Relationships between Case-based Quality Measures and Long-term Survival for Colorectal Cancer Patients
Date Issued
2011
Date
2011
Author(s)
Chang, Yun-Jau
Abstract
Background: Performance measurement for medical care has gone through several decades. Only recently, the emphasis extended to cancer care quality. Thogh colorectal cancer ranks third as leading cuase of cancer deaths, relationships between performance measures and patient’s outcomes had never been investigated. In addition, the minimum 12 lymph node is recommended as benchmark of cancer care for colorectal cancer to prevent understaging recent but concern about its adequacy follows.
Objectives: The main five topics discussed in this study encompass: 1. prognostic factors of 5-year survival; 2. association between adherence to individual quality measures and 5-year survival; 3. association between composite process scores (by six different aggregating algorithms) and 5-year survival; 4. impact of different threshold of number of lymph node on 5-year survival; 5. hospital factors influence on understaging.
Materials and Methods: We identified 2003-2004 TCDB patients who were diagnosed with colorectal cancer undergoing bowel resection (Cohort 1 and subgroup Cohort 2, Cohort 3 as well as Cohort 4) and a regional hospital (Cohort 5, non-TCDB group) Primary end point was 5-year survival rate (including overall, disease-free and disease specific survival). The set of quality measures was initially finalized by two rounds of expert meetings. Expert questionnaires including these eleven indicators were mailed to specialists nationwide to get indicator weights (i.e., weight of AHP and Fuzzy AHP in this study), which would be used in the subsequent computation.
Results: Cohort 1 included 4973 colorectal cancer patients undergoing colectomy treated at 29 hospitals with mean age 65.0 years old, and Cohort 5 included 122 colorectal cancer patients with mean age 68.5 years old. For TCDB patients regardless of stages, prognostic factors were age, sex, comorbidity, tumor grade, negative surgical margin, adequate lymphadectomy and accreditation status are prognostic for 5-year disease-specific survival. For stage 0& I of TCDB patients, age, grade, accreditation status and annual surgical volume of colorectal surgery correlated 5-year disease- specific survival. For stage II patients, age, comorbidity, negative surgical margin and adequate lymphadectomy are prognostic for 5-year disease-specific survival. For stage III, age, gender, negative, grade and surgical margin are prognostic for 5-year disease-specific survival. For non-TCDB patients, comorbidity, tumor locations, stages, negative surgical margin and pre-OP CEA, albumin, hemoglobin level as well as hospital stays correlated with 5-year disease-specific survival. When it comes to quality measures, two indicators (P1, T4) didn’t correlate 5-year survival in any Cohort. The others were correlated with patients’ 5-year survival, among which P2, T3 and T6 always work well. Composite process score also correlate 5-year survival by various aggregating algorithms, among which Equal Weighting, AHP, Fuzzy AHP and PCA works well. But the significant association with 5-year survival didn’t happen to rectal cancer patient by any method. Number of lymph node study showed cut-off of 18 provided the most model fitting in association with 5-year survival. Multilevel model study of understaging revealed hospital factors (accreditation status and ownership type) didn’t influence lymph node examined.
Conclusions: Quality measures for cancer care cannot only indicate cancer care quality but also correlate with patients” 5-year survival either by individual or composite quality score. The number of lymph node examined was also associated with patients’ long-term outcome. Further researches include validation of quality measures on other major cancer care and physician as well as hospital factors on adherence to quality measures.
Subjects
quality measures
colorectal cancer
composite process scores
analytic hierarchy process
fuzzy analytic hierarchy process
principal component analysis
5-year survival rate
understaging
multilevel regression
SDGs
Type
thesis
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