Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma

Abstract

BackgroundProcess-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection. MethodsPatients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival. ResultsA total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61–75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0–4 points, 8.7 [8.0–9.6] months; 5–8 points, 17.5 [16.9–18.2] months; 9–12 points, 22.1 [21.6–22.8] months; and 13–16 points, 30.8 [30.2–31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0–4 points: reference; 5–8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57–0.63; 9–12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47–0.52; 13–16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34–0.40; all P < .001). ConclusionAdherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.