From quality management to quality improvement—structures, processes and outcomes

Abstract

The current topic issue of the World Journal is dedicated to ‘Quality Management of Patients with Prostate Cancer Care’, an issue that has drawn much attention in the past among patients, health care providers, and politicians. Without knowledge of which potential management strategies are best suited for the individual patient, quality management needs to assure that treatment is based on current scientific knowledge. This includes care according to clinical guidelines and measurement of quality, structures, processes, and outcomes. The latter is particularly important since outcomes in prostate cancer (PCa) significantly depend on complex surgical/radio-therapeutical intervention, skills of the individual surgeon/radio-therapist, and the multidisciplinary team [1], as well as preparation of the intervention and immediate aftercare [2–4]. This is where Donabedian’s [5] approach and its translation into quality indicators meet their limits—it is not only important that but also how something is done. Our knowledge of the impact of specific ‘ingrediencies’ to complex interventions is limited. Although numerous textbooks address operating skills, scientific-based guidelines are missing for surgical procedures such as radical prostatectomy (RP). One approach is to use observational data to identify where and why outcomes are superior and to potentially learn from exceptionally good performance [6, 7]. Another approach to address the need of guidelines was taken by Butea-Bocu et al. [7] who analyzed a large cohort who presented in a rehabilitation clinic after RP. Their RP was either performed in a certified hospital according to the quality assuring criteria of the German Cancer Society or in a non-certified clinic [8]. Certified center patients presented with better oncological and functional outcomes (negative margins, continence, erectile dysfunction), a finding that is in line with previous studies for colorectal cancer [9, 10]. However, this study does not explain which elements of treatment in certified units account for better results, but it suggests that investing in rigorous quality management contributes substantially to better outcomes. Survival of localized PCa is significantly better than for many other cancers. At the same time, functional complications such as incontinence and erectile dysfunction following RP reduce quality of life substantially for many patients. Knowledge of differences across sites or surgeons that lead to such impairment is critical. Long-term complications can be reported ideally by the patient himself, completing scientifically accepted patient-reported outcome measures (PROMs). Involving patient advocates, the International Consortium for Health Outcomes Measurement (ICHOM) developed a standard data set for localized PCa that includes the measurement of PROMs [11] using the EPIC-26 questionnaire [12]. This standard is implemented into practice in a large registry [13], including patients from 15 countries and 220 clinical sites. The intention is to compare and reduce variations in PCa care. Comparing outcomes across countries requires that results are measured the same way. Sibert et al. therefore assessed the psychometric validity of the German version of the EPIC-26 [14]. The authors analyzed data from the first enrolled 3094 patients [15]. Their analysis proofs that the German version of the EPIC-26 is suitable for measuring functional outcomes and psychometric properties, in line with the original American version and other translations. When quality is compared across providers, different populations need to be analyzed because different patients are at various risks for impaired outcomes, independent of the * Simone Wesselmann [email protected]