The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care

Background Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. Objective This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. Methods Process indicators for the selected multimodal strategies to optimize rectal cancer care will be selected and prospectively collected for all patients with stages 1 to 3 rectal cancer undergoing TME surgery. KT interventions, including audit and feedback, opinion leaders, and community of practice, will be implemented to increase the uptake of these clinical strategies. Results The uptake of the process indicators over time and the effect of the uptake of the process indicators on short- and long-term oncologic outcomes will be evaluated for each multimodal strategy. Conclusions This quality improvement initiative will identify existing gaps in care for the selected multimodal strategies and implement KT interventions to close these gaps. The results of this study will inform further efforts to optimize rectal cancer care. International Registered Report Identifier (IRRID) DERR1-10.2196/15535


Request For Proposal (RFP) No. RP431-2013-01: Accelerated Diffusion of Strategic Quality Initiatives for Diagnosis and Treatment of Cancer
Scientific Officer Report For Proposal: Accelerated Implementation Diffusion of Quality Initiates for Rectal Cancer Across Canada

Lead Applicant: Erin Kennedy
Overall Summary of Proposal: This project proposes to accelerate implementation of established quality initiatives for rectal cancer including Total Mesorectal Excision (TME) surgery and assessment, multidisciplinary cancer conferences, and Magnetic Resonance Imaging (MRI) using a multi faceted knowledge translation (KT) strategy. While all have proven to improve clinical outcomes, there is significant variation in uptake and use of these quality initiatives across the country, with no centre having implemented all three initiatives. This project will involve 8 high volume centres across Canada and will include surgeons, radiologists, radiation oncologists, medical oncologists and pathologists involved in the care of rectal cancer patients as well as patient and family advisors. The Applicant has suggested that successful implementation of these quality initiatives will (i) lead to improved rectal cancer care and clinical outcomes for rectal cancer patients and (ii) set a national standard for these quality initiatives across Canada.

Strengths:
This is a very important and relevant issue with supporting evidence on impact to clinical outcomes. This Proposal is multi-jurisdictional with 8 sites in 6 provinces, involving a minimum of 1000 patients from across the country. The team has done a great job identifying barriers and facilitators so that KT interventions can be tailored to the needs of each site. The Reviewers expressed confidence in their sustainability plan since each site has committed funds to maintain the database and further disseminate within their own jurisdictions beyond the funding period. The patient engagement plan was robust and process outcomes appeared to be measurable and realistic.

Weaknesses:
In the absence of data, there were concerns about the feasibility of implementing all 3 initiatives in each centre concurrently. Particularly, given the variability in baseline practice between centres, mapping out the same timeline and implementation plan for each centre appeared unrealistic. Some of the goals also appeared potentially unrealistic such as the multidisciplinary cancer conference for all newly diagnosed patients, as well as the emphasis on the use of MRI. Further clarification surrounding the use of the Tailoring Grid provided in Figure 2 would have been helpful to clearly understand the process.
The team composition and process for selecting site leaders could have been further developed. For example, the team did not include medical oncology who play an integral role in the management of these patients. The role of project coordinators in each centre was not clearly articulated. There was also no site lead identified for British Columbia, and the proposed selfselection of site leaders did not seem optimal compared to matching underperforming sites to a site leader and jurisdiction that is doing well with a particular initiative.

Budget:
The budget was lacking detail and not well justified. For example, a large portion of the budget was dedicated to salaries for project coordinators whose roles and responsibilities were unclear. There was no budget built in for site visits for underperforming sites as outlined in the risk management plan. While the in-kind contribution was extensive and demonstrated commitment, there was concern that the proposed work may be too ambitious given the proposed budget.