Quality criteria for pediatric oncology centers: A systematic literature review

Abstract Introduction Survival of children and adolescents diagnosed with cancer improved over the last decades due to better diagnostics, treatment, and supportive care. Quality criteria that measure, compare, and make the quality of care of individual pediatric oncology centers more transparent are heterogeneous and inconsistent. Aim With this systematic review, we aimed to summarize existing quality criteria for pediatric oncology centers in countries with highly developed health‐care systems. Methods We searched three databases for publications, and websites for guidelines about quality criteria for pediatric oncology centers in February 2022. We considered all types of publications except expert opinions. We excluded publications not focusing on highly developed health‐care systems, addressing the certification of professionals, or focusing on subspecialties (e.g., pediatric neuro‐oncology). We discarded quality criteria if they were too specific (e.g., for a specific treatment center), too broad (e.g., national 5‐year overall survival), or if the aspect was covered by standardized clinical procedures or at the national level. We grouped the identified criteria thematically. Results We identified 18 publications and guideline documents with 530 criteria, of which 201 fulfilled the inclusion criteria. The combination of similar criteria resulted in 90 overarching criteria, which we assigned to the following categories: facilities and networks, multidisciplinary team and other experts, supportive care, treatment, long‐term care, and volume and numbers. Conclusion Our results provide a comprehensive overview of existing quality criteria for pediatric oncology in countries with highly developed health‐care systems. These criteria can serve as a basis to develop national quality criteria in pediatric oncology.


Olshefski
(2020) 6 Pediatric anesthesiology for radiation oncology When radiation therapy is delivered at an adultorientedsite outside the primary hospital: optimal anesthesia-related care for sedation of these children requires a provider with pediatric training.The cancer care index tracks patients requiring sedation for radiation therapy managed by an anesthesiologist without extensive pediatric training Radiation therapy G-BA (2021) 1 Pediatric Surgery yes/no Pediatric surgery G-BA (2021) 1 Surgery yes/no Pediatric surgery Kowalczyk (2009) 4 Requirements of a Paediatric Haematology and/or Oncology Unit Immediate access at all times to paediatric surgery, neurosurgery and other specialties Pediatric surgery Pediatric neurosurgery G-BA (2021) 1 Neurosurgery yes/no Pediatric neurosurgery Knops (2012) 3 In a paediatric oncology centre, the following facilities are 24 h/day available: Paediatric intensive care unit, reachable within 10 min Extensive possibilities for imaging, like conventional X-rays, ultra sound, CT-scan/magnetic resonance imaging with the possibility for anaesthetics  7 Evidence that MDTs are established in each principal treatment centre MDT established, including regularly scheduled MDT conferences G-BA (2021) 1 There is close and structured cooperation within the multiprofessional team, the results of which are documented.

Presentation of multiprofessional team
Indicator target: As complete as possible presentation of the center cases in the multiprofessional team.
Numerator: center cases of the denominator that MDT established, including regularly scheduled MDT conferences were presented in the multiprofessional team Denominator: center cases Target: ≥ 95% Knops (2012) 3 A paediatric oncology centre has so called 'Treatment Multidisciplinary Teams' (TMDT) at its disposal for the treatment of children with cancer directed at the following tumour types: central nervous system (CNS) tumours, solid tumours (outside the CNS), retinoblastoma, lymphomas and leukaemia's (including allogenic bone marrow transplantation).The TMDTs are in charge of the care for the patient and consist of representatives of all relevant care providers.
Recommendation MDT established, including regularly scheduled MDT conferences Kowalczyk (2009) 4 The rights of the hospitalised child A multi-disciplinary treatment team MDT established, including regularly scheduled MDT conferences NICE (2005) 7 Protocols for referral to specialist MDTs MDT established, including regularly scheduled MDT conferences G-BA (2021) 1 Each patient is presented in an internal departmental meeting in the multiprofessional team and the treatment is strategically determined yes/no MDT established, including regularly scheduled MDT conferences Hord (2014) 2 A regularly scheduled multidisciplinary care conference MDT established, including regularly scheduled MDT conferences Bradley (2013b) 8

Interdisciplinary Team Meetings
Indicator Rationale: Identifies the existence of regularly scheduled interdisciplinary team meetings in which nursing, medical and behavioural professionals assemble to collectively review the progress of patients and develop a comprehensive care plan addressing all needs of patients and families.Such care plans should be documented.An interdisciplinary team meeting is distinct from a tumour board.Definition: The proportion of pediatric oncology tertiary hospitals that have regularly scheduled interdisciplinary pediatric oncology team meetings to discuss patient care issues resulting in a written record.
Indicator Specification: Proportion Numerator: Number of pediatric oncology tertiary MDT established, including regularly scheduled MDT conferences centres that have regularly scheduled interdisciplinary pediatric oncology team meetings that produce a written record.Denominator: Number of pediatric oncology tertiary hospitals.NICE (2005) 7 Staff attendance at the MDT meetings MDT established, including regularly scheduled MDT conferences NICE (2005) 7 Adequate provision of specialist staff for every MDT Number of pediatric oncology disciplines with multidisciplinary staffing ratios for pediatric oncology Bradley (2013b) 8

Sufficient Multidisciplinary stuff
Indicator Rationale: Provides a measure of access to comprehensive, multidisciplinary pediatric oncology teams.Pediatric Oncology Group of Ontario (POGO)'s staffing ratio recommendations are based on the critical importance of a comprehensive, multidisciplinary team-based approach to optimal outcomes in pediatric oncology practice.
Definition: a) Compliance with/ achievement of POGO recommended pediatric oncology discipline specific staffing ratios of patients to discipline.
b) The proportion of professional pediatric oncology disciplines (for which POGO recommended multidisciplinary staffing ratios for pediatric oncology exist) for which the POGO-recommended staffing ratios have been met.A paediatric oncology centre has a functioning supportive Multidisciplinary Team at its disposal directed at the psychosocial care for paediatric oncology patients and their families.This psychosocial MDT consists at least of child psychologists, play therapists, social workers, paediatric oncology nurses, educational service workers, paediatric oncologists and if desired other specialists of the Treatment Multidisciplinary Team.  3 A paediatric oncology centre has a functioning supportive Multidisciplinary Team at its disposal directed at the management of pain in children.utritional status of patients Supportive care (guidelines for): Nutritional assessment Knops (2012) 3 The caregiver makes assistance in nutrition, also for the homesituation, available.Knops (2012) 3 The physician-in-charge and the case manager of palliative care make a palliative care scheme based on values, goals, needs and developmental stage of the patient and its family, in accordance with law.

Recommendation
Supportive care (guidelines for): Palliative care (including bereavement) Knops (2012) 3 The caregiver emphasizes that optimal palliative care will be given when cure is no longer feasible.

Recommendation
evelopment of national guidelines on febrile neutropenia Guidelines on how to approach a child with F&N (availability, risk-stratified approach, escalation for fever persistence) NICE (2005) 7 Development of risk-stratified protocols for the management of febrile neutropenia Guidelines on how to approach a child with F&N (availability, risk-stratified approach, escalation for fever persistence) NICE (2005) 7 Development of protocols for outpatient treatment of febrile neutropenia Guidelines on how to approach a child with F&N (availability, risk-stratified approach, escalation for fever persistence) NICE (2005) 7 Compliance with protocols and guidelines (febrile neutropenia) Guidelines on how to approach a child with F&N (availability, risk-stratified approach, escalation for fever persistence) ten Berg (2018) 14 Having a general recommendation on the antimicrobial policy of febrile neutropenia in children with cancer 1.No recommendation 2. Verbal agreement 3. Written recommendation in own document system Guidelines on how to approach a child with F&N (availability, risk-stratified approach, escalation for fever persistence)  Evidence of care plans for long-term care for all patients Number/Proportion of survivors of childhood cancer with a survivor care plan Knops (2012) 3 The physician-in-charge and case manager of follow-up care make in collaboration with other members of the follow-up MDT and the patient a follow-up scheme at the end, one year and 5 years after treatment directed at control of the specific tumor and early detection of relapse or secondary tumours.

Recommendation
Number/Proportion of survivors of childhood cancer with a survivor care plan Knops (2012) 3 The physician-in-charge and case manager of follow-up care make in collaboration with other members of the follow-up MDT and the patient a follow-up scheme at the end, one year and 5 years after treatment directed at the early detection and treatment of possible side effects, psychosocial and neuropsychological problems after the treatment of childhood cancer.

Recommendation
Number/Proportion of survivors of childhood cancer with a survivor care plan Knops (2012) 3 The physician-in-charge makes in collaboration with the patient arrangements for transition from paediatric oncology to adult medical oncology when applicable.

Requirements of a Paediatric Haematology and/or Oncology Unit
There should be a minimum number of cases that a unit sees to remain efficient and competent.This probably equates to at least 30 new cases per year.
Number of cases per year and provider/clinic de Rojas (2019) 10

Number of patients/year
Number of cases per year and provider/clinic Knops (2013) 18 Volume of a hospital ...the treatment of more than five cases per year per provider (i.e.either hospital or physician) as 'high volume' ...that higher volume hospitals, higher case volume providers, and specialised hospitals are related to the better outcome in paediatric oncology Although there is no consensus about a threshold in paediatric oncology that indicates the transition from low volume providers to high volume providers, for this review we defined the treatment of more than five cases per year per provider (i.e.either hospital or physician) as 'high volume'.This definition of high volume was made after reading the selected studies and based on the encountered volume numbers.

Number of cases per year and provider/clinic
Process: a) The proportion of children [...] completing treatment for cancer who have an end-of-treatment summary and care plan.Numerator -the number of people in the denominator who have an end-of-treatment summary and care plan.Denominator -the number of children [...] completing treatment for cancer.Number/Proportion of survivors of childhood cancer with a survivor care plan NICE (2014) 11 Process: b) The proportion of children [...] treated for cancer who have their end-of-treatment summary and care plan reviewed 5 years after the end of their initial treatment.Numerator -the number of people in the denominator who have their end-of-treatment summary and care plan reviewed 5 years after the end of their initial treatment.Denominator -the number of children [...] treated for cancer with an end-of-treatment summary and care plan.Number/Proportion of survivors who have their survivorship care plan reviewed 5 years after the end of treatment NICE (2005) 7 designed to provide long-term, multidisciplinary follow-up of successfully treated patients at the original treatment center or by a physician led team of health care professionals who are familiar with the potential adverse effects of treatment of childhood cancer; as survivors of Established transition structure childhood cancer move into adulthood, transition to an adult provider may be appropriate Volume and numbers DKG (2022/2021)5 Primary cases (all first diagnoses of first and second tumors; multiple answers possible; (Pat.with first tumor + cases with second tumors

care: CVC and supportive care (guidelines) and febrile neutropenia (F&N)
Furthermore, it is key to ensure that the central venous catheter (CVC) tip is in an acceptable location for long-term use.Failure to insert the desired device or leaving the catheter tip in an unacceptable location within the heart or great vessels counts as a Cancer Care Index event Central Venous Line (CVL) Infection Rate Indicator Rationale: Indexes a common but potentially serious complication of use of CVLs for fluid, drug and blood product administration.CVLs are commonly used in pediatric cancer patients and infection in this patient population is particularly hazardous.Definition: The number of confirmed central venous line (CVL)-derived primary blood stream infection cases amongst pediatric oncology patients, per 1,000 pediatric oncology central venous line days.Definition: The proportion of pediatric oncology tertiary and/or Satellite programs that have formal, written policies/ procedures for the management of: a) fever/ neutropenia (in both tertiary and Satellite centres); b) ambulatory management of fever/ neutropenia (in the tertiary centres only); c) central venous line management (in both tertiary and Satellite centres); d) anti-neoplastic induced nausea and vomiting (in both tertiary and Satellite centres) Indicator Specification: Proportion Numerator: Number of tertiary and/ or Satellite pediatric oncology programs who have formal supportive care guidelines for the management of each of the above four supportive care issues for children with cancer. 3A paediatric oncology centre has written guidelines about diagnostics and treatment of all paediatric cancer types, Recommendation Existence of supportive care guidelines Supportive care (guidelines for): supportive care (including pain management), follow-up care after the end of treatment and palliative care.Nutritional assessment Detailed survey of the patient`s nutritional status by a nutritional expert [….] should be performed before initiating a therapy, which provides a baseline to manage utrition throughout treatment.Not documenting this assessment constitutes an event Supportive care (guidelines for): Nutritional assessment Bradley (2013b) 8 Guidelines for Nutritional Support Indicator Rationale: Proposed as a high-level indicator of best practice regarding nutritional support for children with cancer.Appropriate nutritional support influences outcome and quality of life for pediatric cancer patients.Definition: The proportion of pediatric oncology tertiary centres that utilize a standardized guideline for nutritional support for pediatric oncology patients.
Survivors with a survivor care planIndicator Rationale: Provides a measure of the efficiency and integration of the pediatric cancer system across the trajectory of disease and age.Survivor care plans allow for the provision of knowledge to and the empowerment of survivors, facilitating self-advocacy, while enabling healthcare providers to best meet the individual needs of survivors.Definition: The proportion of pediatric and adult survivors of childhood cancer enrolled in AfterCare with an individualized and standardized survivor care plan.Indicator Specification: Proportion Numerator: Number of pediatric and adult survivors of childhood cancer enrolled in AfterCare who have been provided with a survivor care plan.Denominator: Number of pediatric and adult survivors of childhood cancer enrolled in AfterCare.Survivors with a Survivor Care Plan Indicator Rationale: Provides a measure of the efficiency and integration of the pediatric cancer system across the trajectory of disease and age.Survivor care plans allow for the provision of knowledge to and the empowerment of survivors, facilitating self-advocacy, while enabling healthcare providers to best meet the individual needs of survivors.Evidence of local arrangements to ensure that children [...] who have been treated for cancer have an end-of-treatment summary and care plan that includes agreed follow-up and monitoring arrangements.