional review board approval is obtained ateach site. Data are submitted electronically to the NCCN and analyzed for concordance with practiceguidelines. Aggregate and blinded data are shared with project directors and institutions at collaborativemeetings, and ongoing practice patterns are observed for change. We analyzed variation in breast biopsytechnique for initial cancer diagnosis over time and between institutions. Diagnostic biopsies werecategorized as core needle, surgical excisional, surgical incisional, and other surgical biopsy.Results. Procedural data for 8,066 patients treated for breast cancer between November 1, 2006 andDecember 31, 2009 were analyzed. The mean patient age was 59.5 years (range, 25.490.0 years).Within MiBOQI, 21% of patients underwent surgical biopsy for initial diagnosis. The percentage ofpatients undergoing surgical biopsy ranged from 8% to 37%, and the majority of surgical biopsies wereclassified as excisional biopsies. Patients with ductal carcinoma in situ were more likely to undergosurgical biopsy compared to those with invasive cancer (30.4% vs 17.8%; P &lt; .001). There was noassociation between biopsy type and patient age, race, or comorbidity. Data on biopsy technique wereshared with site project directors and a target surgical biopsy rate of </p></li><li><p>QI p</p><p>ion cr</p><p>s withtypes</p><p>is witew etionbreae panom</p><p>o evosise noays bed su</p><p>ion c</p><p>ion wion w</p><p>reatmQI</p><p>Surgery636 Breslin et alTable I. Inclusion and exclusion criteria for MiBO</p><p>Inclus</p><p>1. Newly diagnosed female breast cancer patientCommittee on Cancerdefined histologicnipple, and other)</p><p>2. Age 18 years or older at the time of diagnos3. Patients must have been diagnosed with the n</p><p>date of presentation to the MiBOQI institu4. Patients receive some or all of their primary</p><p>chemotherapy, or hormonal therapy) at th5. Patients with a history of an invasive nonmela</p><p>one of the following:a. Previous breast cancer episodes: There is ndiagnosed at least 90 days before the diagn</p><p>b. Prior nonbreast cancer episodes: There arpresently and were diagnosed at least 90 dor with distant metastases, which were treatbeen no recurrence for at least 5 years</p><p>Exclus</p><p>1. Patients who present to the MiBOQI institut2. Patients who present to the MiBOQI institut</p><p>diagnosed within 90 days of each other3. Patients receiving all primary breast cancer t4. Patients presenting to the participating MiBO</p><p>transplantation or radiation therapyProject to the community setting. The foundationof the program is a network-based data collection,reporting, and analytic system that is designed todescribe patterns of care, monitor concordancewith NCCN guidelines, and evaluate outcomes. Inorder to promote not only quality monitoring butquality improvement, the program includes afeedback process whereby participating institu-tions, physicians, and guideline developmentpanels can compare data across the network andbetween institutions.</p><p>The NCCN Breast Cancer Outcomes ProjectDatabase contains more than 300 data elementsincluding data on drug/biologic and diagnosticsuse and trends; specific treatment indications andsequencing; toxicity and reasons for discontinuation;complications and medical events; progression-freeand overall survival; comparative effectiveness andresource consumption; andpayor-specific data. Anal-yses of this dataset have led to multiple publicationsdescribing patterns of surgical and adjuvant therapyfor breast cancer1-4 and informed studies evaluatingquality measurement.5,6</p><p>The diagnostic period is the patients first con-tact with breast cancer care providers and institu-tions. Timely and accurate diagnostic evaluationrequires close collaboration between surgeons,</p><p>MiBOQI, Michigan Breast Oncology Quality Initiative; NCCN, National Comprearticipation</p><p>iteria</p><p>histology consistent with at least 1 of the American Joint(carcinoma not otherwise specified, ductal, lobular,</p><p>h primary breast cancerpisode of breast cancer no more than 180 days before the</p><p>st cancer treatment (cancer-directed surgery,rticipating institutionatous cancer diagnosis are eligible if the history includes</p><p>idence of distant metastases or recurrence and wereof the current breast cancer episodedistant metastases and there is no evidence of diseaseefore the diagnosis of the current breast cancer episode;ccessfully resulting in a complete response and there has</p><p>riteria</p><p>ith or are diagnosed with cancer recurrenceith breast sarcoma or with simultaneous cancers</p><p>ent outside of the participating MiBOQI institutioninstitution and receiving only bone marrow</p><p>October 2011radiologists, and primary care providers. With lowcomplication rates and a long latency between di-agnostic procedures and outcomes such as survivaland local recurrence, quality measurement inbreast cancer diagnosis relies on process measures.One process measure that has received extensiveattention recently is diagnostic breast biopsy tech-nique. Core needle biopsy is preferred over opensurgical biopsy for diagnosing breast cancer, andThe National Accreditation Program for BreastCenters and the American Society of Breast Sur-geons require reporting of core needle biopsyrates for program participation.7,8 Previous studiesexamining trends in diagnostic breast biopsy indi-cate that core needle biopsy may be underused.9</p><p>As a quality measure, diagnostic biopsy is measur-able and potentially amenable to change throughprovider education and feedback. We present ini-tial results from our analysis of institutional varia-tion in diagnostic breast biopsy technique withina regional breast cancer quality collaborative.</p><p>METHODS</p><p>Established in 2006,MiBOQI is a voluntary groupof hospitals andprivate practices that collect data onbreast cancer care using the NCCN Oncology Out-comes Database Project. Institutional review board</p><p>hensive Cancer Centers Network.</p></li><li><p>breast cancer at MiBOQI institutions betweenNovember 1, 2006 and December 31, 2009 wereincluded in this analysis. Patient and tumor char-acteristics are summarized in Table II. The meanpatient age was 59.5 years (range, 25.490.0 years).Twenty percent of patients had ductal carcinomain situ (DCIS), and 80% were diagnosed with inva-sive breast cancer.</p><p>Over the 3-year study period, 21% of patientsunderwent surgical biopsy for initial diagnosis.The percentage of patients at each of the 14institutions undergoing surgical biopsy rangedfrom 8% to 37% (Fig 1, A), and the majority of sur-gical biopsies were classified as excisional biopsies(Fig 1, B). Over time, there was a statistically signif-icant (P &lt; .0001) decrease in the percentage of pa-tients undergoing surgical biopsy across theMiBOQI collaborative (Fig 2). Although therewas a net decrease in surgical biopsy use at 11 cen-ters, there was actually an increase at 3 centers.</p><p>Surgical biopsy use was significantly associatedwith a diagnosis of DCIS compared with invasivecancer (30.4% vs 17.8%; P &lt; .001), and this findingwas fairly consistent across the collaborative. Pa-</p><p>Surgery Breslin et al 637approval is obtained at each site. There are 42 acutecare (nonpsychiatric, nonrehabilitation) hospitalsor programs with sufficient breast cancer volumefor MiBOQI participation, and 18 centers currentlyparticipate. Data from the 14 participating hospitalswith sufficient patient numbers were analyzed forthis project. Each site designates a project directorand a research associate. Initially, potential partici-pating centers were invited to participate in Mi-BOQI by the coordinating center (UMCCC). As theprogram has matured, interested centers with suffi-cient case volume (100 breast cancer cases/year)may now apply for participation.</p><p>Funding for MiBOQI is provided by Blue CrossBlue Shield of Michigan (BCBSM), which covers80% of the recommended full-time equivalentsalary for data collection and submission. Partici-pating sites are responsible for the remaining datacollection costs, travel to meetings, and projectdirector and administrative expenses. Data aresubmitted electronically to the NCCN and ana-lyzed for concordance with practice guidelines.Data are abstracted from clinical charts 4 monthsafter patient presentation and are available imme-diately to individual centers; however, an analysisof treatment-specific information requires addi-tional measurement time for events to occur (180days for chemotherapy and 270 days for hormoneand radiotherapy). Center-specific benchmarkeddata are provided to project directors on a quar-terly basis. Aggregate and blinded data are sharedwith project directors and institutions at regularcollaborative meetings 3 times per year, and ongo-ing practice patterns are observed for change.</p><p>Criteria for inclusion in MiBOQI and the NCCNBreast Outcome Database are summarized in TableI. Only patients with at least 90 days of follow-upwere included in this analysis in order to capturethe diagnostic and surgical period. Data from 4 siteswere not included because they had recently joinedthe collaborative and had low case numbers.</p><p>We analyzed breast biopsy technique for initialcancer diagnosis over time and between institu-tions. Diagnostic biopsies were categorized as coreneedle, surgical excisional, surgical incisional, andother surgical biopsy. The other surgical biopsycategory included nipple or breast skin biopsies,fine needle biopsy, and axillary lymph node biopsy.The procedure resulting in the most advanceddiagnosis is designated as the diagnostic proce-dure. Chi-squared analysis was used to comparecategorical data. General linear modeling was usedto test group means. To confirm accuracy, all</p><p>Volume 150, Number 4surgical biopsy cases from a single institutionwere reviewed via direct chart review to confirmcoding and to understand indications for surgicalbiopsy.</p><p>RESULTS</p><p>Procedural data for 8,066 patients treated for</p><p>Table II. Patient and tumor characteristics</p><p>Characteristic N (%)</p><p>Age (years)</p></li><li><p>Surgery638 Breslin et alundergo surgical biopsy. There was no associationbetween biopsy type and patient age, race, or pa-tient medical comorbidity. Between 5% and 47%of surgical biopsies were performed before presen-tation at MiBOQI institutions.</p><p>Review of all surgical biopsy cases (n = 232) at asingle participating institution revealed that 47%of the surgical biopsies were performed at refer-ring institutions before presenting to the MiBOQIsite for care. Of the surgical biopsies performed atthat institution, 56% were performed because themammographic or sonographic abnormality wasnot amenable to image-guided core biopsy becauseof lesion size, location, or patient body habitus.The reasons for the remainder of the surgical biop-sies are summarized in Table III. Interestingly, 11%of the surgical biopsies (of the 123 performed at</p><p>Fig 1. (A) Surgical biopsy use across the MiBOQI collab-orative. (B) Breakdown of surgical biopsy type byinstitution.the MiBOQI institution) represented cases ofDCIS diagnosed on core needle biopsy where inva-sive carcinoma was identified on surgical pathologyfrom the definitive surgical resection.</p><p>Specific interventions and changes in processesof care were left to the project directors andparticipating centers. Examples of the strategiesused included group education at hospital medicalstaff meetings, direct provider feedback to individ-ual surgeons with data on surgical vs core biopsyuse, and education aimed at primary care pro-viders referring patients for biopsy. Future inter-ventions will include ongoing project directorfeedback at the institution level and primarycare and surgeon-targeted education sessions onbreast diagnosis at the Michigan State MedicalSociety annual meeting.</p><p>DISCUSSION</p><p>In this report, we describe institutional variationand a temporal shift in diagnostic breast biopsypractices at member institutions of a state widebreast cancer quality collaborative. This model canbe used to collect, analyze, and disseminate surgi-cal breast care quality data to organizations and</p><p>10,11</p><p>Fig 2. Use of surgical biopsy in the Michigan Breast On-cology Quality Initiative collaboration.</p><p>October 2011treating physicians in the community setting.In addition, these data can be used to describe pat-terns of care, monitor changes in practice, and setquality standards.</p><p>We chose to measure core needle biopsy ratesbecause several member institutions were inter-ested in using these data for breast program accred-itation. Core needle biopsy is accurate andrecognized by many as the preferred approach fordiagnosing breast cancer.12 Advantages of this ap-proach compared with surgical biopsy include im-proved multidisciplinary treatment planning,superior breast symmetry and cosmesis, and less fre-quent need for surgical margin re-excision.13,14 Arecent report from Gutwein et al15 describes the po-tential for substantial cost containment with</p></li><li><p>l bio</p><p>UA</p><p>D</p><p>S</p><p>O</p><p>rimar</p><p>Surgery Breslin et al 639increased core needle biopsy use. We show that,over time, the use of surgical biopsy decreased andthe use of core needle biopsy for breast cancer diag-nosis increased.</p><p>With high-quality mammographic screening,the incidence of nonpalpable compared to palpa-ble breast cancers has increased. The majority ofthese screening detected lesions, and manypalpation-detected abnormalities are amenable tocore needle biopsy.16,17 However, there are severalreasonable indications for performing surgical bi-opsy. These indications include atypical or otherhigh-risk lesions diagnosed with core needle bi-opsy, small breast size, obesity, unfavorable lesionlocation close to skin, chest wall, or breast implant.Some patients may decline core needle biopsy be-cause of anxiety, difficulty tolerating the prone po-sition required for stereotactically guided biopsies,or personal preference. Small suspicious palpable</p><p>Table III. Results from chart review of 232 surgica</p><p>Biopsy location No. Percent</p><p>Referring institution 109/232 47%MiBOQI institution 123/232 53%Single institutionaudit results</p><p>68/123 56%17/123 14%</p><p>14/123 11%</p><p>13/123 10%</p><p>11/123 9%</p><p>*Other includes patient preference, diagnosis via fine needle biopsy of pattempt.MiBOQI, Michigan Breast Oncology Quality Initiative.</p><p>Volume 150, Number 4but radiographically occult lesions may be most ap-propriately diagnosed with surgical biopsy to avoida nondiagnostic biopsy.</p><p>We found that half of the surgical biopsiesreviewed from 1 participating center in this cohortwere performed before presentation to a MiBOQIinstitution. While practice pat...</p></li></ul>

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