Many hospital and freestanding breast disease programs around the country are scurrying to qualify for the National Accreditation Program for Breast Centers, a new survey validation that began Jan. 1.
So far, says David P. Winchester, MD, chairman of the program's board, only 125 hospitals nationally in 30 states have been accredited, but another 150 are in the last stages of the application process, which is administered by the American College of Surgeons. About 1,200 have sent inquiries.
The effort to develop an accreditation program for breast disease care began because, with 250,000 patients diagnosed annually with breast disease—190,000 with invasive and 60,000 with non-invasive disease—"there is such a major public health problem, and there has been a proliferation of 'breast centers' around the country in the last decade" Winchester says. Yet there was no organization or effort to establish evidence-based care criteria, visit the centers, and give guidance for improving quality, he says.
"Here we are with an unknown number of breast cancer centers in the country, probably about 1,500, yet nobody could answer the question about whether there is a problem with quality," Winchester says. No one knew which centers embraced "widely accepted evidence-based standards," and which ones perhaps fell short.
"The old system was very fragmented, involved several individuals offering their own opinions of different types of care, even in our own geographic area," says William Dugoni , MD, medical director of Washington Hospital's women's health program, the latest to receive accreditation. "What we've done is standardize and we've given patients opportunities to have equal access, and to have their cases discussed by a multidisciplinary team."
The only other accreditation agency that looks at cancer care quality, Winchester says, is the Commission on Cancer, an 80-year-old program that reviews 36 standards for cancer care, but doesn't focus on or specialize in any one. It certainly does not look at breast care with nearly the detail, says Winchester, who also is the Commission on Cancer's medical director.
The new NAPBC program requires that each designated breast center provide 17 components of care: an interdisciplinary conference to discuss a patient's disease treatment, data management, patient navigator, survivorship program, pathology, imaging, needle biopsy (core preferred) surgical care, and radiation oncology consultation and treatment. It also looks at medical oncology consultation and treatment, nursing, genetic evaluation and management, education, support and rehabilitation, plastic surgery consultation and treatment, research, outreach and education, and quality improvement.
The NAPBC requires 27 program standards or components, which set forth organizational, responsibility and accountability criteria, require multidisciplinary patient management, a standardized breast cancer staging, imaging, pathology, and biopsy criteria. At least half of all patients diagnosed with early-stage breast cancer must be offered or treated with breast conserving surgery.
And the centers must have a clinical trial component that promotes prevention, early diagnosis, and treatment.
The programs must also have breast cancer surveillance for following patients. Winchester says the NAPBC will actually monitor care. "Let's say Mrs. Smith had a lumpectomy eight months ago, with positive nodes, and was premenopausal, and didn't get chemotherapy. We know that. We fire back a report to the center saying, 'Why not?'"
"We'll survey another three years, with an audit on site, and make sure nobody slips through the cracks. And so far it's working. We feel like we're raising the bar."
Very few if any of the centers are fully compliant during their first pass at the application process, Winchester says. "We've observed in a very consistent manner that it's taking breast centers anywhere from three to six months to complete the SAR (the online survey application record)," a key component in the process.
The biggest problems are inadequate patient navigation programs and problems with radiologist and surgeon skill certification for performing certain breast specific procedures, such as imaging-guide breast biopsies, Winchester says. "If we'd gone out with these first 125 and found that everyone was perfect, there would be no reason for this program," he says.
There is no requirement for number of breast cancer cases the center must treat each year. The NAPBC charges the center $3,500 to $4,000 for the survey process, which, similar to the Joint Commission, will be up for renewal every three years.
The accreditation, however, does not make the breast center eligible for federal reimbursements or health plan contracts, but that may come in time.
One system that was among the earliest adopters is Washington Hospital in Fremont, CA, 37 miles southeast of San Francisco. Washington recently become the only west coast hospital between Seattle and San Diego to be accredited, primarily because Washington's breast care program was so far along when the concept was launched, says Winchester and Dugoni.
"Overall, it's led to a much better quality of care, and allowed us to monitor the outcomes of disease," says Dugoni.
Dugoni says that one benefit from having such a program—and Washington's is all under one roof—is how the streamlining care has reduced time to diagnosis. "We've taken it from 35 days to under 14 days, and that's with all the limitations of insurance."
Winchester and Dugoni agree that hospitals may want to consider marketing this accreditation, and many already are. "In this tough economic time, when you sell yourself as a national accredited center of excellence, you pass a rigorous set of standards, that should indicate this is a very good place for me to be treated," Dugoni says.
"But," he quickly adds, "whether this is used as a marketing tool or not, there's a recognition that we have put together a program that make sure everything is vigorously followed, pursued through science and with patient education and that the outcome is the very best possible one for women."
So far, only four states have more than five designated centers: Pennsylvania, 13; Virginia and Wisconsin, 11 each; and North Carolina, 8.