Circumferential Resection Margin as a Hospital Quality Assessment Tool for Rectal Cancer Surgery - 22/05/20

Doi : 10.1016/j.jamcollsurg.2020.02.033

Sameer H. Patel, MD, FACS ^a,^d, Chung-Yuan Hu, MPH, PhD ^a, Nader N. Massarweh, MD, MPH, FACS ^c, Y. Nancy You, MD, MHSc, FACS ^a, Ryan McCabe, PhD ^f, David Dietz, MD, FACS ^e, Matthew A. Facktor, MD, FACS ^g,^h, George J. Chang, MD, MS, FACS ^a,^b,^⁎
^a Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
^b Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
^c Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX
^d Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
^e Department of Surgery, Case Western Reserve University, Cleveland, OH
^f American College of Surgeons, National Cancer Database of the Commission on Cancer, Chicago, IL
^g Quality Integration Committee, Commission on Cancer, Chicago, IL
^h Department of Thoracic Surgery, Geisinger Health System, Danville, PA

^∗Correspondence address: George J Chang, MD, MS, FACS, Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, FCT 17.6000, Houston, TX 77230-1402.Department of Surgical OncologyUnit 1484The University of Texas MD Anderson Cancer Center1400 Pressler StFCT 17.6000HoustonTX77230-1402

Abstract

Background

Circumferential resection margin (CRM) status is an important predictor of outcomes after rectal cancer operation, and is influenced not only by operative technique, but also by incorporation of a multidisciplinary treatment strategy. This study sought to develop a risk-adjusted quality metric based on CRM status to assess hospital-level performance for rectal cancer operation.

Study Design

We conducted a retrospective observational cohort study of 58,374 patients with resected stage I to III rectal cancer within 1,303 hospitals who were identified from the National Cancer Database (2010 to 2015). The number of observed cases with a positive CRM (≤ 1 mm) was divided by the risk-adjusted expected number of cases with positive CRM to form the observed-to-expected (O/E) ratio. Secondary endpoint was overall survival.

Results

The overall rate of CRM positivity was 15.9%. Based on the O/E ratio for 1,139 hospitals, 147 (12.9%) and 103 (9.0%) were significantly worse and better performers, respectively. The majority of hospitals (n = 570) performed as expected. Positive CRMs using criteria of 0 mm and 0.1 to 1 mm were associated with a significantly shorter 5-year overall survival of 49% and 63.5% (hazard ratio 1.67; 95% CI, 1.57 to 1.76 and hazard ratio 1.19; 95% CI, 1.12 to 1.26) than negative CRM > 1 mm of 74.1% (all p < 0.001).

Conclusions

CRM-based O/E ratio is a robust hospital-based quality measure for rectal cancer operation. It allows facilities to compare their performance with that of centers of similar characteristics and helps identify underperforming, at-risk, and high-performing centers. National quality-improvement initiatives for rectal cancer should focus on ensuring high-quality data collection and providing ready access to risk-adjusted comparative metrics.

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Abbreviations and Acronyms : CoC, CRM, HR, LOWESS, NCDB, O/E, OR, TME

Plan

Outlier status for circumferential resection margin positivity

	CME questions for this article available at jacscme.facs.org
	Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Ronald J Weigel, CME Editor, has nothing to disclose.
	Support for this study: This study is supported by the Aman Trust (GJC), the Andrews Family Fund (GJC), and National Institutes of Health/National Cancer Institute grants T32 CA009599 and CA016672 (The University of Texas MD Anderson Cancer Center Support Grant).
	Disclaimer: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.