Abstract
Although current federal quality improvement programs do not include cancer surgery, the Centers for Medicare & Medicaid Services and other payers are considering extending readmission reduction initiatives to include these and other common high-cost episodes. To quantify between-hospital variation in quality-related outcomes and identify hospital characteristics associated with high and low performance. This retrospective cohort study obtained data through linkage of the California Cancer Registry to hospital discharge claims databases maintained by the California Office of Statewide Health Planning and Development. All 351 acute care hospitals in California at which 1 or more adults underwent curative intent surgery between January 1, 2007, and December 31, 2011, with analyses finalized July 15, 2018, were included. A total of 138 799 adults undergoing surgery for colorectal, breast, lung, prostate, bladder, thyroid, kidney, endometrial, pancreatic, liver, or esophageal cancer within 6 months of diagnosis, with an American Joint Committee on Cancer stage of I to III at diagnosis, were included. Measures included adjusted odds ratios and variance components from hierarchical mixed-effects logistic regression analyses of in-hospital mortality, 90-day readmission, and 90-day mortality, as well as hospital-specific risk-adjusted rates and risk-adjusted standardized rate ratios for hospitals with a mean annual surgical volume of 10 or more. Across 138 799 patients at the 351 included hospitals, 8.9% were aged 18 to 44 years and 45.9% were aged 65 years or older, 57.4% were women, and 18.2% were nonwhite. Among these, 1240 patients (0.9%) died during the index admission. Among 137 559 patients discharged alive, 19 670 (14.3%) were readmitted and 1754 (1.3%) died within 90 days. After adjusting for patient case-mix differences, evidence of statistically significant variation in risk across hospitals was identified, as characterized by the variance of the random effects in the mixed model, for all 3 metrics (P < .001). In addition, substantial variation was observed in hospital performance profiles: across 260 hospitals with a mean annual surgical volume of 10 or more, 59 (22.7%) had lower-than-expected rates for all 3 metrics, 105 (40.4%) had higher-than-expected rates for 2 of the 3, and 19 (7.3%) had higher-than-expected rates for all 3 metrics. Accounting for patient case-mix differences, there appears to be substantial between-hospital variation in in-hospital mortality, 90-day readmission, and 90-day mortality after cancer surgical procedures. Recognizing the multifaceted nature of hospital performance through consideration of mortality and readmission simultaneously may help to prioritize strategies for improving surgical outcomes.
Highlights
Hospitals are under increasing scrutiny and financial pressure to publicly report quality-of-care measures.[1]
Current policies do not include cancer surgery, which is the mainstay treatment for most patients with solid tumor malignancies,[4] the Centers for Medicaid & Medicare Services (CMS) and other payers are considering extending readmission reduction initiatives to include common, high-cost episodes
Study Sample Between 2007 and 2011, 138 799 adults were diagnosed with 1 of the 11 tumors we consider at American Joint Committee on Cancer (AJCC) stages I to III and underwent curative intent surgery at 1 of 351 hospitals in California within 6 months of diagnosis
Summary
Hospitals are under increasing scrutiny and financial pressure to publicly report quality-of-care measures.[1]. Current policies do not include cancer surgery, which is the mainstay treatment for most patients with solid tumor malignancies,[4] the Centers for Medicaid & Medicare Services (CMS) and other payers are considering extending readmission reduction initiatives to include common, high-cost episodes. Previous studies have demonstrated high rates of readmission after common cancer operations and identified reduction as an opportunity to improve quality of care and efficiency.[5,6,7] prior to developing effective quality improvement initiatives for cancer surgery, it is critical to understand between-hospital variation in quality-related outcomes and identify hospital characteristics that are associated with superior or inferior performance This information could inform patient decisions regarding where to undergo surgery
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