LETTERS CLINICAL QUALITY REGISTRIES: ENGAGING EFFECTIVENESS DATA FOR QUALITY IMPROVEMENT Quality definitions in health care vary; however, the key domains demand that it should be safe, patient-centered, timely, efficient, and equitable.1 The assessment of quality requires measure of clinical effectiveness and this can in part be reflected by the use of performance indicators.2 The identification of inequality and variation in access, process and outcome provides important focus to direct initiatives toward quality improvement.3 Samuel et al.4 have reported a thorough and considered evaluation of cancer outcomes (colorectal, lung, and prostate) derived from the Veterans Administration Central Cancer Registry between 2001 and 2004. The study reviewed 20 cancer-related process and outcome measures finding significant differences between ethnic groups. Compared with Whites, Blacks were half as likely to undergo curative surgery for early stage lung cancer (adjusted odds ratio = 0.50; 95% confidence interval = 0.41, 0.60), half as likely to receive appropriate radiotherapy, and significantly less likely to receive appropriate symptom control following chemotherapy. Significant and

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clinically important disparities were observed for seven of 20 measures of cancer care reported. This important report highlights several targets for health improvement initiatives, and yet the capacity for these data to drive improvement may be limited. First, the decade-old data may no longer accurately reflect current health care and may be perceived by stakeholders as no longer relevant to current health care delivery. Second, the report describes cancer outcomes within the Veterans Administration, providing important internal benchmarking but little guidance to outcomes generated in alternate care structures such as Medicare and private health systems. Third, the indicator panel was internally generated, nonstandardized, and may differ in structure and content from indicators captured in other health care systems. Importantly, simply repeating the measurement of performance indicators in lung cancer care in the absence of an implementation strategy to engage the quality improvement cycle may have no positive effect on measures of effectiveness.5 Data can, however, be effectively engaged to drive quality improvement through the linkage provided by clinical disease quality registries.6 There are emerging models for cancer registry development,7 and evaluation of the now mature national Danish Lung Cancer Registry8,9 confirms substantial ongoing improvement in outcomes, effectiveness, and quality in health care delivery. The full value of these data may not be realized without regular performance review, rigorous evaluation by clinical and administrative governance, clinical and patient bodies, and the development and implementation of strategies to improve outcomes in areas of need.10 j Rob G. Stirling, BSc(Hons), MBBCh(Hons), MRCPI, FRACP

About the Author Rob G. Stirling is with the Department of Allergy Immunology and Respiratory Medicine, Alfred Hospital, Monash University, Melbourne, Victoria, Australia.

Correspondence should be sent to Rob G. Stirling, Alfred Hospital, Allergy Immunology and Respiratory Medicine, Commercial Rd, Melbourne, Vic 3004 Australia (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted September 5, 2014. doi:10.2105/AJPH.2014.302319

References 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for The 21st Century. Washington, DC: National Academy Press; 2001. 2. Arah OA, Klazinga NS, Delnoij DM, ten Asbroek AH, Custers T. Conceptual frameworks for health systems performance: a quest for effectiveness, quality, and improvement. Int J Qual Health Care. 2003;15(5): 377---398. 3. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19): 2579---2584. 4. Samuel CA, Landrum MB, McNeil BJ, Bozeman SR, Williams CD, Keating NL. Racial disparities in cancer care in the veterans affairs health care system and the role of site of care. Am J Public Health. 2014;104(suppl 4): S562---S571. 5. Mitchell PL, Thursfield VJ, Ball DL, et al. Lung cancer in Victoria: are we making progress? Med J Aust. 2013;199(10):674---679. 6. Evans SM, Scott IA, Johnson NP, Cameron PA, McNeil JJ. Development of clinical-quality registries in Australia: the way forward. Med J Aust. 2011;194 (7):360---363. 7. Stirling RG, Evans SM, McLaughlin P, et al. The Victorian Lung Cancer Registry pilot: improving the quality of lung cancer care through the use of a disease quality registry. Lung. 2014;Epub ahead of print. 8. Jakobsen E, Palshof T, Osterlind K, Pilegaard H. Data from a national lung cancer registry contributes to improve outcome and quality of surgery: Danish results. Eur J Cardiothorac Surg. 2009;35(2):348---352. 9. Jakobsen E, Green A, Oesterlind K, Rasmussen TR, Iachina M, Palshof T. Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry. J Thorac Oncol. 2013;8(10):1238--1247. 10. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312(7031):619---622.

SAMUEL AND KEATING RESPOND We agree with Stirling on the need for quality measurement and reporting practices that effectively engage health systems in the improvement of care delivery and outcomes. The efforts of the cancer registries in Australia and Denmark to improve lung cancer care1,2 are

American Journal of Public Health | December 2014, Vol 104, No. 12

Clinical quality registries: engaging effectiveness data for quality improvement.

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