Annelotte van Bommel

167 General discussion and future perspectives From the start of the NBCA in 2011, quality indicators have been adjusted and refined, new ones developed and others abolished, aiming for clearer definitions of process and outcome indicators. Quality parameters should be unambiguous and meaningless indicators should be abandoned. The rate of BCPP, a multidisciplinary indicator of local outcome and an alternative to themere breast conserving surgery rate well illustrates the continuing adjustment of the Audit’s quality parameters. The development of other surgical and non-surgical indicators (e.g. indicators for side-effects related to radiotherapy or chemotherapy) remains “work in progress”. Ideally, locoregional recurrence and survival data should become accessible in relation to NBCA data as well. Linking the NBCA data with data in the Netherlands Cancer Registry (NCR) may achieve this without the additional work of collecting more long-term follow-up data. Measuring quality of care is in itself not a unique concept. Breast cancer audits also exist in other countries like Sweden 5 , Australia 6 , New Zealand 6 and the United Kingdom 7 . In the United States of America, other databases are used to investigate quality of care to a certain extent. 8 In our country, the NCR has been collecting information regarding treatment and outcomes of breast cancer since 1989 by specially trained data-managers who periodically visit all hospitals in the Netherlands. 9 The NBCA is a result of the collaboration between the Comprehensive Cancer Organization the Netherlands (IKNL), which facilitates the NCR, and the Dutch Institute for Clinical Auditing 10 , which facilitates the NBCA. The NBCA has the strength of being initiated by clinicians themselves with drive to improve outcomes of care. It has led to a multidisciplinary, nationwide audit which annually delivers public reports of patient, treatment, and outcome data. Moreover, feedback in the context of benchmark results is provided to individual hospitals and their clinicians treating breast cancer patients, and also an update of the quality parameters. The ongoing process of structuring and restructuring this “outer circle” ( Figure 1 ) of the NBCA serves as a quality monitor on a national level and provides a basis to conduct a “Plan Do Check Act” cycle in individual hospitals for the “inner circle”. 9