Interinstitutional Variations in Cancer Treatment Identified

August 2014, Vol 5, No 6

Little is known about why patient care varies greatly for patients with similar illnesses, such as in patients with different types of cancer. Variation in the care of patients with cancer signals a lack of consensus about what constitutes optimal care; this suggests important gaps in the evidence base in which research may have an effect. In a new study, researchers sought to systemically assess interinstitutional variation in the management decisions for 4 common cancers using the National Comprehensive Cancer Network (NCCN) Outcomes Database (Weeks JC, et al. Ann Intern Med. 2014;161:20-30).

This multi-institutional, observational cohort study included patients with 1 of 4 types of cancer who were diagnosed between July 2006 and May 2011 at 18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the NCCN. The investigators identified 25,589 patients with incident of breast cancer (N = 11,293), colorectal cancer (N = 4564), lung cancer (N = 6718), or non-Hodgkin lymphoma (NHL; N = 3014). They measured interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions.

Important management decisions for patients with the 4 types of cancer varied greatly among the major cancer centers. Interinstitutional variation was high (median absolute deviation, >10%) for 35 of 171 (20%) oncology management decisions, including 41% for NHL, 21% for breast cancer, 15% for lung cancer, and 12% for colorectal cancer. Overall, 46% of high-variance decisions involved imaging or diagnostic procedures, and 37% involved the choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, category 2A for 49%, and category 2B or other for 51% of the decisions.

The findings showed that high interinstitutional variation in common decisions regarding oncology management reveals opportunities to health systems to prioritize comparative effectiveness research, patient–provider education, or pathway development. Also, careful attention should be given to customized decision-making that includes patient preferences, concluded the researchers.

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