What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

Abstract

Aim: To evaluate BreastSurgANZ members' compliance at various threshold rates for 4 evaluable High-Quality Performance Indicators (HQPIs) introduced to improve patient care. To benchmark global best practice to assist in determining the eventual threshold standards.

Method: BreastSurgANZ Quality Audit data 2012-2016 & 2018 was used to determine rates of attainment through a range of thresholds for 4 HQPI's. Rates were assessed for different volume surgeons and comparison made to international standards.

Results: 1.3761 patients needing mastectomy for in situ disease, if the threshold rate for immediate breast reconstruction (IBR) was ≥ 40% then 30% of all members and 78% of very high-volume surgeons achieved that rate, which is comparable to international recommendations. 2.26,007 patients requiring mastectomy, if the threshold rate for IBR was ≥ 20% then 28% of all surgeons and 78% very high-volume surgeons met the standard. This is below most international recommendations. 3. For 31,698 invasive tumours ≤ 2 cm, if the threshold rate for breast conservation was ≥ 70% then 64% of all surgeons met the standard; 70% is comparable internationally. 4.1382 women =<50 years if the threshold rate for neoadjuvant chemotherapy was set at ≥ 15% then 36% of surgeons complied; 15% is below most international recommendations.

Conclusions: Even at these modest thresholds there are low levels of achievement by BreastSurgANZ members with high volume surgeons more likely to comply. These thresholds are either comparable or lower than globally accepted standards. Members should strive to meet, even exceed these important goals as they are a metric of improved patient care.

Keywords: Breast cancer outcomes; Quality; Standards of care.

Fig. 1

HQPI 1: rates of immediate breast reconstruction (IBR) for in situ breast cancer (DCIS) requiring mastectomy: A total of 3761 cases found and if the threshold rate was set at ≥ 40% of a surgeon’s cases having IBR then 30% of all BreastSurgANZ contributing surgeons were compliant (Fig. 1). There were 19% low volume surgeons (only 188 of 240 contributed), 46% of medium volume surgeons, 39% of high-volume surgeons and 78% of very high-volume surgeons compliant at that level. Only 62% of surgeons were compliant at an IBR threshold of 5%.

Fig. 2

HQPI 2: Rate of immediate breast reconstruction for invasive breast cancer patients requiring mastectomy: If the threshold was set at ≥ 20% IBR for invasive breast cancer requiring mastectomy, of the 22,007 cases evaluated 28% of all surgeons met the standard. For low volume surgeons the rate of compliance was 24%, medium volume 36%, high volume 17% and 78% of very high-volume caseload surgeons. Only 52% of surgeons were compliant at an IBR threshold of 5%.

Fig. 3

HQPI 3: rate of breast conservation for tumours <2 cm in size: if the threshold rate for breast conservation for the 31,698 eligible cases was set at ≥ 70% of all member cases then 64% were compliant. There were 58% low volume surgeons and 76% of medium volume compliant at that level. For higher volume caseload members 74% of high-volume surgeons and 89% of very high-volume caseload surgeons met the standard.

Fig. 4

HPQI 6: Rate of use of neo-adjuvant chemotherapy (NACT) in women ≤ 50yrs of age: if the threshold rate for use of NACT for 1382 eligible patients in 2018 was set at ≥ 15% then 36% of all BreastSurgANZ members met this standard. For low volume surgeons 34% were compliant, 40% medium volume surgeons, 45% of high caseload surgeons and 29% of very high-volume surgeons would have complied with this standard. Only 49% of surgeons were compliant at a NACT threshold of 5%.