Profiling hospitals by survival of patients with colorectal cancer

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators

AIM

To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs).

METHODS

The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance.

RESULTS

A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level.

CONCLUSION

This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

Assessment of variation in 30-day mortality following cancer surgeries among older adults across US hospitals

Background

While public reporting of surgical outcomes for noncancer conditions is common, cancer surgeries have generally been excluded. This is true despite numerous studies showing outcomes to differ between hospitals based on their characteristics. Our objective was to assess whether three prerequisites for quality assessment and reporting are present for 30‐day mortality after cancer surgery: low burden for timely reporting, hospital variation, and potential for public health gains.

Study Design

We used Fee‐for‐Service (FFS) Medicare claims to examine the extent of variation in 30‐day cancer surgical mortality between 3860 US hospitals. We included 340 489 surgeries for 12 cancer types for FFS Medicare beneficiaries aged ≥66 years, 2011‐2013. Hierarchical mixed‐effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital‐specific risk‐standardized mortality rates (RSMRs) and 99% confidence intervals (CI). We calculated a hospital odds ratio to describe the difference in mortality risk for a hospital above vs below average quality and estimated the potential mortality reduction.

Results

The median number of cancer surgeries per hospital was 34. The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). In aggregate and for most cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics. For individual cancers, relative differences exceeded 20% in mortality risk between patients undergoing surgery at a hospital below vs above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements.

Conclusion

Quality measurement and reporting of 30‐day mortality for cancer surgery is worthy of consideration.

Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients

BACKGROUND

The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival.

METHODS

Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1.

RESULTS

Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival.

DISCUSSION

Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.

Risk factors of 30-day mortality following surgery for colorectal cancer

The 30-day mortality is one of the factors reflecting the quality of treatment. All these efforts focused on decreasing 30-day mortality will directly improve quality of care. The aim of the study was to identify risk factors of 30-day postoperative mortality in a cohort of patients operated on for colorectal cancer in one tertiary colorectal centre.

MATERIAL AND METHODS

Patients operated on due to colorectal cancer (CRC) between 2008 and 2014 were included in the study. 30-day mortality was assessed as an endpoint of the retrospective study. All records were collected from prospective database.

RESULTS

1744 patients were operated on due to CRC. The 30-day mortality was noted in 65 patients (3.5%). In multivariable analyses we revealed that spread disease and poor general condition at admission were risk factors of 30-day mortality: OR 2.35; 2.01-2.57 95%CI, p=0.03 and OR 2.18; 1.95-2.41 95% CI; p=0.01, respectively. Emergency surgery significantly increased the risk of 30-day mortality: OR 2.64; 2.45-2.87 95%CI; p=0.009. Low serum albumin concentration level and diabetes mellitus were additional risk factors for 30-day mortality, OR 1.65; 1.52-1.78 95%CI; p=0.01 and OR 1.67; 1.41-1.82 95%CI; p=0.03, respectively. Mortality was significantly higher after resection procedures than after only palliative operations: 4.21% vs 1.57%; p=0.002.

CONCLUSIONS

Emergent patients, patients with advanced disease and in poor general state have to be assessed by multidisciplinary team to prepare them to operation. Additionally to reduce the risk of 30-day mortality decision of extend of surgery should be made by experienced surgeons.

On the accuracy of classifying hospitals on their performance measures

The evaluation, comparison, and public report of health care provider performance is essential to improving the quality of health care. Hospitals, as one type of provider, are often classified into quality tiers (e.g., top or suboptimal) based on their performance data for various purposes. However, potential misclassification might lead to detrimental effects for both consumers and payers. Although such risk has been highlighted by applied health services researchers, a systematic investigation of statistical approaches has been lacking. We assess and compare the expected accuracy of several commonly used classification methods: unadjusted hospital-level averages, shrinkage estimators under a random-effects model accommodating between-hospital variation, and two others based on posterior probabilities. Assuming that performance data follow a classic one-way random-effects model with unequal sample size per hospital, we derive accuracy formulae for these classification approaches and gain insight into how the misclassification might be affected by various factors such as reliability of the data, hospital-level sample size distribution, and cutoff values between quality tiers. The case of binary performance data is also explored using Monte Carlo simulation strategies. We apply the methods to real data and discuss the practical implications.

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery

Background

Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery.

Methods

All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality.

Results

A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (r_s = 0·957, P < 0·001 versus 180-day mortality; r_s = 0·860, P < 0·001 versus 365-day mortality).

Conclusion

Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.

Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit

BACKGROUND

Postoperative mortality is frequently used in hospital comparisons as marker for quality of care. Differences in mortality between hospitals may be explained by varying complication rates. A possible modifying factor may be the ability to let patients with a serious complication survive, referred to as failure to rescue (FTR). The purpose of this study was to evaluate how hospital performance on postoperative mortality is related to severe complications or to FTR and to explore the value of FTR in quality improvement programs.

METHODS

All patients operated for colorectal cancer from 2009 to 2011, registered in the Dutch Surgical Colorectal Audit, were included. Logistic regression models were used to obtain adjusted mortality, complication, and FTR rates. Hospitals were grouped into 5 quintiles according to adjusted mortality. Outcomes were compared between quintiles.

RESULTS

A total of 24,667 patients were included. Severe complications ranged from 19 % in the lowest to 25 % in the highest mortality quintile (odds ratio 1.5, 95 % confidence interval 1.37-1.67). Risk-adjusted FTR rates showed a marked difference between the quintiles, ranging from 9 % to 26 % (odds ratio 3.0, 95 % confidence interval 2.29-3.98). There was significant variability in FTR rates. Seven hospitals had significantly lower FTR rates than average.

CONCLUSIONS

High-mortality hospitals had slightly higher rates of severe complications than low-mortality hospitals. However, FTR was three times higher in high-mortality hospitals than in low-mortality hospitals. In quality improvement projects, feedback to hospitals of FTR rates, along with complication rates, may illustrate shortcomings (prevention or management of complications) per hospital, which may be an important step in reducing mortality.