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Hospital adherence to quality metrics may not improve colon cancer outcomes
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The lack of a dose–response relationship between hospital adherence to National Quality Forum colon cancer quality metrics and survival suggested these metrics may be poor quality measures, according to data presented during the plenary session of the Society for Surgical Oncology Annual Cancer Symposium.
Prior research has shown that hospital adherence to three National Quality Forum quality metrics for colon cancer — adequate lymph node evaluation, adjuvant chemotherapy administration for patients with stage III disease and the initiation of adjuvant chemotherapy within 4 months of resection — is poorly correlated.
However, little research has focused on whether an association exists between adherence to these quality metrics and improved OS, according to study background.
Thus, Meredith C. Mason, MD, general surgery resident at Baylor College of Medicine in Houston, and colleagues conducted a retrospective study to determine whether hospital adherence to these measures led to better OS among patients with surgically resected stage III colon cancer.
The researchers used the National Cancer Data Base to identify 22,242 patients treated between 2003 and 2005.
The researchers then categorized each hospital where these patients received treatment by the proportion of patients who achieved each quality metric. Categories included very low (0-25%), low (25-50%), high (50-75%) or very high (> 75%).
Overall, 47% of patients achieved all three metrics.
Researchers observed no clinically meaningful or statistically significant association between the quality metrics and postoperative hospitalization of longer than 7 days or readmission within 30 days.
When the researchers used multivariate models to evaluate the relationship between very high hospital performance and 5-year OS, they found very high adherence to any one or more metrics lowered risk for death. This association persisted among hospitals with one (HR = 0.83; 95% CI, 0.74-0.94), two (HR = 0.79; 95% CI, 0.72-0.87) or three (HR = 0.75; 95% CI, 0.66-0.84) very high-performing measures compared with hospitals performing well on no measures.
However, a dose–response relationship did not persist at any level when the researchers evaluated hospitals with very high adherence to one vs. two metrics (HR = 1.06; 95% CI, 0.95-1.18), one vs. three metrics (HR = 1.12; 95% CI, 0.98-1.28) or two vs. three metrics (HR = 1.06; 95% CI, 0.94-1.19). Further, the association did not appear dependent on which specific metric or metrics were achieved.
“In the context of poor national performance on all three National Quality Forum metrics, the lack of a dose–response relationship between hospital performance and survival suggests either the minority of patients is receiving optimal colon cancer care or these metrics are weak quality measures,” Mason and colleagues wrote. “These findings suggest improving hospital metric adherence would be unlikely to improve outcomes and highlight both the challenges facing quality improvement efforts, as well as the need for more clinically meaningful quality indicators.” – by Cameron Kelsall
Reference:
Mason MC, et al. Abstract 6. Presented at: Society for Surgical Oncology Annual Cancer Symposium; March 2-5, 2016; Boston.
Disclosure: HemOnc Today could not confirm the researchers’ relevant financial disclosures at the time of reporting.
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Joshua Shaeffer Hill, MD, MS
In this trial, Mason and colleagues demonstrated that national quality metrics for colon cancer are not correlated with long-term patient survival. The study was based upon records identified within the National Cancer Data Base (NCDB). The NCDB captures approximately 70% of all colon cancer diagnoses in the United States, making it the largest repository for cancer cases within the country.
Unfortunately, this study and others that have been recently published using the American College of Surgeons National Quality Improvement Program have shown that large-scale monitoring does not influence long-term survival or perioperative survival. One possible explanation it that poor performance on national quality measures may not prompt hospitals to strive to improve. The hope that public reporting of provider behavior would improve the overall care of patients has been the impetus behind nearly all reporting programs, whether they originated through professional societies, payer sources/insurance or public reporting. Another possibility is that the currently reported quality metrics are not predictive of outcomes.
There is a growing body of evidence that there is no clear relationship between reporting programs for provider compliance and survival. However, the report by Mason and colleagues has once again shown that compliance with quality measures is poor. It is important that we strive to improve the metric — so that we have methods to predict outcomes based upon provider characteristics — but we also must improve the care for our patients so that they are compliant with the standard of care.
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