Table 2.
Hierarchy of quality domains for breast surgeons after the 3rd round of modified Delphi ranking
| Quality domain | Median scorea | Validityb | Agreementc |
|---|---|---|---|
| Patients receiving diagnosis of cancer by needle biopsy | 9 | Yes | Agreement |
| Patients undergoing a formal patient-side-site-procedure verification procedure in the operating room | 9 | No | Agreement |
| Percentage of cancer patients with orientation of lumpectomy specimen | 9 | Yes | Agreement |
| Clinical stages 1 and 2 node-negative patients offered sentinel lymph node (SLN) surgery | 9 | Yes | Agreement |
| Mastectomy patients with ≥4 positive nodes referred to radiation oncologist | 9 | Yes | Agreement |
| Stages 1, 2, and 3 patients undergoing initial breast cancer surgery with documentation of ER, PR receptor status | 9 | No | Agreement |
| Stage 1, 2, and 3 undergoing initial breast cancer surgery with documentation of HER2 neu status | 9 | No | Agreement |
| Breast conservation therapy (BCT) patients referred to radiation oncology | 9 | Yes | Agreement |
| Percentage of patients undergoing neoadjuvant therapy before planned breast conservation surgery (BCS) who have imaging marker clip placed in breast | 9 | Yes | Agreement |
| Percentage of patients undergoing lumpectomy for non-palpable cancer with specimen imaging performed | 9 | Yes | Agreement |
| Patients with concordance assessment (testing) of Exam-Imaging-Path by care provider | 9 | No | Agreement |
| Patients undergoing breast cancer surgery with final path report indicating largest single tumor size | 8.5 | No | Agreement |
| Patient’s compliant with National Quality Forum Quality Measures (NQF QM) for endocrine therapy in hormonal receptor positive patients | 8.5 | Yes | Agreement |
| Trastuzumab is considered or administered within 4 months (120 days) after diagnosis for stage 1, 2, or 3 breast cancer that is HER2-positive | 8.5 | No | Agreement |
| Documentation of mastectomy patients offered referral to plastic surgery | 8.5 | Yes | Agreement |
| Documentation of eligibility of BCT and eligible patients offered BCT | 8.5 | Yes | Agreement |
| Patients with documentation of patient options for treatment regardless of procedure type | 8.5 | Yes | Agreement |
| Percentage of patients undergoing BCT with a final ink-negative margin, regardless of number of operations | 8.5 | No | Agreement |
| Patients with adequate history by care provider | 8 | No | Agreement |
| Patients with documentation of postoperative cancer staging (AJCC) | 8 | Yes | Agreement |
| Patient’s compliant with NQF QM for radiation after lumpectomy | 8 | No | Agreement |
| Patients with documentation preoperative (pretreatment) AJCC clinical staging | 8 | Yes | Agreement |
| NCCN compliance with radiation guidelines | 8 | No | Agreement |
| Mastectomy patients receiving preoperative antibiotics | 8 | Yes | Agreement |
| Patients with NCCN guideline compliant care for “high risk lesions” identified on needle biopsy (ADH, ALH, FEA, LCIS, papillary lesion, radial scar, mucin-containing lesion) | 8 | No | Agreement |
| Patients with NCCN guidelines compliant care for diagnostic evaluation of breast lump | 8 | No | Agreement |
| Patients with NCCN compliance for postoperative lab imaging, biomarkers in stages 0, 1, and 2 patients | 8 | No | Agreement |
| NCCN guideline compliance for genetic testing among patients with newly diagnosed breast cancer | 8 | No | Agreement |
| NCCN guideline compliance for genetics assessment/referral among patients with newly diagnosed breast cancer | 8 | No | Agreement |
| Patients with adequate examination by care provider | 7.5 | No | Agreement |
| Patients with final pathologic size ≥ stage 1 T1cN0M0 who have documentation of discussion regarding adjuvant treatment | 7.5 | Yes | Agreement |
| Documentation of reason why patient is not eligible for BCT | 7.5 | No | Indeterminant |
| Patients with adequate review of imagining by care provider | 7.5 | No | Indeterminant |
| Patients with inflammatory or locally advanced breast cancer who undergo neoadjuvant treatment before surgery | 7.5 | No | Agreement |
| High-risk patients with estimated lifetime risk >20% offered screening MRI | 7.5 | No | Indeterminant |
| NCCN compliance for medical oncology recommendations | 7.5 | No | Indeterminant |
| Risk adjusted re-excision lumpectomy rate after breast-conserving therapy | 7.5 | Yes | Agreement |
| NCCN guideline compliance for inflammatory breast cancer | 7.5 | No | Indeterminant |
| NCCN guideline compliance for breast cancer in pregnancy | 7.5 | No | Indeterminant |
| Patients with predicted estimate of BRCA mutation >10% offered BRCA testing | 7.5 | No | Indeterminant |
| High-risk patients (no known cancer) with documentation of risk-reduction counseling | 7.5 | No | Indeterminant |
| NCCN guideline compliance for inadequate margins requiring re-excision in BCS patients | 7.5 | No | Agreement |
| Patients receiving antibiotics within 1 h before surgery | 7 | Yes | Agreement |
| Patients receiving a first- or second-generation cephalosporin before incision | 7 | Yes | Agreement |
| Patients with discontinuations of antibiotics within 24 h after surgery | 7 | Yes | Agreement |
| Patients with Surgical Care Improvement Project (SCIP) antibiotic measure compliance (includes all 3 measures above) | 7 | Yes | Agreement |
| Patients with breast cancer with documentation of risk assessment for germline mutation | 7 | No | Indeterminant |
| Patients compliant with SCIP DVT/PE prophylaxis recommendations | 7 | No | Indeterminant |
| Patients ≤50 years with newly diagnosed breast cancer offered genetic testing | 7 | Yes | Agreement |
| Patients presented to interdisciplinary tumor board (real or virtual) at any time | 7 | No | Agreement |
| Patients compliant with NQF QM for chemotherapy in hormonal receptor-negative patients | 7 | No | Indeterminant |
| Surgical-site infection rate (mastectomy patients) | 7 | No | Indeterminant |
| Percentage of patients entered into a patient registry to identify patient complications and cancer outcomes | 7 | No | Indeterminant |
| One-step surgery success rate stratified by type of operation (mastectomy) | 7 | No | Indeterminant |
| Sentinel lymph node identification rate (%) in breast cancer surgery | 7 | Yes | Agreement |
| Cosmetic score (measure of cosmesis) after BCS (patient self-assessment with Harvard score) | 7 | No | Indeterminant |
| Time (business days) from diagnostic evaluation to needle biopsy | 7 | No | Indeterminant |
| Time (business days) from needle biopsy path report to surgical appointment | 7 | No | Indeterminant |
| Surgical-site infection rate (mastectomy plus plastic surgery patients) | 7 | No | Indeterminant |
| Ipsilateral breast tumor recurrence (IBTR) | 7 | No | Indeterminant |
| Percentage of patients undergoing lumpectomy for non-palpable cancer with two-view specimen imaging performed | 7 | No | Indeterminant |
| Percentage of compliance with ASBrS or ACR annotation of ultrasound (US) images | 7 | No | Indeterminant |
| Percentage of compliance with ASBrS or ACR recommendations for US reports | 7 | No | Indeterminant |
| Percentage of compliance with ASBrS or ACR recommendations for US needle biopsy reports | 7 | No | Indeterminant |
| Compliance with ASBrS or ACR recommendations for US needle biopsy reports | 7 | No | Indeterminant |
| NCCN guideline compliance for pre-op lab and imaging in clinical stages 0, 1, and 2 patients with cancer | 7 | No | Indeterminant |
| Patients with preoperative needle biopsy proven axillary node who do not undergo sentinel node procedure | 7 | No | Indeterminant |
| Local regional recurrence | 7 | No | Indeterminant |
| Patients age ≥70 years, hormone receptor positive, with invasive cancer offered endocrine therapy instead of radiation (documentation) | 7 | No | Indeterminant |
| Disease-free survival | 6.5 | No | Indeterminant |
| Time business days from new breast cancer to office appointment | 6.5 | No | Indeterminant |
| Patients with predicted estimate of BRCA mutation >10% who are tested | 6.5 | No | Indeterminant |
| Time business days from needle biopsy path report of cancer to surgical operation | 6.5 | No | Indeterminant |
| Time business days from abnormal screening mammography to diagnostic evaluation | 6.5 | No | Indeterminant |
| Percentage of cancer patients entered into a quality audit (any type: institutional, personal case log, regional, national) | 6.5 | No | Indeterminant |
| Time business days from new breast symptom to office appointment | 6.5 | No | Indeterminant |
| Patients with benign breast disease with documentation of risk assessment for cancer | 6.5 | No | Indeterminant |
| Percentage of patients with partial breast irradiation after lumpectomy who are compliant with “ASBrS guidelines for eligibility” | 6.5 | No | Indeterminant |
| Percentage of patients with partial breast irradiation after lumpectomy who are compliant with “ASTRO guidelines for eligibility” | 6.5 | No | Indeterminant |
| Number of breast-specific CMEs per year | 6.5 | No | Indeterminant |
| NCCN compliance for SLN surgery in stage 0 DCIS | 6.5 | No | Indeterminant |
| Skin flap necrosis rate after mastectomy stratified by type of mastectomy reconstruction, type of reconstruction | 6.5 | No | Indeterminant |
| Overall survival | 6 | No | Indeterminant |
| Ratio of malignant-to-benign minimally invasive breast biopsies | 6 | No | Indeterminant |
| Surgical-site infection rate (all patients) | 6 | No | Indeterminant |
| Surgeon US (2 × 2 test table performance) (sensitivity, specificity, PPV, NPV) for surgeons performing diagnostic breast evaluation with imaging | 6 | No | Indeterminant |
| NCCN guideline compliance for phyllodes tumor | 6 | No | Indeterminant |
| Compliance with ASBrS or ACR recommendations for stereotactic biopsy reports | 6 | No | Indeterminant |
| Time business days from surgeon appointment for cancer to surgery for cancer | 6 | No | Indeterminant |
| Percentage of mastectomy patients undergoing reconstruction | 6 | No | Indeterminant |
| Cost of perioperative episode of care (affordability) | 6 | No | Agreement |
| Patients with cancer diagnosed for core needle biopsy (CNB) for BiRads 4a lesion | 6 | No | Indeterminant |
| Patients with cancer diagnosed for CNB for BiRads 4b lesion | 6 | No | Indeterminant |
| Patients with cancer diagnosed for CNB for BiRads 4c lesion | 6 | No | Indeterminant |
| Patients with cancer diagnosed for CNB for BiRads 5 lesion | 6 | No | Indeterminant |
| NCCN guideline compliance for Paget’s disease | 6 | No | Indeterminant |
| Surgical-site infection rate (BCS patients) | 6 | No | Indeterminant |
| Number of axillary nodes obtained in patients undergoing level 1 or 2 nodal surgery (median) | 6 | No | Indeterminant |
| Percentage of DCIS patients undergoing BCS for cancer who do not have axillary surgery | 6 | No | Indeterminant |
| Patients with College of American Pathologists (CAP) compliant reporting | 5.5 | No | Indeterminant |
| Breast cancer patients presented to interdisciplinary tumor board (real or virtual) before 1st treatment | 5.5 | No | Indeterminant |
| Percentage of cancer patients enrolled in clinical trials | 5.5 | No | Indeterminant |
| Mastectomy patients with positive SLN who undergo completion of axillary dissection | 5.5 | No | Indeterminant |
| Patients with cancer diagnosed on CNB for BiRads 3 lesion | 5.5 | No | Indeterminant |
| Patients with unifocal cancer smaller than 3 cm who undergo BCT | 5.5 | No | Indeterminant |
| Patients with documentation of pre-op breast size and symmetry | 5.5 | No | Indeterminant |
| Clinical stage 0 DCIS patients who do not undergo SLN surgery for BCT | 5.5 | No | Indeterminant |
| Patients undergoing level 1 or 2 axillary dissection with ≥15 nodes removed | 5.5 | No | Indeterminant |
| Number of SLN’s (median) in patients undergoing SLN procedure | 5.5 | No | Indeterminant |
| Breast volume (number of cancer cases per year per surgeon) | 5.5 | No | Indeterminant |
| Percentage of cancer patients with documentation of search for clinical trial | 5.5 | No | Indeterminant |
| Percentage of breast biopsy pathology requisition forms containing adequate information for pathologist (history, CBE, imaging) | 5 | No | Agreement |
| Time from initial cancer surgery to pathology report | 5 | No | Indeterminant |
| Patients with documentation of pre-op contralateral breast cancer risk | 5 | No | Indeterminant |
| Clinical stage 0 DCIS patients who do not undergo SLN surgery for mastectomy | 5 | No | Indeterminant |
| BCT rate (actual and potential) | 5 | No | Indeterminant |
| Time business days from abnormal screening mammogram (SM) to office appointment | 5 | No | Indeterminant |
| Patients with documentation of needle biopsy results delivered to patients within 48 h | 5 | No | Indeterminant |
| BCT-eligible patients offered neoadjuvant treatment | 5 | No | Agreement |
| Interval cancers (cancer detected within 1 year after negative US biopsy or stereotactic biopsy) | 5 | No | Indeterminant |
| Cosmetic score (measure of cosmesis) after mastectomy, no reconstruction (patient self-assessment) | 5 | No | Indeterminant |
| Percentage of cancer patients referred to medical oncology | 5 | No | Indeterminant |
| Axillary recurrence rate | 5 | No | Indeterminant |
| Patients with NCCN guidelines compliant care for nipple discharge | 5 | No | Disagreement |
| Percentage of BCT patients with marker clips placed in lumpectomy cavity to aid radiation oncologist for location of boost dose for radiation | 5 | No | Indeterminant |
| Percentage of patients with documentation of arm edema status post-operatively | 4.5 | No | Indeterminant |
| Patients undergoing re-operation within 30 days (stratified by case type) | 4.5 | No | Indeterminant |
| Patients undergoing re-admission within 30 days (stratified by base type) | 4.5 | No | Indeterminant |
| Percentage of BCT patients with oncoplastic procedure performed | 4.5 | No | Indeterminant |
| Patients with documentation of gynecologic/sexual side effects of endocrine therapy | 4.5 | No | Indeterminant |
| Patients with documentation of gynecologic/sexual changes during follow-up | 4.5 | No | Indeterminant |
| Mastectomy patients who undergo immediate intraoperative SLN assessment | 4.5 | No | Indeterminant |
| Patients with latragenic injury to adjacent organ, structure (stratified by case type) | 4 | No | Indeterminant |
| Percentage of lumpectomy patients with surgeon use of US intraoperatively | 4 | No | Indeterminant |
| Patients with documentation of surgical pathology results delivered to patients within 96 h | 4 | No | Indeterminant |
| Patients who have “grouped” postoperative appointments (same day, same location with care providers) | 4 | No | Indeterminant |
| Percutaneous procedure complications | 3.5 | No | Indeterminant |
| Percentage of patients with development of lymphedema of arm after axillary surgery | 3.5 | No | Indeterminant |
| Time from initial cancer surgery to pathology report | 3 | No | Disagreement |
| Patients with new DVT less than or equal to 30 days post-operatively | 3 | No | Disagreement |
| Patients with new PE ≤30 days post-operatively | 3 | No | Indeterminant |
| Documentation of use of new NSQIP-generated ACS risk calculator preoperatively | 3 | No | Indeterminant |
| Patients with unplanned overnight stay stratified by procedure type | 2.5 | No | Indeterminant |
| Sensitivity of immediate intraoperative detection of positive SLN (pathology quality measure) | 2.5 | No | Agreement |
| Patients with myocardial infarction ≤30 days postoperatively | 2 | No | Agreement |
| Patients with new renal failure ≤30 days postoperatively | 2 | No | Agreement |
| Patients with new respiratory failure ≤30 days post-operatively | 2 | No | Agreement |
ER estrogen receptor; PR progesterone receptor; HER2 human epidermal growth factor 2; AJCC American Joint Committee on Cancer; NCCN National Comprehensive Cancer Network; ADH Atypical Ductal Hyperplasia; ALH Atypical lobular hyperplasia; FEA Flat epithelial atypia; LCIS Lobular carcinoma in situ; MRI magnetic resonance imaging; SCIP Surgical care improvment project; DVT Deep venous thrombosis; PE Pulmonary embolism; ASBrS American Society of Breast Surgeons; ACR American College of Radiology; ASTRO American Society of therapuetic radiation oncologists; CME Continuing medical education credits; DCIS Ductal carcinoma in situ; PPV positive predictive value; NPV negative predictive value; CBE clinical breast exam; NSQIP National Surgical Quality Improvement Program; ACS American Cancer Society
aMedian score 1–9: lowest to highest
bValidity: ≥90% of the rankings are in the 7–9 range
cAgreement: Based on scoring dispersion (e.g., for a panel of 13, there is “agreement” if >8 rankings are in any 3-point range and disagreement if >3 rankings are 1–3 and 7–9
Italicized text: Final ASBrS QM chosen for CMS quality payment programs