4. Discussion
Although the sample size was small, the results of the national survey surgeons identified four categories of CPAC’ s breast cancer surgical standards that were the most under-implemented in their practice. These included processes related to quality assurance, turnaround time for breast pathology results, psychosocial and health-related support for the breast cancer patient, and breast reconstruction for patients undergoing mastectomy. Although there was clearly variability in the degree to which each individual standard was implemented across provinces, these four categories were perceived to be the most significantly lacking across the country overall.
While specific determinants were present for every category of surgical standards; overall there were general themes that were common across all standards and across multiple provinces. Firstly, surgical standards were more likely to be implemented in practice if they aligned with organizational priorities (such as wait time to diagnosis or treatment, performance of multidisciplinary cancer conferences) or already existing national standards that the organization followed (such as pathology standards for breast biopsies that follow the Canadian Association of Pathology standards). Secondly, standards were more likely to be implemented if the individual physicians or physician groups were accountable to the organization regarding compliance with the standard, especially if the organization itself was also accountable to the cancer jurisdiction in terms of compliance as well. An example of this included wait times to diagnosis and treatment, which is being monitored by the cancer agencies; or compliance with clinical pathways developed by the cancer jurisdictions that breast cancer patients should follow. This was especially important if there were financial incentives related to compliance, either at the organizational or at the individual surgeon level. In Ontario, for example, achievement of breast cancer surgeries within specified wait time targets, compliance with clinical pathways and performance on outcome-related indicators is tied to organizational funding from Cancer Care Ontario. This organizational incentive translates into incentives for surgeons as well, if the organization uses this funding to provide more operating room resources for example. This model has certainly been used in other non-cancer disease sites to improve timely access to surgery across Canada (such as hip, knees, cataracts, dental surgeries). Thirdly, standards related to quality improvement processes were more likely to occur if the infrastructure or resources existed within the organization or system for the reliable collection of relevant, meaningful, practice changing data combined with the capability of benchmarking, peer-peer comparisons and timely feedback to the surgeons. There may be an opportunity to leverage the infrastructure for quality improvement that exists in many organizations and provinces with the capacity that is available (either at system or organizational level) to create incentives for proper data collection and reporting. The provincial surgical synoptic reporting initiative in Alberta, for example, has made it easy for surgeons to enter data and receive feedback regarding their practices in comparison to their peers. Synoptic operative reporting tools have been implemented in several jurisdictions which offer the opportunity to report individual performance against provincial comparisons. The American College of Surgeons’ National Surgical Quality Improvement Project (ACS-NSQIP) is a risk-adjusted database that first started collecting data in 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects [
7]. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, including many hospitals in Canada. NSQIP captures uniform morbidity variables for all operations and calculates expected risk-adjusted morbidity probabilities. While its extensive use in the US has allowed for regional and national collaboration by sharing of robust data related to outcomes in breast surgery [
8], this practice is virtually non-existent in Canada and significant opportunities exist to formalize this process to improve breast cancer surgical outcomes nationally.
The focus group discussions also highlighted that better communication to organizations and provinces regarding the existence of CPAC’s breast cancer surgical standards [
6], perhaps with linkages to hospital or cancer centre accreditation processes, was seen to be potentially helpful in standards implementation. Cancer agencies could potentially endorse the CPAC standards and take accountability for compliance of these standards.
With respect to achieving standards related to patient needs and support, whether it be psychosocial, nutritional, rehabilitation related, it was suggested that the system could benefit from creative partnerships with private sector healthcare services. It was noted that patient support resources were often the first to be cut during organizational budgetary restraints, and that patients may be open to private healthcare services if they were approved by the hospitals or cancer agencies. Institutions could negotiate discounted incentives on behalf of the patients in order to facilitate access; furthermore, lists of supportive care providers and resources available could be shared amongst institutions within the same province, for example.
Surgical standards, such as that of access to immediate and delayed breast reconstruction, can benefit from the voices of patient advocacy groups and media in their implementation process; these are often underutilized tools that facilitate the prioritization of cancer surgical standards by the provinces and organizations. Many physicians underestimate the importance and influence that healthcare advocacy has on the profession and feel that they lack the skill and leverage to advocate on behalf of themselves, their practices, their patients, and their profession [
9]. However, breast and plastic surgeons are uniquely positioned to advocate based on their clinical acumen, personal experiences with patient care, and their position in the healthcare ecosystem value chain. In the US, the American Society of Plastic Surgeons (ASPS) has long recognized the importance of empowering surgeons alongside patients in advocacy work. To this end, for a few years they have hosted the annual ASPS Advocacy Summit [
10], where plastic surgeons not only learn firsthand about the federal, state and regulatory issues impacting the specialty and its patients from nationally recognized political experts and members of the US Congress, but also gain knowledge, experience, and tactics relating to advocacy, which could then be applied toward issues important to them and their institution. Attendance to the ASPS Advocacy Summit has been encouraged and marketed also to medical students and residents, the future leaders in the field of plastic surgery. Such platforms for advocacy training may be a useful method to help empower Canadian breast surgeons to implement CPAC’s breast cancer surgical standards across Canada.
This study has some notable strengths. First, this is the first Canadian national evaluation of the determinants of standards implementation in breast cancer surgery. Although the sample size of the surgeon survey responders was small, the surgeon participants had good representation across sex, age and years in practice. Secondly, the qualitative approach undertaken during the focus groups allowed for a detailed analysis of the determinants necessary to inform strategies to implement high-quality breast cancer surgery nationally.
The current study also has some limitations. For the survey responses, the sample size was small and the survey could have selected surgeons with a stronger interest and an already higher existing level of compliance with breast surgical standards. There could also be a response bias from the surgeons when asked about their perception of the degree of standards implementation, and this may have been different from reality. This is especially true when discussing standards implementation at the provincial level, as some surgeons may not have reliable knowledge at this level. For the focus group, surgeon participants were extracted from the list of surgeons attending the CAGS meeting who were interested in participating. Our opt-in sampling strategy may mean that we only captured attendees of the meeting who had the strongest views (either positive or negative) on the topic and who are most passionate about sharing them, meaning that we may have missed some valuable feedback from those who are more impartial. Finally, while breast cancer surgical care is multidisciplinary, not all members of the multidisciplinary breast team were interviewed, such as pathologists, radiologists and plastic surgeons. Incorporating the views of these groups may provide a potentially fuller picture of the determinants to standards implementation in breast cancer surgical care.
