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Does Quality of Care Matter? a Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients With Locally Advanced Esophageal Cancer
Daniela Molena*1, Benedetto Mungo1, Miloslawa Stem1, Amy K. Poupore2, Sophia Y. Chen1, Anne O. Lidor1
1Johns Hopkins Medicine, Baltimore, MD; 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Introduction: The National Cancer Policy Board of the Institute of Medicine stated that the American health care system fails to provide consistent, high quality cancer care to all patients. There are limited data on the level of quality of care received for patients with esophageal cancer in the United States. Although national guidelines have been developed to guide treatment, often the diagnosis, staging and management of this type of tumor is left to the clinician's experience and preference. We analyzed data from a National Cancer Institute designated cancer center in order to study if adherence to National Comprehensive Cancer Network (NCCN) guidelines leads to differences in survival in patients with locally advanced esophageal cancer.
Methods: This is a retrospective cohort study of patients with locally advanced esophageal cancer (stage II and III) included in the Sidney Kimmel Comprehensive Cancer Center database at the Johns Hopkins Hospital from 2008 to 2013. Seven quality indicators were identified using the 2014 NCCN guidelines and individual and overall quality measure scores were calculated. We used the median overall score to divide patients into low and high quality care groups based on individual patient scores in relation to the median score. Overall survival was analyzed using the Kaplan-Meier method and univariate Cox proportional hazards regression.
Results: 141 patients met inclusion criteria and 88 patients (62%) were identified as receiving high quality care. Based on the individual quality indicator, adherence to guidelines ranged from 63.1% to 100% , with an overall compliance of 81%. Adherence to individual quality indicators is listed below (Table). Several quality indicators were found to significantly impact mortality: lack of appropriate induction with combined chemoradiation therapy (HR, 2.12; 95% CI, 1.23-3.64; p=0.007); no surgery performed (HR, 1.83; 95% CI, 1.17-2.85; p=0.008); and inadequate restaging imaging (HR, 1.66; 95% CI 1.06-2.60; p=0.026). A significantly better overall survival was observed in patients who received high quality care (HR, 0.58; 95%, 0.37-0.90, p=0.015) (Figure). Of note, Caucasian race, higher income and education (but not type of health insurance) were significantly associated with receiving high quality care.
Conclusions: Based on this analysis, we found that high quality care is frequently provided for patients with locally advanced esophageal cancer at our institution. Delivery of high quality care is associated with improved survival in these patients. Efforts should be directed at minimizing disparities in treatment in regards to race, educational and income levels.
TABLE. Quality of care
Quality Indicator
% reported/performed | Low quality of care
n=53 | High quality of care
n=88 | | Histology | 100% | 100% | | Location | 75.47% | 96.59% | | Grade | 100% | 100% | | Surgery1 | 26.42% | 87.50% | | Induction treatment2 | 52.83% | 100% | | Pre-operative PET and CT and EUS | 43.40% | 86.36% | | Restaging PET and CT | 26.42% | 85.23% |
1Esophagectomy or gastrectomy 2Concurrent chemo and radiation therapy  Fig. Kaplan-Meier curves of overall survival rates for stage II and III esophageal cancer patients who received high quality of care versus those who did not.
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