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Background:
There is considerable variation in the quality of melanoma care in the United States. There is a growing concern that quality indicators need to be identified. By using developed quality indicators, hospitals can assess their adherence with current melanoma care guidelines through feedback mechanisms from the National Cancer Data Base (NCDB) and direct quality improvement efforts. The American College of Surgeons (ACS), based on a landmark publication by Bilimoria selected 26 quality measures, three of which were minimum number of lymph nodes from lymphadenectomy that must be resected and pathologically examined. These were 15 cervical, 10 axillary and 5 inguinal nodes. Based on hospital level assessment and compliance of at least 90% of patients meeting the minimum, they found that less than 25% of US hospitals met the criteria. However, this is a multifactorial problem that is dependent on the surgeon, the pathologist, the individual grossing the specimen and patient factors. The objective of this study was to evaluate the nodal evaluation adequacy for melanoma and identify issues surrounding nodal evaluation before and after a quality improvement process.
Methods:
All patients that underwent complete lymphadenectomy due to diagnosis of melanoma from 2009 until October 2015 at Pennsylvania State University Hershey Medical Center were identified. Each chart was evaluated to confirm lymphadenectomy for melanoma, and the surgical pathology report used to determine how many lymph nodes were evaluated by the pathologist. These numbers were then separated by anatomical area (cervical, axillary, and inguinal). These were then evaluated for variability and compliance with the minimums previously described by the ACS Committee on Cancer before and after a quality improvement project was implemented in 2012 by the Penn State Skin Oncology Program. The project consisted of: documentation of levels dissected, photographic documentation to confirm adequacy, alert gross room of minimum number of lymph nodes, retain tissue for 15 days to allow for recounting, document matted lymph nodes, and annual audit of pathology reports.
Results:
In the studied period 157 lymphadenectomies for melanoma were identified being 42 cervical, 70 axillary and 45 inguinal. Before the implementation of the quality improvement project 72% of cervical, 70% of axillary and 95% of inguinal lymphadenectomies met the minimum number of lymph nodes resected, examined and documented. However, after the implementation of the quality improvement project, compliance to these minimums has risen to 100% in all anatomical areas.
Conclusions:
Complete lymph node dissection continues to play a significant role in the treatment of positive lymph nodes in melanoma. Even though the threshold of lymph nodes from lymphadenectomy that were resected, pathologically examined and documented suggested by ACS is low, we initially had room for improvement like most hospitals. By implementing the quality improvement project using validated measures and a consistent process, we substantially reduced the variation in the quality of melanoma care delivered in our institution. Hospitals can use these indicators to direct a quality improvement effort, which thus offers an opportunity to standardize and improve the quality of care in patients with melanoma.