Hospital-level quality indicators for kidney cancer surgery: A Veteran’s Affairs national health system validation of concept.

Abstract

667 Background: Validation and implementation of quality indicators (QIs) for oncological surgical care is imperative in national health care systems. However, QIs must be adjusted for significant case-mix variations among hospitals and to capture disparate patient outcomes. Here, we explore and validate a compound quality score (CQS) as a metric for hospital-level quality of care in kidney cancer patients. Methods: Kidney cancer patients (n = 8233) treated at the VA (2005-2015) were identified. Two previously described and validated process QIs were explored: the proportion of patients with a) T1a tumors undergoing partial nephrectomy; and b) T1-T2 tumors undergoing minimally invasive radical nephrectomy. Demographics, comorbidity, tumor characteristics and treatment year were used for case-mix adjustment using indirect standardization / multivariable regression models. The predicted vs observed ratio of cases was calculated to generate each QI score. CQS represents the sum of both QIs scores. Ninety-six hospitals were benchmarked by CQS and patient-level outcomes were regressed on CQS levels to assess for length of stay (LOS), 30 days complications/readmission, 90 days overall mortality and total cost of surgical admission. Results: CQS identified 25, 33 and 38 hospitals with higher, lower and average performance, respectively. Total CQS score was independently associated with LOS [β = -0.04, p< 0.01, predicted LOS 0.84 days shorter for CQS = 2 vs. CQS = -2], 30 days surgical complications [OR = 0.88, p < 0.01] or 30 days medical complications [OR = 0.93, p < 0.01] and total cost of surgical admission [β = -0.014, p< 0.01, predicted 12% lower cost for CQS = 2 vs. CQS = -2]. No association was found between CQS and 30 day readmissions or 90 days mortality (all p>0.05), although low event rates were observed (8.9% and 1.7%, respectively). Conclusions : Variability in quality of surgical care at a hospital-level can be captured with the CQS among kidney cancer patients. CQS is associated with length of stay, post-operative complications and total cost of surgical admission. Quality indicators should be used to identify, audit and implement quality improvement strategies across health systems.