Sundin: Assessing quality of care [CMAJ

Assessing quality of care

CMAJ 2000;162:317

See response from: N. Hébert-Croteau, et al

The article by Nicole Hébert-Croteau and colleagues [full article]¹ is another attempt to prove that hospital caseload is a determining factor in adopting new therapeutic modalities, in this case for breast cancer, and that larger hospitals are more likely to give optimal treatment. Having worked as a surgeon for many years in a tertiary care hospital and during the last few years in a community hospital 100 km from a cancer treatment centre, treating close to 50 new cases of breast cancer yearly, I have had to radically change the way I treat breast cancer. The factors that most influence the decisions that my patients and I arrive at are never assessed in analyses of small-area variations.

Socioeconomic factors are important determinants of the variation in surgical care in my community and probably apply to most smaller communities across Canada. In my community the population is elderly, the Atlantic fishery has collapsed, and the woman may be the family breadwinner. There is no public transportation and in many cases the family does not have a car (or if they do, they would never drive to and within the city). They have rarely stayed away from home, and the prospect of 5 weeks' stay in the city for radiotherapy, which they cannot afford, is daunting. They immediately gravitate toward choosing to have a mastectomy. They want a short stay in the local hospital where they can be given all the treatment they need, at once.

The fact that women having breast-conservative treatment have a high rate of radiotherapy is natural. They would not be given conservative surgery if they had not agreed to postoperative radiation. We can and do give chemotherapy at our hospital, most often after consultation with our colleagues at the nearest cancer treatment centre.

I understand from the article that I am not providing optimal treatment for my breast cancer patients as outlined in the guidelines. However, it is optimal for my particular patients. What worries me about this type of article is that some health care policy-makers may conclude from it that optimal care will require the patient to access large, centralized treatment facilities. Such a conclusion may harm groups of patients and, in the long term, jeopardize the survival of institutions that are currently delivering good patient-centred care, but not exactly the way some clinical practice guidelines suggest.

Jan O. Sundin
General surgeon
Bridgewater, NS

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Reference

Hébert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschênes L. Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1994. CMAJ 1999;161(8):951-5.