Originally published as JCO Early Release 10.1200/JCO.2008.20.9965 on October 13 2009

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National Assessment of Melanoma Care Using Formally Developed Quality Indicators

From the Cancer Programs, American College Surgeons; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD; Department of Surgery, University of California, Los Angeles; and Veterans Affairs of Greater Los Angeles Healthcare System, Los Angeles, CA.

Corresponding author: Karl Y. Bilimoria, MD, MS, American College of Surgeons, Cancer Programs, 633 N St Clair St, 22nd Floor, Chicago, IL 60611-3211; e-mail: kbilimoria{at}facs.org.

Purpose There is considerable variation in the quality of cancer care delivered in the United States. Assessing care by using quality indicators could help decrease this variability. The objectives of this study were to formally develop valid quality indicators for melanoma and to assess hospital-level adherence with these measures in the United States.

Methods Quality indicators were identified from available literature, consensus guidelines, and melanoma experts. Thirteen experts ranked potential measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. Adherence with individual valid indicators and a composite measure of all indicators were assessed at 1,249 Commission on Cancer hospitals by using the National Cancer Data Base (NCDB; 2004 through 2005).

Results Of 55 proposed quality indicators, 26 measures (47%) were rated as valid. These indicators assessed structure (n = 1), process (n = 24), and outcome (n = 1). Of the 26 measures, 10 are readily assessable by using cancer registry data. Adherence with valid indicators ranged from 11.8% to 96.5% at the patient level and 3.7% to 83.0% at the hospital level. (Adherence required that 90% of patients at a hospital receive concordant care.) Most hospitals were adherent with 50% or fewer of the individual indicators (median composite score, five; interquartile range, four to seven). Adherence was higher for diagnosis and staging measures and was lower for treatment indicators.

Conclusion There is considerable variation in the quality of melanoma care in the United States. By using these formally developed quality indicators, hospitals can assess their adherence with current melanoma care guidelines through feedback mechanisms from the NCDB and can better direct quality improvement efforts.

Written on the behalf of the Melanoma Quality Indicator Development Expert Panel.

Supported by the American College of Surgeons Clinical Scholars in Residence program (K.Y.B. and M.V.R.); and by the American College of Surgeons, the Commission on Cancer, and the American Cancer Society (National Cancer Data Base).

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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