Guideline Concordance Rate and Oncology Surgery in Medicare Beneficiaries

Part of quality healthcare involves delivering the right care to the right patient at the right time. According to researchers, the current variation of healthcare quality in the United States may “reflect (1) a lack of knowledge about the optimal approach to care; or (2) a lack of acceptance regarding currently defined standards of care.” Using practice guidelines as a guide, the researchers recently conducted a retrospective cohort study to determine whether appropriate surgical care was provided to Medicare beneficiaries newly diagnosed with cancer. The study utilized the national Surveillance, Epidemiology, and End Results registry linked to Medicare claims data. Study results were reported in Archives of Surgery [2011;146(10):1128-1134]. The study was designed around 3 areas of proficiency involved in the surgical treatment of cancer: (1) surgical management of the primary tumor, (2) evaluation and treatment of regional nodal basins, and (3) appropriate referral for multidisciplinary adjuvant therapy. The researchers identified current disease-specific guidelines in each of the 3 areas for 5 common cancers (breast, colon, gastric, rectal, and thyroid) in which surgery plays an important role. The researchers identified 11 guidelines for analysis (see Below for guidelines), including 5 for breast cancer, 2 for colon cancer, 1 for gastric cancer, 1 for rectal cancer, and 2 for thyroid cancer, representing various domains of surgical oncology care (surgery directed at the primary tumor [n=1], nodal management [n=5], and adjuvant therapy [n=5]). In measurements of 7 of the 11 guidelines, concordance was >90%; 100% of the measures regarding evaluation for or receipt of adjuvant therapy had concordance rates >90%. The guidelines recommended for the surgical management of breast cancer had the highest rates of concordance, including radiation therapy or evaluation following breast-conserving surgery (99.2%), chemotherapy or medical oncology evaluation for estrogen receptor–negative breast cancer (98.1%), axillary dissection for node-positive breast cancer (96.7%), postmastectomy radiation therapy or evaluation for patients with >4 positive nodes, with positive lymph nodes and a tumor >5 cm, or with stage III cancer (94.9%), and nodal evaluation for invasive breast cancer (91.8%). The lowest rates of concordance were seen for central neck dissection for node-positive thyroid papillary cancer (72.7%), colon cancer nodal evaluation of at least 12 nodes (48.5%), and gastric nodal evaluation of at least 15 nodes (32.5%). The analysis also assessed the factors associated with the increased or decreased likelihood of receiving care in concordance with the recommended guidelines. For higher concordance rates, the analysis found associations with younger age, less aggressive disease, higher income level, being married, and receiving care at a hospital that participates in an oncology group. Geographic location was also a factor, with patients treated in the Midwest more likely to receive care in concordance with all guidelines for all measures. Study limitations cited by the researchers included incomplete capture of cases, missing data, and limiting the analysis to patients ≥65 years of age. In summary, the researchers noted they “found a high level of concordance with guidelines in some domains of surgical oncology care but far less so in others, particularly for gastric and colon nodal management. Given the current national focus on improving the quality of healthcare, surgeons must focus on generating data to define appropriate care and translating those data into everyday practice.” Guideline Recommendations Total thyroidectomy for papillary cancer ≥1.5 cm or node positive Central neck dissection for node-positive papillary cancer Gastric node count ≥15 Colon node count ≥12 Axillary dissection for node-positive breast cancer Nodal evaluation for invasive breast cancer Chemotherapy or medical oncology evaluation for stage II colon cancer (for patients >80 years of age) Axillary radiation therapy or radiation oncology evaluation for T4 or stage III rectal cancer (for patients >8- years of age) Chemotherapy or medical oncology evaluation for estrogen receptor–negative breast cancer (for patients >70 years of age) Axillary radiation therapy or radiation oncology evaluation following breast-conserving surgery (for patients >70 years of age) Postmastectomy radiation therapy or radiation oncology evaluation for >4 positive nodes, stage III, node positive, and t>5 cm