Feeding back results to hospitals will only lead to quality improvement if we embrace the challenge of complexity

Kate Walker, NATCAN Senior Statistician and methodological lead of the National Bowel Cancer Audit and the National Non-Hodgkin Lymphoma Audit

If NATCAN is to succeed in its aim of improving the quality of cancer care across England and Wales, it needs to provide regular feedback to hospitals of where treatments and outcomes vary.

And for this approach to be effective we need to recognise that neither hospitals nor patients begin their process of cancer treatment from a level playing-field.

We have to embrace the challenge of complexity.

Patients are complex, with different socioeconomic deprivation, ethnicity and ages. Many have pre-existing medical conditions and greater or lesser degrees of frailty.

Cancer is a complex disease with many different molecular sub-types. Patients arrive at secondary care through different routes and with different stages of disease.

Finally, cancer treatments and service structures are complex. No single solution will prove to be effective. Treatment pathways are increasingly complex, with some hospitals offering specialist treatments to patients with more advanced disease.

It’s clear then that when feeding back performance indicators to hospitals we need to allow for these differences in patients and their tumours at the point they arrived in secondary care. And we need to avoid ‘adjusting away’ any differences in how hospitals treat patients that may explain differences in outcomes.

Careful risk adjustment allows us to make fair comparisons between hospitals, ensuring that those who treat higher-risk patients are not unfairly penalised. Accurate risk adjustment also helps to reduce any tendency for clinical teams to avoid the treatment of high-risk patients.

We also need to accurately predict a patient’s risk to guide decisions about their care.

Accurate risk prediction is crucial for shared decision-making between patients, their families and their clinical team: weighing up the different survival benefits and adverse outcomes between different curative treatment pathways, for example; or trying to ensure that the highest risk patients benefit from appropriate interventions such as consultant care in theatre or direct transfer from theatre to critical care.

Accurate risk-adjustment and risk prediction requires methodological and clinical experts to work in partnership. This is where NATCAN will make a difference.

Its methodological expertise comes from being part of the Clinical Effectiveness Unit (CEU), a collaboration between the Royal College of Surgeons of England and London School of Hygiene and Tropical Medicine. Its clinical expertise comes from its teams of analysts, methodologists and project managers working closely in partnership with senior clinicians and clinical fellows.

National data on patients with cancer is the richest it has ever been, and available to analyse much more quickly than ever. The increasing use of rapid cancer registration data, released every three months with much shorter delays, is a powerful tool.

These advancements create the opportunity to give hospitals feedback on their risk-adjusted outcomes more accurately, more frequently, and with more timely reporting than ever.

This will allow prompt and accurate information to guide hospitals to the most important areas for local quality improvement. And should lead to better treatment and better results for patients.