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Lee L, Dietz DW, Fleming FJ, et al. Accreditation Readiness in US Multidisciplinary Rectal Cancer Care: A Survey of OSTRICH Member Institutions. JAMA Surg. 2018;153(4):388–390. doi:10.1001/jamasurg.2017.4871
There is tremendous variability in care for patients with rectal cancer in the United States.1 The Consortium for Optimizing the Surgical Treatment of Rectal Cancer (OSTRICH) was established in 2011, with 18 centers, to pursue a goal of improving the treatment of patients with rectal cancer.2 As of April 2017, it has grown to more than 350 centers. This group (working with the Commission on Cancer, American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Society of Surgical Oncology, the Society of Surgery for the Alimentary Tract, the Society of American Gastrointestinal and Endoscopic Surgeons, the College of American Pathology, and the American College of Radiology) has developed the National Accreditation Program in Rectal Cancer (NAPRC), a set of standards for multidisciplinary rectal cancer care.3 The goal of this study is to determine the status of multidisciplinary rectal cancer treatment among OSTRICH Consortium institutions.
An anonymous 39-item questionnaire was created based on the draft NAPRC standards in November 2016; the questions addressed facility characteristics, available clinical services, and the organization of a multidisciplinary rectal tumor board. The items were formulated without direct reference to the 22-item list of NAPRC standards, but rather were designed to determine self-reported readiness for the accreditation process.3
The institutional review board at Florida Hospital approved the study protocol. Informed consent was obtained from each participant at the initiation of the survey.
The survey was distributed online on January 27, 2017, to all 328 facilities that were OSTRICH members at the time. Two reminders were issued to unresponsive facilities in the subsequent 2 months. After the survey closed on March 31, 2017, members of the NAPRC research team reviewed the data and assigned compliance scores to each institution based on a standardized interpretation of how the 39 survey questions aligned with the 22 NAPRC standards. Data were analyzed with Stata, version 12 (StataCorp). The χ2 test was used to compared categorical variables, and P values of less than .05 were considered significant.
Of the 328 member facilities, 137 responded by the time of survey closure, resulting in a 41.8% response rate. The proportion of centers in self-reported compliance with each standard is shown in the Table. The mean (SD) number of compliant standards was 10.6 (4.0). The study defined high compliance as adherence to 13 or more standards. Only 37 of the 137 respondents (27.0%) reported compliance at this level, including 4 centers (2.9%) that reported compliance to every standard (Figure).
High-volume centers (n = 88), which we defined as those that provide 30 or more rectal resections annually, were more likely to report high compliance than low-volume centers (n = 44), which were defined as those that did fewer than 30 such procedures annually (81% vs 58%; P = .01). (An additional 5 centers, or 3.7%, did not report their case volume.) The 4 centers with 100% compliance all reported being high-volume centers.
This study surveyed the OSTRICH membership on the status of multidisciplinary treatment of rectal cancer at their institutions. The results suggest that, even among centers engaged in quality assurance efforts, there exists wide variability in the structures and processes associated with the delivery of multidisciplinary rectal cancer care.
Cancer care outcomes for rectal cancer were more strongly associated with hospital volume than with surgeon volume,4 suggesting that the structures and processes of care in a multidisciplinary setting may be more important than the expertise of the individual clinician. Recognition of the value of the multidisciplinary approach, as demonstrated by the European experience of centralizing rectal cancer care to specialized multidisciplinary units,5,6 has led to the founding of the NAPRC as a mechanism to standardize and improve the quality of rectal cancer care. However, this study shows that few centers were projected to meet 13 or more of the 22 NAPRC standards, and only 4 centers are projected to meet all standards. Several standards with insufficient compliance were related to the organization of the multidisciplinary tumor board; these can easily be addressed. Other deficient standards, such as those related to magnetic resonance imaging and pathology reporting, may require additional training of facility clinicians and staff. The educational modules developed by the College of American Pathology and the American College of Radiology may ameliorate these deficiencies.
Survey data are prone to self-reporting and recall biases. It is expected that these biases would favor overestimation of compliance, which suggests that these results may be optimistic. In addition, the response rate was only 41.8%, which may be owing to volunteer bias.
A second limitation is that the NAPRC standards were modestly revised from the time of survey creation to its final version. The final version only contains 1 new standard that would have been relevant to include in this survey (standard 2.8), but projected compliance is necessarily approximate because of this change and any future revisions in standards.
Finally, these results may not be generalizable to non-OSTRICH institutions. Additional research is warranted.
There is a high level of variability in the multidisciplinary management of OSTRICH member institutions as well as poor projected compliance with anticipated NAPRC accreditation standards. As a result, considerable opportunity is available for improvements in multidisciplinary treatment standardization.
Corresponding Author: Lawrence Lee, MD, PhD, 4501 N Orange Ave, Ste 240, Orlando, FL 32804 (email@example.com).
Accepted for Publication: August 25, 2017.
Published Online: December 13, 2017. doi:10.1001/jamasurg.2017.4871
Author Contributions: Drs Lee and Monson had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Lee, Dietz, Remzi, Wexner, Monson.
Acquisition, analysis, or interpretation of data: Lee, Fleming, Remzi, Winchester.
Drafting of the manuscript: Lee, Remzi, Monson.
Critical revision of the manuscript for important intellectual content: Dietz, Fleming, Remzi, Wexner, Winchester, Monson.
Statistical analysis: Lee.
Administrative, technical, or material support: Fleming, Remzi, Winchester, Monson.
Study supervision: Dietz, Remzi, Wexner, Winchester, Monson.
Conflict of Interest Disclosures: Dr Wexner reports consulting fees from Actamax, Axonics Modulation Technologies, Brace Pharmaceuticals, Karl Storz Endoscopy, LifeBond, Mederi Therapeutics, Medtronic, and Novadaq; stock options from Asana Medical, LifeBond, Pragma, and Renew Medical; and royalties from Covidien, Karl Storz Endoscopy, and Unique Surgical Innovations LLC. Dr Fleming reports royalties from UptoDate. No other disclosures were reported.
Additional Contributions: We thank the OSTRICH consortium, which served as content expert for this survey. Please see the OSTRICH Consortium website for a full list of members (http://www.ostrichconsortium.org/members.htm).
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