Circumferential Resection Margin as a Hospital Quality Assessment Tool for Rectal Cancer Surgery.

Sameer H Patel, Chung-Yuan Hu, Nader N Massarweh, Y Nancy You, Ryan McCabe, David Dietz, Matthew A Facktor, George J Chang

Journal: Journal of the American College of Surgeons 2021;230(6):1008-1018.e5

PMID: 32142927

Full Text on Elsevier Science View on PubMed

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.

Address: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.; Houston VA Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX.; American College of Surgeons, National Cancer Database of the Commission on Cancer, Chicago, IL.; Department of Surgery, Case Western Reserve University, Cleveland, OH.; Quality Integration Committee, Commission on Cancer, Chicago, IL; Department of Thoracic Surgery, Geisinger Health System, Danville, PA.; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: [email protected].

DOI: 10.1016/j.jamcollsurg.2020.02.033

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MeSH Terms: Adenocarcinoma, Aged, Female, Humans, Logistic Models, Male, Margins of Excision, Middle Aged, Neoplasm Staging, Proctectomy, Quality Assurance, Health Care, Rectal Neoplasms, Retrospective Studies, Treatment Outcome