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Initial Validation of Feasibility and Assessment of Variation Among Surgeons

Laurence E. McCahill, MD; Alicia Privette, MD; Ted James, MD; Johanna Sheehey-Jones, RN; John Ratliff, JD; Donald Majercik, MD; David N. Krag, MD; Mary Stanley, MD; Seth Harlow, MD

Arch Surg. 2009;144(5):455-462.

Objectives  To identify and quantify surgical outcomes as possible quality measures of initial breast cancer surgery and to assess variation among surgeons.

Design  Descriptive analysis of concurrently collected outcome measures.

Setting  University hospital with a designated breast cancer center.

Patients  Patients with a preoperative diagnosis of invasive breast cancer or ductal carcinoma in situ undergoing their initial cancer surgery from April 1, 2003, to March 30, 2008.

Main Outcome Measures  Eight measures were identified: (1) total mastectomy rate; (2) close (<1 mm) and positive margin rate following initial partial mastectomy; (3) number of operations required in breast conservation; (4) number of nodes obtained from sentinel lymph node biopsy; (5) number of nodes from axillary dissection; (6) proportion of patients with positive sentinel lymph node biopsy undergoing axillary dissection; (7) use of intraoperative lymph node assessment; and (8) time from diagnosis to surgery.

Results  Nine hundred ten operations (218 for ductal carcinoma in situ, 692 for invasive breast cancer) were performed by 6 surgeons. Variation existed among surgeons in the combined close and positive margin rate, number of nodes obtained from sentinel lymph node biopsy, and use of intraoperative lymph node assessment. No significant variation was seen for the overall mastectomy rate, mean number of operations, positive margin rate alone, and number of lymph nodes from axillary dissection.

Conclusions  Quality indicators for breast cancer surgery can be identified and readily monitored. Outcome variation exists at a high-volume breast center. Further study into the causes and effects of this variation on short- and long-term patient outcomes as well as health care costs is needed.

Author Affiliations: Division of Surgical Oncology, Department of Surgery (Drs McCahill, Privette, James, Majercik, Krag, Stanley, and Harlow) and James M. Jeffords Institute for Quality (Ms Sheehey-Jones and Dr Ratliff), University of Vermont and Fletcher Allen Health Care, Burlington.

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