The value of external peer review in oncology: evaluating the impact on cancer services in Dutch hospitals

During the 1980’s and 90’s, cancer treatment became increasingly multidisciplinary. Adjuvant chemotherapy and radiotherapy transferred cancer treatment from a monodisciplinary responsibility to that of multiple medical disciplines. To improve the quality of multidisciplinary care, eight regional Comprehensive Cancer Organizations were established. They formed networks of healthcare professionals and cancer institutes aiming to improve cancer care through registry, research, guideline development, knowledge exchange and organizational improvement without having a treatment function themselves. In 2011, they fused into the Netherlands Comprehensive Cancer Organization (IKNL). Anticipating the increasing multidisciplinary character of cancer treatment, the Comprehensive Cancer Organization in the North of the Netherlands introduced an external peer review programme in 1994 to review the multidisciplinary organization of cancer care in hospitals. It gradually spread over the country and was eventually used nationwide. The majority of Dutch hospitals has gone through the procedure at least once and in some regions already thrice. The programme initially focussed on organizational requirements for multidisciplinary care. Over time, it evolved and also paid attention to important (inter)national trends such as centralization, but the primary focus remained on the organization of cancer care as a whole (not specific tumour types). Even though there is almost 20 years of experience with the external peer review programme for multidisciplinary cancer care there is no structured evidence of its effectiveness on quality improvement. This is a more general problem for external peer review and accreditation programmes worldwide and the lack of conclusive evidence has led to many calls for research in this field. The aim of this dissertation was to investigate the impact of the external peer review programme for multidisciplinary cancer care on clinical outcomes and organization. Four main research questions structured the research in this dissertation: (1) How can the impact of external peer review on quality of care be studied methodologically? (2) What is the impact of the programme on clinical quality of cancer care? (3) What are the experiences of stakeholders and what is the perceived value of the programme? (4) What drives quality related organizational change in cancer care