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In 2016, the European Society of Gynaecological Oncology (ESGO) developed a list of quality indicators (QIs) for advanced ovarian cancer surgery with the aim of helping and auditing clinical practice.1 The QIs were based on evidence-based research, meetings of a multidisciplinary International Development Group, an internal validation of the targets and scoring system, and an external review process involving physicians and patients. The ultimate plan was for QIs to be used for self-assessment, quality assurance programs, and for certification of centers.
More recently, a number of amendments were made after several years of implementation of our initially defined QIs into clinical practice and accreditation of centers. This was done in order to emphasize and focus on the surgical scores. The amendments were defined and proposed during a new meeting of the interdisciplinary group that aimed to target the clinical significance of the QIs and assessed evidence after implementation of the initial scoring system.
The definitions and specifications of the actual QIs remain unchanged and have been previously described in detail.1 Also, the total 40 score, with a 32 cut-off, is maintained.
The process of definitions and modifications are summarized as follows. The QIs for advanced ovarian cancer surgery were developed using a four-step evaluation process based on physical meetings of the multidisciplinary committee. The process was founded on the following values: (1) multidisciplinary international expert panel, (2) evidence-based medicine and expert consensus, (3) patient engagement, (4) external review process, (5) structured format to present QIs, and (6) strict assessment of conflicts of interests. This development process is outlined in Table 1.
Each of the QIs is categorized as a structural, process, or outcome indicator. The specifications of how these are measured are outlined in Table 2. The time frame for assessment criteria is set as the last calendar year. In addition to the actual measurement of the indicator, a target indicates the level that each center should aim to meet such quality requirements. Targets are based on available scientific evidence, personal experience of group members, on expert consensus, and on feedback from external reviewers. Quality indicators 1 to 3 deal with caseload in the center, training, skills, and experience of surgeons and the surgical team. Quality indicators 4 to 6 are related to the overall management of patients with advanced ovarian cancer. Quality indicator 7 addresses the value of adequate anesthesiology and peri-operative care to assure an optimal surgical outcome, focusing on not only the reduction of surgical morbidity but also optimization of facility and personnel to appropriately manage complications. Quality indicators 8 to 10 emphasize the need for a complete and transparent flow of information on the management and surgical outcome of patients, which encompasses information documentation, communication with consultants and colleagues, assessment of quality, and monitoring of improvement.
Each QI is associated with a score, and an assessment form is required (Table 3). The goals of the form are to support the self-assessment, or the external assessment, of a given institution. The sum of the individual scores being 40, it was decided that an institution meeting 80% of the score (score 32) provides satisfactory surgical management of patients with advanced ovarian cancer.
Summary of changes:
The scoring of the criteria 3, 4, 8, and 10 is maintained.
The rating of the other criteria is modified in favor of purely surgical items: the score of the criterium 5 is reduced to 2. The scores of the criteria 6, 7, and 9 are reduced to 1 each.
The seven (7) points made available after implementation of the reduced score are assigned as follows:
Criterium 1.1: score increased to 8 (+3) if the optimal target is met (rates of complete cytoreduction over 65%)
Criterium 2.1: score increased to 7 (+2) if the optimal target is met (≥100 surgeries performed per center per year) and to score 4 (+1) if the intermediate target is met (50–99 surgeries performed per center per year)
Criterium 2.2: the target is modified as follows: “95% of surgeries performed by surgeons operating at least 20 patients a year” with a score 5 (+ 2).
There is ample evidence that centralization of care results in improved overall oncologic outcomes. ESGO has developed a number of criteria that provide centers ith accreditation for ovarian cancer surgery based on parameters that will distinguish centers with the classification of either ‘Standard Accreditation’ or ‘Center of Excellence’. Those centers accredited as a Center of Excellence may then build a network for education, training, and research. These criteria are outlined in Box 1.
Modified center criteria for European Society of Gynaecological Oncology (ESGO) certification for ovarian cancer surgery: (A) Standard Accreditation and (B) Center of Excellence
A. Entry criteria for standard ESGO certification for ovarian cancer surgery (all criteria must apply)
24 complete surgeries per year in advanced stage III and IV ovarian cancer over the last 3 years (a total of 72 over the 3-year period accepted, at least 20 in the last year)
12 complete primary cytoreductive surgeries per year in advanced stage III and IV ovarian cancer over the last 3 years (36 over the 3-year period accepted, at least 10 in the last year)
Secondary and tertiary surgeries for recurrences or palliative procedures are not included
Submission of six operation and pathology reports randomly selected from the submitted database by the ESGO secretariat: three reports will be from the last year (Year 3), two reports from Year 2 and one from Year 1 from the evaluation period.
B. Additional requirements for ESGO certification for ovarian cancer surgery as a Center of Excellence (all criteria must apply)
Publications: three articles on ovarian cancer per year authored by a gynecological surgical oncology member of the team over the last 3 years, including at least one article as first or last author over the entire period
Number of surgeries per year: 50 complete surgeries each year in stage III or IV disease (no exceptions) over a period of 3 years. Recurrent or palliative surgeries are not considered.
The new scores are presented in detail on the ESGO website (https://www.esgo.org/ovarian-surgery-certification/) and are valid for any new accreditation of a center for ovarian cancer surgery. The ESGO certification for advanced ovarian cancer surgery is an award attributed to institutions that offer patients the specific skills, experience, organization, and dedication that are required to achieve optimal levels of surgical care.
CF and NC contributed equally.
Contributors All the authors have contributed to establishing the quality indicators by their participation in a thorough review of the relevant scientific literature.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.