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Of the 143 quality indicators identified by this review, only a
small minority had received any attention as to development
into formal quality measures either prior to or during the
adherence studies in which they were employed. One can, as a
result, have little confidence in the meaningfulness of the gaps
in care suggested by the adherence rates produced by quality
indicators other than patient-centered ones (i.e., QOL,
satisfaction with care). Even the interpretability and
generalizability of the results produced by McGlynn et al.'s
rigorous effort2 to establish the support for and clinical
relevance of their breast cancer care quality indicators were
Although based on a systematic review of the evidence
and a peer consensus process, these results were limited by the
small number of eligible breast cancer cases; the less than
optimal level of evidence (observational evidence and expert
opinion) supporting some standards, especially treatment
standards; and the likelihood that their quality indicators had
not been fully pilot tested as measures. It may be best to
proceed with caution before allowing even minor policy
decisions to be guided by any of the adherence data reviewed in
The research implications of the present findings suggest the
need to close the gap between existing ways of measuring the
quality of breast cancer care and the ideal, scientific way
required to highlight possible gaps in care. While more
research is needed, employing principles by which any formal
measure is derived, it may be wise to wait until the results of at
least one important research project are reported before
independently undertaking what ASCO may already be in the
process of achieving.
At present, ASCO is developing a robust set of largely
evidence-based quality measures relating to stage I-III breast
cancer. Their goal is to produce a detailed profile of the
reliability (e.g., inter-rater), feasibility, and validity of measures
based on pilot testing using multiple data sources (e.g., patient
survey, the National Cancer Database of the American College
of Surgeons). The results of ASCO's project are widely
anticipated, since it is possible that they will have developed the
validated measures required to push forward the field of quality
measurement with respect to breast cancer care. It remains to
be seen whether ASCO's quality measures will cover the
definitions of care (e.g., quality of delivery of care, structural
factors) identified by the present review as mostly absent from
A number of limitations characterized the present systematic
review. In having to narrow the review scope, UO-EPC lost
the chance to go back to reference standards (e.g., clinical
practice guidelines) and their evidence sources (empirical
studies) to determine the clinical appropriateness of quality
indicators in terms of the strength of the evidence linking these
standards to improved outcomes. Eligibility criteria were
predefined to include in the review only quality indicators that
were evidence based. However, it was sometimes difficult to
confirm either within or beyond a study report that the
evidence authors noted as evidence based actually constituted
empirical support. As a result, it is possible that some types of
quality indicators included in the review could easily have been
excluded. Finally, the "trajectory of scientific development"
scheme was designed especially for this study without benefit of
a validational process. The data obtained through its use are
not likely to be overly reliable or valid. Nevertheless, almost
none of the grades received by quality indicators suggested a
history of scientific development, confirming what is likely the
most unequivocal finding of this review: other than a few QOL
or patient satisfaction instruments, no validated quality
measures to quantify patterns of breast cancer care could be
Some have asserted that the degree to which health care
quality in the United States is consistent with quality standards
is basically unknown and that the continuing failure to have a
clear and comprehensive view of the level of quality care
received by the average American will reinforce the belief that
quality care is not a serious national problem.44
In our view,
the failure to have reliable and valid quality measures with
which to confidently point to possible gaps in breast cancer
care—and to afford accountability, improvement, and
research45—is a situation that does nothing to help resolve this
important dilemma. Some promise is attached to ASCO's
ongoing enterprise, although it will be some time before the
results are known. Until validated quality measures are
established, it will likely be impossible to derive a meaningful
overview of gaps in breast cancer care that can inform the
public about the quality of its health care choices.46
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Availability of Full Report
The full evidence report from which this summary was taken
was prepared for the Agency for Healthcare Research and
Quality (AHRQ) by the University of Ottawa Evidence-based
Practice Center under Contract No. 290-02-0021. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 800-358-9295.
Requesters should ask for Evidence Report/Technology
Assessment No. 105, Measuring the Quality of Breast Cancer
Care in Women.
The Evidence Report is also online on the National Library of Medicine Bookshelf, or can be downloaded as a PDF File (1.4 MB). PDF Help.
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AHRQ Publication Number 04-E030-1
Current as of September 2004