11. Qualitätsindikatoren – Prevention of Skin Cancer

 

Editorial note: The following is the result of the derivation of quality indicators from version 1.2. The quality indicators for version 2.0 were not edited for the reasons outlined below.

The derivation of quality indicators (QI) based on the strong recommendations within the S3 guideline Prevention of skin cancer went through the standardized process established within the guideline program oncology (see guideline report). This process has so far been used exclusively for guidelines on the diagnosis, therapy and follow-up of tumor diseases. The guideline presented here is the first to deal exclusively with the topic of prevention. This fundamentally different situation was discussed extensively in the QI working group. In the following, the special features and the consequences for the QI derivation are presented.

A core problem is the lack of translatability of guideline recommendations into clearly and unambiguously defined QIs, as well as the availability of corresponding data on possible indicators. In the field of primary prevention, behavioural indicators are the most important component of evaluation, with the aim of detecting changes in behaviour through appropriate interventions. However, such behavioural indicators would often have to be collected in the form of retrospective self-reporting, particularly in the context of primary prevention; as a result, the data are subject to subjective bias to a greater extent than behavioural measurements or routine medical data and must therefore be assessed as comparatively limited in terms of their objectivity and validity. This also applies in part to secondary prevention measures, where epidemiological data and data from health services research play a role in addition to behavioral indicators. Furthermore, if individual recommendations refer, for example, to the behaviour of large subpopulations or the general population, a complete survey based on routine data is hardly possible, if at all.

To compensate for the difficulties described, the guideline provides comprehensive recommendations for the formative and summative evaluation of information and education programmes in the field of primary and secondary prevention of skin cancer. Two areas can be distinguished in which the effectiveness of an intervention should be comprehensively evaluated in terms of both process and outcome: Behavioural prevention and relationship prevention.

In the area of behavioural prevention, questions need to be answered such as What information has the citizen or certain target groups (e.g. parents) received and from what source? How are these perceived and processed? This involves the survey of knowledge, but also the mapping of risk perception or attitudes as well as subjective informedness. Therefore, in addition to the behaviourally relevant endpoints, it is necessary to include intermediary factors that reflect the process of information dissemination and processing.

In relation prevention, the focus is on environmental factors and structures in the public sphere, such as in schools, kindergartens and the workplace, or in the area of urban development and urban planning. In this context, political or administrative framework conditions and processes play a formative role, which should be included in the evaluation. Evaluation can take place both within the framework of field experiments and with the help of process-accompanying non-experimental evaluation studies. Possible questions may include: (How) have the legal, political and financial framework conditions required for the implementation of the measure been created? How were the relevant decision-makers involved and informed in the planning process? Which measures have been implemented in which areas and how? How are the measures received by the experts and multipliers and what effects do they have in the target groups, e.g. pupils, employees? Furthermore, individual recommendations of the guideline refer to the education, further education and training of multipliers such as physicians, medical assistants or other professional groups. Possible questions for the corresponding evaluation could be: How well are the training contents tailored to the specifics of professional practice and everyday work of the respective professional group? How are the programmes structured in terms of content and how are the training materials prepared? Have prerequisites for participation in such training been created by the respective occupational groups? How are the programmes accepted by the respective occupational group, how are the imparted competences integrated into professional practice and what effects can be demonstrated, e.g. in patient counselling? In addition, changes or additions in the further training regulations, licensing regulations, in nursing training, but also in the training of educators, child care workers or teachers also play a role. There is also the question of the extent to which framework conditions for the implementation of prevention measures are taken into account in administrative systems, such as the medical billing system, e.g. in the form of a "consultation number" .

In the evaluation of the HKS, hurdles due to the documentation requirements must also be presented. For the purpose of billing, each HKS examination must be fully documented electronically (according to §34 of the Cancer Screening Guideline) using software certified by the National Association of Statutory Health Insurance Physicians. This electronic documentation is also used for the evaluation, which is stipulated in §35 of the Cancer Screening Guideline. Target parameters of the evaluation include participation rates, suspected diagnoses and false-positive findings. However, a comprehensive evaluation of HKS also includes epidemiological endpoints such as mortality and morbidity (stage shift to earlier detected tumors), as well as interval cancers. These endpoints are of great importance for the evaluation of the effectiveness of a cancer screening programme and are also required internationally. However, due to the current data collection, a robust evaluation of the HKS is not possible, as the documentation is done without the necessary personal identification. A personal reference would allow a comparison with the epidemiological cancer registers, and the target tumours of the HKS can be divided into 'detected in screening' and 'not detected in screening'. This allows screening to be performed, for example, for possible mortality reduction in participants and non-participants.

In addition, due to the two-tier nature of skin cancer screening, it is possible that diagnoses are documented twice and therefore bias occurs when comparing suspected and confirmed diagnoses. Personal identification would also eliminate these biases. In order to provide comprehensive and scientific evidence of the effects of the HKS, it is recommended that the current electronic documentation be expanded and adapted with the relevant stakeholders to include the above-mentioned items.

For the reasons outlined above, no quality indicators could be derived based on this guideline.