|09:15 - 10:00 || |
Over the last two decades, the concept of person (or patient) centred care has become increasingly prominent in health services across the world. The aim of person centred care is to provide health services in a way that respects and responds to the knowledge, preferences, needs, and values of individual service users. At the core of the approach is the principle that users of health services should have a role in assessing the quality of care, by being given the opportunity to provide feedback about their own experiences. Measures of "patient experience", including but not limited to patient surveys, are now widely used to assess the extent to which care is person-centred. This talk will trace the development of person-centred care and, alongside it, the increasing importance of measuring and using patient experience. This will address the role of patient feedback in measuring and understanding service quality, with examples from cancer care and chronic disease settings.
|10:00 - 11:00 || |
Hungary is a middle-income Central-Eastern European country, joined the EU in 2004. She currently has 9.87 million inhabitants. The cancer burden the country has to carry is rather heavy. Overall cancer mortality rate in 2013 was the highest among the EU28. As to the breast cancer incidence, 34.7 / 100.00 new cases and 25.0 / 100.000 fatal cases were reported. The Chief Medical Officers' Office, on behalf of the National Public Health and Medical Officers Services (ÁNTSZ), carries the task for organization, coordination, monitoring and evaluation of breast cancer screening. For overall cancer care the National Cancer Institute bears the professional responsibility. Population-based organized breast screening facilities in Hungary are available since 2002; 42 Breast Screening Centres have been contracted by tender. Each centre has been connected with other elements of breast cancer care, forming a Breast Unit, as defined by the European Guidelines, 4th edition (2006). The National Screening Registry regularly receives feedback from the mammography units about all indicators. By the appropriate interpretation of these data quality assurance for breast cancer screening can be guaranteed.
Comprehensive breast cancer care services are offered in Malta. To date, these services are not governed by any specific legal or regulatory requirements. Furthermore, these services have not as yet been awarded or included in a national or international accreditation or certification system. At different levels (including both national and individual organisational levels), there is works in progress to introduce applicable accreditation and certification systems.
|11:30 - 13:00 || |
CanCon - Tit Albreht
, National Institute of Public Health, Slovenia
Joint Action CANCON (Cancer Control) is focusing on the quality improvement in four important areas of cancer control– development of comprehensive cancer care networks, community cancer care, survivorship issues and guidance on several existing or potential screening programmes. In the latter, several challenges and new knowledge have shed new light on how screening programmes should be organised. A workpackage on screening is exploring guidance on cervical, breast, colorectal, prostate, lung and stomach cancer. This should provide an up-to- date knowledge and advice to policy-makers on how to act in the face of the challenges arising from these screening programmes. The listed core topics will each prepare a comprehensive chapter for the publication entitled European Guide for Quality Improvement in Cancer Control, which will be published at the end of the project and presented at the final conference, which will be one of the events of the Maltese Presidency to the Council of the European Union.
Breast, colorectal and cervical cancer cause 250000 deaths each year, representing 20 % of EU-cancer mortality. Although important progress has been made in both detection and treatment, there is persisting inequity in progress to reduce its burden. The objective of EU-TOPIA is to systematically evaluate and quantify the harms and benefits of the running programmes for breast, cervical, and colorectal cancer in all European countries, and identify ways to improve health outcomes and equity for citizens. We will first identify significant inequities in screening outcomes by assessing the key set of quality indicators for benefits and harms in each country. Using these indicators, outcomes and cost-effectiveness of existing cancer screening pro- grammes in 2015 will be estimated. For this, state-of-the-art models of the natural history of the cancers will be constructed, using country-specific data. Barriers hindering implementation of optimal screening programs will be assessed, leading to road maps for improved screening. These road maps contain feasible changes, e.g., to extend or reduce the program, to change the screen test used or change key quality indicators, to perform activities that reduce screening related harm or incorporate new developments in screening, and provide policy-makers with evidence for increased, decreased or optimized use of screening. The project will lead to reduced inequity, reduced number of cancer deaths and over-diagnosed cases, and increase in life years gained and better cost-effectiveness by 2025.
US-Breast Center Accreditation - Cary Kaufmann
, Bellingham Breast Cancer Center, USA
Breast Care provided by the multidisciplinary team makes it difficult to correlate results with interventions, whether good or bad results. In addition, there are relatively few evidence based quality metrics available to apply to centers wishing certification. Appropriate quality measures are those which are a) recognized by providers as being important, b) have variation in performance across centers, c) are feasible to extract performance data, and d) have a positive cost-benefit ratio. Another confounding problem is that quality measures must apply to the many varieties of breast centers, large and small, academic and community, urban and rural. In the US, two programs developed independently, each providing half of the quality equation. One program (NAPBC) focused on defining the structural components of care. They had to de- fine structural requirements that were rigid enough to maintain high quality care but flexible enough to recognize the realities of the local community. The second quality program (NQMBC) focused on process measurements, or how well does the multidisciplinary team perform in each area of breast care. Although they measured specific performance levels, they had difficulty identifying benchmarks. Providing a single benchmark may be too high for many centers, while appearing too low and not providing improvement incentive for the better quality centers. The ideal breast center certification combines both multidisciplinary structural requirements along with process of care assessment (including benchmarks) that recognize both the realities of local environment and the needs of individual patients.
European Network of Cancer Registries - Nadya Dimitrova
, National Cancer Registry, Bulgaria
There are over 20 national and 82 regional cancer registries in Europe, covering 72 % of the population of the EU. All of these registries have contributed, or have the potential to contribute, to the quality of breast cancer care in some way. Because definitions are standardised across Europe, registries can provide long-term descriptions of trends in breast cancer incidence, stage, treatment, survival and mortality by country, region or hospital. Registries linked to screening programme data can also identify and compare in detail (including molecular makers) symptomatic, screened and interval cancers, and allow international comparisons. Improving data collection through the establishment of links to clinical cancer registries and the wider availability of electronic data means registries have an increasing scope and timeliness of data which can be linked to measures of quality of care and screening history. They can also help estimate the cost-effectiveness of new technologies, and of interventions such as rapid referral clinics or specialist breast centres. The potential of cancer registries to contribute to breast cancer quality assessment is limited by a number of factors. Cancer registration in Europe remains heterogeneous for historical, economic and legal reasons, so the scope of data captured by registries is very variable. Some countries have complete population coverage, others have regional coverage, and a few have no effective population-based cancer registration. Some registries do not have access to death certificates, which makes survival calculation inaccurate. Many capture stage and treatment at diagnosis, but not all. Some can provide more detail– for instance on type of surgery, completeness of excision, molecular markers, comorbidity and follow-up data – and a few collect data on quality of life, for selected cohorts. Linkage of screening data to cancer registries is not being done in some countries for cost, legal or administrative reasons. The ENCR, with JRC, is working on improving the standardisation and coverage of cancer registration in Europe. There is considerable potential for quality assurance and research through more widespread sharing of the more extensive data now collected by registries, clinical programmes and screening programmes, and the more detailed analysis of the data already collected.
|14:00 - 16:00 || |
To successfully treat breast cancer patients it does not only need a multi-disciplinary approach but also a network of various services. Thereby assuring continuity of care becomes a crucial issue for the quality of care. Continuity of care implies continuity in terms of the management of the disease, continuity in terms how information is passed on from one service (provider) to the next and continuity in the relation of patient to service providers.
This parallel session will:
1. explore which are the sensitive issues in assuring continuity in breast cancer care,
2. and how quality of care can be assessed in respect to its continuity.
The parallel session aims at developing examples, options and ideas for assessing continuity of care in a reliable and valid way that allows for comparing services.
The parallel session will be opened by two presentations; both reporting examples of how to measure continuity of care as a dimension of the quality of care:
Integrated Care: what is important and how do we measure it? - Jenny King
, Picker Institute, UK
This presentation first looks at what is important from a user perspective in person-centred coordinated care including the things users believe should always happen for care to be coordinated. It will then look at a project aimed to produce a robust user-reported measure that can capture the experience of older people with chronic conditions receiving health and/ or social care services from different providers. The tool, under development by the International Foundation for Integrated Care, National Voices, the Nuffield Trust, the Picker Institute, and The King’s Fund in England, looks to assess coherence, coordination and quality of care.
Continuity of care from the patients' perspective is a core element of good care. Continuity of care comprises three major points: (1) one care provider for the patient with breast cancer who is a stable contact person through the complete care pathway, (2) communication between care providers, and (3) cooperation between care providers. The European QA scheme follows a patient-centered approach and therefore requirements must be defined which reflect the three aspects and focus on multidisciplinary, interprofessional communication and cooperation of care providers in a certified network along the treatment pathway of breast cancer patients. Additionally the requirements must be uniquely defined and (if applicable) measurable in order to be used by care providers for quality assurance and improvement.
as the chair of this parallel session and Anke Bramesfeld
from the JRC will explore and discuss with the participants to what extend these examples could be transferred to other health systems, or health care system requirements and how assessment of continuity of care would possibly need to look like, if applied on a European level.
All information concerning breast cancer should be delivered to both patients and healthy women (e.g. in screening) in an honest, clear and easily understandable way, and if applicable, visual information and decision-aids may be used. All patients should be given choices and enough time to decide on treatment options, participation in trials and tissue donation. Communication training is an essential tool for healthcare professionals to be able to correctly interact with patients. Furthermore, the continuity of communication needs to be ensured throughout the entire patient journey– keeping the person in the centre.
This parallel session aims to explore:
1. which are the sensitive issues in the continuity of person-centered communication in breast cancer care (e.g. problems),
2. how the continuity of communication can be improved (e.g. tools),
3. and, how the continuity and person-centredness of communication can be measured (e.g. indicators).
This parallel session aims to discuss examples and possibilities for assessing person-centred communication in breast cancer services in order to facilitate development of recommendations and enable comparison of the quality of breast cancer services.
The session will consist of three presentations, from different perspectives, providing examples of how the continuity of communication and patient centredness can be achieved:
Psychosocial support and communication needs in breast cancer patients - Luzia Travado
, Champalimaud Clinical Centre, Lisboa, Portugal
Good communication with patients and their families is closely linked to better treatment compliance and better clinical outcomes. Effective communication has the potential to reduce patients' anxiety and uncertainty, identify their unique concerns and needs, and lead to appropriate referrals for necessary care, thereby promoting patient-centered care. Good or effective communication is considered a key component of good medical practice, and a core competence that can be trained. As such it has been proposed that promoting effective communication between patients, caregivers and healthcare professionals can be achieved through: including communication skills training (CST) in undergraduate and postgraduate curricula for physicians, nurses, and other allied health care professionals in cancer care; continued professional development programmes in psychosocial oncology in all cancer settings. However much remains to be done as to make it a mandatory requirement for clinical practice and for accreditation of medical units including SBU.
How continuity of communication can be ensured throughout the patient journey - Yvonne Wengström
, Karolinska Institute and University Hospital, Stockholm, Sweden
Patient perspectives and experiences on the need to move from disease-centred to patient-centred communication - Kathi Apostolidis
, European Cancer Patient Coalition, Brussels, Belgium
All presentations will focus on how the continuity and patient-centredness in communication can be improved and measured. After the presentations the working group will discuss to what extent these examples and viewpoints could be applied in the development of patient-centred communication in breast cancer care at the European level. Luzia Travado
will chair this parallel session and serve as a rapporteur. Liisa Pylkkanen
from the JRC will support the working group in their tasks.
The parallel session aims at discussing on a core set of desirable and undesirable outcomes to be assessed in breast cancer screening studies in order to facilitate an informed decision making.
Key outcomes for studies on breast cancer screening - Mireille Broeders
, Radboud University Medical Center, the Netherlands
Continuous monitoring and evaluation of a screening programme is necessary to ensure that it is as effective as expected. Screening outcomes, both desirable and undesirable, become available throughout the screening process and afterwards. In general, a distinction can be made between evaluating the performance of the screening programme and its impact on health indicators such as mortality. Performance indicators reflect the provision and quality of the activities constituting the screening process without directly reflecting the reduction in mortality. Evaluating the long-term benefits and harms of screening for breast cancer takes many years and requires the application of complex epidemiological and statistical methodologies. Ascertainment of impact of the programme further demands that follow up of screened and non-screened cohorts continues over extended periods of time and that adequate links exist between programme data and other relevant data sources. A frequently used but challenging alternative is to identify and monitor early surrogate measures, such as the rate of advanced cancers, that can possibly predict outcome.
Key outcomes for studies on breast cancer screening - Bettina Borisch
, University of Geneva, Switzerland
The study and evaluation of outcomes for breast cancer screening (programs) is important for the individual as well as for the public health institutions that run screening programs. EU Member States and their respective health care systems may value outcomes differently and the single citizen has again another demand as to the quality and outcomes of screening. The citizen as well as the "national" questions that may need further outcome studies will be presented.
(University of Modena and Reggio Emilia, Italy), as chair of this parallel session, will steer the discussion after the presentations. The results of the parallel session will be reported by a rapporteur, Holger Schünemann
(McMaster University, Canada).
In spite of the consistent results shown for several other diseases (i.e. AIDS, abdominal aortic aneurysm coronary angioplasty, myocardial infarction, knee arthroplasty, coronary artery by- pass, etc.), the extent of the association between the volume of activity and the outcomes for breast cancer care is not always straightforward, because the results depend, among other factors, on the definition of caseload (whole hospital, centre, surgeon, etc.), the outcome chosen (mortality, proxies, etc.), and the set threshold. Selection bias and a different case-mix also deserve careful statistical adjustment. The objectives of this session are:
1. explore the existing evidence on the association between caseload and outcome for breast cancer,
2. discuss the most appropriate and feasible outcomes to be measured for this purpose.
Contributions from experts from different countries may stimulate a discussion on how health- care policies introducing (or not) thresholds in the number of cases treated affected the organisation of cancer care and the access to the services.
The parallel session will be opened by two presentations, both reporting examples of the assessment of the impact on volumes on outcomes in (breast) cancer care:
Monitoring of Italian hospital data - Marina Davoli
, Outcome Evaluation Programme – National Agency for Health Services, Italy
Hospital or physician volume represents a measurable variable with a relevant impact on effectiveness of health care. Since 2009, the National Outcomes Programme (PNE) evaluates outcomes of care of the Italian hospitals; nowadays it represents an official tool to assess the National Health System (NHS). There is clear evidence from the scientific literature of an association between volume of breast cancer surgery, 30 days intra hospital mortality, five years survival and rate of conservative surgery. Although the systematic review of the literature does not permit to identify predefined volume thresholds, the EUSOMA guidelines identify a minimum threshold of 150 for a breast unit and 50 for single surgeon. In Italy in 2014 there are 467 hospitals performing more than 10 breast cancer surgeries, among these only 123 (26%) perform more than 150 surgeries corresponding to 70% of operated women. The biggest hospitals often have more than one ward in which surgery is subdivided; the proportion of women having surgery in high volume wards (more than 135) is 62% in 2014, as compared with 54% in 2010; we also observed a great geographical variability. In June 2014 the Ministry has approved a national guideline for the organization of the breast units and some regions are reorganizing the breast cancer network of hospitals to comply with different standards including the volume of care. However, the available data from PNE show that it is still very high the proportion of women having breast cancer surgery in proper sites.
Retrospective analysis on case numbers and process quality in breast surgery in Germany - Günther Heller
, Federal Institute for Quality Assurance and Transparency in Healthcare (IQTIG), Germany
Background: Numerous studies from around the world have shown a positive association between case numbers and the quality of medical care. The evidence to date suggests that conformity to guidelines for the treatment of patients with breast cancer is better in German hospitals that have higher case numbers.
Methods: We used data obtained by an external program for quality assurance in inpatient care (externe stationäre Qualitätssicherung, esQS) for the years 2013 and 2014 to investigate seven process indicators in the area of breast surgery, including histologic confirmation of the diagnosis before definitive treatment, axillary dissection as recommended by the guidelines, and an appropriate temporal interval between diagnosis and operation. Case numbers were categorized with the aid of various threshold values. Moreover, subgroup analyses were carried out for patients under age 65, patients in good general health, patients without lymph-node involvement, and patients with a tumor size pT0 or pT1 or an overall tumor size less than 5 cm.
Results: Data on 153475 patients from 939 hospitals were analysed. Six of seven indicators had values that were better overall, to a statistically significant extent, in hospitals with higher case numbers. Although this relationship was not consistently seen, the worst results were generally found in the category with the lowest case numbers. Similar though less striking results were obtained in the subgroup analyses. An exception to the general finding was that, in hospitals with higher case numbers, the interval between diagnosis and operation was more often longer than three weeks.
Conclusion: Guideline adherence is higher in hospitals that treat more cases. The present study does not address the question whether this, in turn, affects morbidity or mortality. To improve process quality in peripheral hospitals, the quality assurance program should be continued.
The chair (Ina Kopp
) of this parallel session and Silvia Deandrea
from the JRC will explore and discuss with the participants the methodology and clinical issues arising from the presentations and if a European quality assurance scheme on breast cancer may take into account the volume of activity of the centres seeking certification. The results of the parallel session will be reported by Robert Mansel
|16:30 - 17:30 || |