Quality measurements for the Colorectal Cancer Registry
The results from the registry can be used to document treatment and results of treatment at the national level, but can also be useful for assessing practice in individual hospitals.
For the past three years, the Colorectal Cancer Registry and the expert group have presented quality indicators with defined target figures. All indicators have also been reviewed and assessed this year.
The Norwegian Gastrointestinal Cancer Group Colorectal (NGICG-CR), which is the reference group for the National Colorectal Cancer Registry, has been commissioned by the Norwegian Directorate of Health to prepare national guidelines for colorectal cancer. The health care patients receive should follow the recommendations found in the Colorectal Cancer Action Programme.
The Norwegian Directorate of Health has previously defined 5-year relative survival for patients diagnosed with colorectal cancer as national quality indicators. The Cancer Registry of Norway and the Professional Council cooperate with the Norwegian Directorate of Health to give a selection of the professional community's quality objectives the status of national quality indicators. Due to resource limitations in the Norwegian Directorate of Health, no new national quality indicators for colorectal cancer have been established in 2022.
Quality indicators
The quality indicator is an indirect measure and says something about the quality of the area being measured. The quality indicators should be seen in context in order to provide a comprehensive picture of the quality of the health services provided to patients with colorectal cancer. They are also important for assessing whether the recommendations in the «National action programme with guidelines for diagnosis, treatment and follow-up of colon and rectal cancer» are being followed.
Quality indicators colon cancer
The results for the quality indicators for colorectal cancer show that six out of eight indicators have good goal attainment and two have moderate goal attainment. The coverage rate for clinical examination reports is 74.1 %, while for surgery reports it is 84.9 %. This is due to the fact that not all patients receive treatment in surgical wards, and there is a need to ensure good local routines for responsibility for the assessment report. One hospital with high volume has low reporting and is the main reason for the falling coverage.
Relative survival for patients with stage I–III colorectal cancer five years after surgery is 89.2% and remains stable. There are also few patients who die within 100 days after elective surgery and postoperative mortality is 2.1 %. The proportion of patients who do not metastase to other organs is 86.2 %, and has been stable in recent years.
The proportion of patients (all stages) who survive five years after diagnosis is 70.4%. The proportion who undergo laparoscopic surgery is still increasing, and most hospitals have achieved good results.
How many people are being examined for MSI or MMR under the age of 60 is a new indicator this year and is shown overall for colorectal cancer. The result shows moderate goal attainment of 69.5%.
Quality improvements
The Norwegian Colorectal Cancer Registry provides updated information on this patient group, which is important when the expert group discusses national guidelines. There are several examples of how results and mapping from the register are useful as a background for the professional discussions in the group. The results from the registry can be used to document treatment and results of treatment at the national level, but can also be useful for assessing practice in individual hospitals.
There is always a balancing act between how much information must be collected to provide answers to desired questions in relation to how much workload the number of information provides for those who are to report. Most of the important recommendations on assessment and surgery in the national guidelines are included as variables in the registry.
The registry collects information on whether the patient undergoes open or laparoscopic (keyhole) surgery. Results in this year's report show that laparoscopic technique has increased steadily for both colorectal cancer, and long-term survival is as good as with open surgery. The national guidelines regard open and laparoscopic surgery as equivalent techniques that complement each other.
The annual report publishes results at institutional level for selected variables reported to the register. This will form the basis for local improvement measures, so that patients can be ensured equal treatment regardless of place of residence.
The following patient-oriented improvement areas are identified in this year's report:
Specified distance from tumor to mesorectal fascia (MRF) – rectal cancer:
The Academic Council wishes that the recommendation on the use of radiology templates is followed, so that the necessary information is available in MDT meetings. The professional council will follow up hospitals with low goal attainment (below 60%) and implement measures to increase the use of structured radiology templates.
This is the first year the analysis is shown with target figures, and we will have to wait a few years to see any effects. The results for the quality indicator show variation between hospitals, while the national result has a high goal attainment of 75.3 %.
Mortality 100 days after elective surgery – colon cancer:
Results for mortality 100 days after elective surgery for patients in stages I–III show variation between hospitals. The Quality Registry has been in contact with hospitals above the target figure of 3 % and offered patient lists for quality assurance of their own results.
Lists have been sent out to Innlandet Hospital, Lillehammer and Vestre Viken, Bærum. Innlandet Hospital, Lillehammer has sent feedback after reviewing its patients, and the hospital has good routines in its own quality register and regular monthly meetings for reviews of these patients.
Read more about quality improvements in this year's report (Norwegian only)
Evaluation for measures for clinical quality improvement (changed practice)
Proportion of structured pathology descriptions:
The use of a template when describing pathology responses was one of the first process indicators established in the registry. The target figure was set at 90% for high goal attainment. The results for 2020 showed high goal achievement nationally, but the result for Central Norway Regional Health Authority Norway was 55 % for colorectal cancer and 52.3 % for rectal cancer in 2020.
Measures were implemented, and after co-location of the departments in Helse Møre og Romsdal, with increased use of standardised templates, the results showed an increase to 93.3 % for colorectal cancer and 95 % for rectal cancer in 2021. Similar measures were taken at St. Olavs Hospital, where the proportion of drugs with targets in 2021 was 91.5 % for colorectal cancer and 87 % for rectal cancer.
Results have shown a steady increase in the use of templates, and for 2021, the proportion of pathology laboratories that used MAL has increased to 97.2% for colorectal cancer and 96% for rectal cancer.
The Academic Council has chosen to omit these process indicators from this year's report, since all laboratories now follow the guidelines and use templates.
Patient safety
Complications such as anastomotic leakage and reoperations in connection with surgery are reported to the Colorectal Cancer Registry of Norway on the surgery report. Complications after treatment are also registered in the Norwegian Registry for Gastrointestinal Surgery (NoRGast), which contains data that make it possible to adjust for differences in the patient population associated with risk factors other than cancer. So far, no linkage studies have been conducted between these registries, but such collaboration would have supplemented both registries, as they register different information about this patient group. Representatives from NoRGast are also members of the academic council.
The registry shows results for postoperative mortality 100 days after surgery as an overall measure of serious complications associated with surgical treatment. There are no major differences between the hospitals, and most have reached the quality target (< 3 %) that has been set.
Side effects/complications may also occur after chemotherapy and radiation therapy. These are usually less serious and are not reported to the registry.
Proms
In order to further strengthen the quality of health services, the Cancer Registry of Norway has in 2019 and 2020 worked on planning and building an infra structure for collecting PROMs (patient-reported outcome and experience measures), including integration with ePROM (Patient Reported Experience Measures), which is the national solution for obtaining PROMs.
The National Colorectal Cancer Registry started with routine collection of PROMs/PREMs in 2021. The registry has been allocated funding from the Professional Centre for Patient-Reported Data to use ePROM. In order to distinguish between common ailments in the population and ailments related to colorectal cancer, a random sample of people without colorectal cancer are also invited to submit a questionnaire.
The population survey is fully digital, and invitations are received in the inbox on Helsenorge.no or in Digipost/eBoks. Not everyone is active at Helsenorge or has a digital mailbox, and the Cancer Registry reached 81% of colorectal cancer patients and 78% of the control group in 2022, an increase from 72% for both groups in 2021.
Results in this year's report show no differences between men and women in terms of self-reported health and quality of life for patients in stages I-IV of colorectal cancer diagnosed in 2022. However, a significant difference in self-reported health and quality of life is seen between people newly diagnosed with colorectal cancer and people without colorectal cancer. However, the figures must be interpreted with caution as the number answered is low, and there is a higher margin of uncertainty for patients with rectal cancer.
Another result shows the extent to which patients are satisfied with the treatment they received. The results for all patients combined show that 86 % are very satisfied or quite satisfied with the treatment offered at the hospital.
See more results from the survey in the annual report (Norwegian only)
