# Quality indicators for breast reconstruction following cancer—an international Delphi consensus study supported by the European Society of Plastic, Reconstructive and Aesthetic Surgery

## TL;DR

This study created a set of 41 quality indicators for breast reconstruction after cancer, using expert and patient input to improve healthcare standards in Europe.

## Contribution

The study presents the first comprehensive, consensus-based quality indicators for breast reconstruction in Europe, covering six key domains and including patient-reported outcomes.

## Key findings

- 41 quality indicators reached consensus through a Delphi process involving experts and patient representatives from 21 European countries.
- The indicators span six domains: Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centredness.
- The indicators include structure, process, and outcome measures, such as surgical outcomes and patient satisfaction.

## Abstract

Quality indicators (QIs) are essential for assessing and improving healthcare delivery. Existing QIs for breast reconstruction are limited and do not comprehensively reflect clinical complexity or patient-centred outcomes. This study aimed to develop a scientifically grounded, consensus-based set of QIs for breast reconstruction using the Delphi method.

A structured Delphi process was conducted. Experts, including plastic surgeons, reconstructive nurses, and patient representatives from 21 European countries, were nominated by national professional and patient organizations. A pre-round generated 141 unique QIs, thematically analysed and categorized into six domains. Three Delphi rounds were conducted via electronic surveys. Consensus was defined a priori as ≥ 75% agreement across the whole group or at least two subgroups. Indicators were classified according to Donabedian’s model (structure, process, outcome).

Among the 43 experts completing all rounds, 41 QIs reached final consensus. These indicators span six key quality domains (Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centredness) and include measures such as access to reconstruction, treatment timelines, multidisciplinary collaboration, unit characteristics, surgical outcomes, and patient satisfaction. Structure, process, and outcome indicators were all represented, including patient-reported outcomes and patient-reported experiences.

This Delphi study provides the first comprehensive set of QIs specific to breast reconstruction in Europe. These indicators lay the groundwork for future standardization, benchmarking, and quality improvement initiatives. Further work is needed to operationalize the indicators through evidence grading, measurement specifications, risk adjustment, and integration into clinical practice.

This study used a structured Delphi process involving experts and patient representatives from 21 European countries to develop a consensus-based set of 41 quality indicators for breast reconstruction. Spanning six quality domains and incorporating structure, process, and outcome measures, including patient-reported outcomes and patient-reported experiences, these quality indicators offer a comprehensive foundation for future benchmarking and quality improvement across Europe.