Identification of quality improvement opportunities in kidney cancer surgery through a regional hospital-based urologic quality collaborative.

Abstract

413 Background: Patient selection for radical (RN) and partial nephrectomy (PN) for suspicion of kidney cancer may depend more on provider factors than patient characteristics. Observational data suggests that patients with small renal tumors have better overall survival when managed with PN rather than RN. We prospectively evaluated perioperative processes of care for patients undergoing kidney cancer surgery at Washington State hospitals participating in a surgical collaborative to identify quality improvement opportunities in kidney cancer care. Methods: We developed a chart abstraction tool that captures potential quality concerns in kidney cancer surgical care. The abstraction tool was implemented at nine regional hospitals with data consolidated for review quarterly. A sampling of PN and RN cases was abstracted. Hospital-specific feedback reports were blinded to hospital identity; data were analyzed as aggregate rates and hospital-specific rates using descriptive statistics. Presented results were not risk-adjusted. Results: We identified 75 patients undergoing RN or PN at 9 area hospitals from 2011-2013. Staging evaluations were uncommon (preoperative chest x-ray and chest CT in 41% and 20%, respectively). 13% percent of patients had a preoperative renal mass biopsy. For renal tumors ≤ 4 cm, 16/32 (50%) underwent PN. Hospital-specific utilization of PN for small renal masses exhibited variation: in 2 hospitals, 100% of tumors ≤ 4 cm were treated with PN, while 1 hospital performed RN in all cases, and the remaining hospitals ranged from 33%-67% utilization of PN. PN was less common for tumors 4-7 cm in size (4/26 cases [15%]). Venous thromboembolic events occurred in 4% of kidney cancer surgeries. Conclusions: We identified substantial variation in selection of surgical technique and postoperative outcomes following PN and RN for kidney cancer. Patients with small renal masses appear to have variable access to PN, which could impact their long-term health outcomes. Better understanding of provider knowledge and attitudes toward management of small renal masses could inform quality improvement initiatives to address the variations in care identified.