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Background: Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes., Study Design: Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control., Results: There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance., Conclusions: Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patient utilization of public reporting has been suboptimal despite attempts to encourage use. Lack of utilization may be due to discordance between reported metrics and what patients want to know when making health care choices., Objective: The objective of this study was to identify measures of quality that individuals want to be presented in public reporting and explore factors associated with researching health care., Research Design: Patient interviews and focus groups were conducted to develop a survey exploring the relative importance of various health care measures., Subjects: Interviews and focus groups conducted at local outpatient clinics. A survey administered nationally on an anonymous digital platform., Measures: Likert scale responses were compared using tests of central tendency. Rank-order responses were compared using analysis of variance testing. Associations with binary outcomes were analyzed using multivariable logistic regression., Results: Overall, 4672 responses were received (42.0% response rate). Census balancing yielded 2004 surveys for analysis. Measures identified as most important were hospital reputation (considered important by 61.9%), physician experience (51.5%), and primary care recommendations (43.2%). Unimportant factors included guideline adherence (17.6%) and hospital academic affiliation (13.3%, P<0.001 for all compared with most important factors). Morbidity and mortality outcome measures were not among the most important factors. Patients were unlikely to rank outcome measures as the most important factors in choosing health care providers, irrespective of age, sex, educational status, or income., Conclusions: Patients valued hospital reputation, physician experience, and primary care recommendations while publicly reported metrics like patient outcomes were less important. Public quality reports contain information that patients perceive to be of relatively low value, which may contribute to low utilization.

Introduction: Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure., Methods: The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status., Results: The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals., Conclusions: Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.

The star rating system for hospitals of the Centers for Medicare and Medicaid Services (CMS) pools all hospitals together and awards each institution one to five stars for quality, despite variation across hospitals in the numbers and types of measures they report. Thus, hospitals essentially are being evaluated differently, which affects the validity of quality comparisons. We considered the number and types of measures reported and the size of measure denominators to represent different forms of a "test," and we used data from the December 2017 star ratings to show that hospitals took one of three general "test forms." Hospitals taking the most extensive test form reported an average of forty-three measures, while those taking the least extensive test reported an average of twenty-two measures. These test forms were differentially associated with star ratings and hospital characteristics. Our results caution against pooling all hospitals together when assigning star ratings, and they demonstrate a feasible approach to segmenting hospitals into peer groups for evaluation by stakeholders such as CMS.

Background/objectives: Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival., Methods: Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004-2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles., Results: Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low- and high-tercile hospitals had statistically worse survival., Conclusions: There is a wide variation in hospital SLNB positivity rates. Hospitals with lower- or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment., (© 2018 Wiley Periodicals, Inc.)

Background: Surgical quality programs, such as the American College of Surgeons NSQIP, provide reports based on specialty or procedure, with patients aggregated together. It is unknown whether hospital performance differs by patient subgroup (eg cancer vs noncancer patients), masking opportunities for improvement. Our objectives were to determine whether performance differs within a given hospital for 6 contrasting patient subgroups and to identify the percentage of hospitals with greater than chance differences in performance., Study Design: Using the American College of Surgeons NSQIP data, adults undergoing lung resection, esophagectomy, hepatectomy, pancreatectomy, colectomy, and proctectomy (2005 through 2012) were divided into 6 contrasting subgroups (elderly vs nonelderly, white vs nonwhite, obese vs nonobese, renal insufficiency vs normal renal function, cancer vs noncancer, emergency vs nonemergency). The main end point was serious morbidity or mortality. Observed to expected ratios were constructed using hierarchical models and compared using paired t-tests (eg observed to expected for cancer cases compared with noncancer). Variation in performance differences was assessed using a randomization test and z-tests for proportions., Results: From 433 hospitals, 221,518 patients were included. Overall quality differed for elderly vs nonelderly, renal insufficiency vs normal renal function patients, cancer vs noncancer, and emergency vs nonemergency (p < 0.05). Variation in within-hospital performance differences exceeded chance expectations for renal insufficiency vs normal renal function in 31.1% of hospitals, cancer vs noncancer in 40.8%, and emergency vs nonemergency patients in 55.4% (p < 0.001)., Conclusions: Hospital performance within a given hospital varies by patient subgroup. Quality programs can consider separate reports for these subgroups to identify opportunities for quality improvement., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate differences in hospital structural quality characteristics and assess the association between national publicly reported quality indicators and cancer center accreditation status., Background: Cancer center accreditation and public reporting are 2 approaches available to help guide patients with cancer to high-quality hospitals. It is unknown whether hospital performance on these measures differs by cancer accreditation., Methods: Data from Medicare's Hospital Compare and the American Hospital Association were merged. Hospitals were categorized into 3 mutually exclusive groups: National Cancer Institute-Designated Cancer Centers (NCI-CCs), Commission on Cancer (CoC) centers, and "nonaccredited" hospitals. Performance was assessed on the basis of structural, processes-of-care, patient-reported experiences, costs, and outcomes., Results: A total of 3563 hospitals (56 NCI-CCs, 1112 CoC centers, and 2395 nonaccredited hospitals) were eligible for analysis. Cancer centers (NCI-CCs and CoC centers) were more likely larger, higher volume teaching hospitals with additional services and specialists than nonaccredited hospitals (P < 0.001). Cancer centers performed better on 3 of 4 process measures, 8 of 10 patient-reported experience measures, and Medicare spending per beneficiary than nonaccredited hospitals. NCI-CCs performed worse than both CoC centers and nonaccredited hospitals on 8 of 10 outcome measures. Similarly, CoC centers performed worse than nonaccredited hospitals on 5 measures. For example, 35% of NCI-CCs, 13.5% of CoC centers, and 3.5% of nonaccredited hospitals were poor performers for serious complications., Conclusions: Accredited cancer centers performed better on most process and patient experience measures but showed worse performance on most outcome measures. These discordant findings emphasize the need to focus on oncology-specific measurement strategies.

Background: There is substantial variation in the surgical complexity of hepatectomy. Currently, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk adjusts for hospital quality comparisons using only the primary procedure code. Our objectives were to (1) assess the association between secondary procedures and complications; (2) assess model performance with inclusion of surgical complexity adjustment; and (3) examine whether secondary procedures affect hospital quality rankings., Methods: Using ACS NSQIP (2007-2012), patients undergoing hepatectomy were identified. Secondary procedure codes and total work relative value units (RVUs) were used to approximate procedural complexity. The effect of procedural complexity variables on outcomes and hospital quality rankings were examined using hierarchical models., Results: Among 11,826 patients who underwent hepatectomy at 261 hospitals, 32.8 % underwent at least one secondary procedure. Serious morbidity occurred in 18.0 % of patients. Seven of nine secondary procedures were significantly associated with death or serious morbidity on multivariable analysis. Model performance improved when secondary procedure categories were included, and secondary procedure categories outperformed total RVUs. The C-statistic for death or serious morbidity was 0.689 in the standard NSQIP model, 0.703 when total RVU was included, and 0.718 when secondary procedure categories were included. Of the 26 hospitals that were poor performers for death or serious morbidity using the standard ACS NSQIP model, three became average performers when secondary procedure categories were included in the model., Conclusions: Secondary procedures are associated with an increased risk of postoperative complications. Inclusion of secondary procedure code categories in research and risk prediction models should be considered for hepatectomy.

Background: Quality initiatives are increasingly focusing on the quality of oncologic surgery. However, there is concern that a lack of cancer-specific variables may make risk-adjusted hospital quality comparisons inadequate. Our objective was to assess whether hospital quality rankings for cancer surgery are influenced by the addition of cancer-specific variables to the risk-adjusted models., Methods: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and National Cancer Data Base (NCDB) who underwent colon or rectal resection for cancer were linked (2006-2008). Hierarchical models were developed predicting ACS NSQIP outcomes based on ACS NSQIP only vs a model using NSQIP and NCDB-derived cancer variables (e.g., stage and neoadjuvant therapy). Changes in hospital quality rankings were compared., Results: A total of 11,405 patients underwent colon (n = 9,678, 146 hospitals) or rectal (n = 1,727, 135 hospitals) resection for cancer (2006-2008). Hospital-level complication rates (and standard deviation) after colon surgery were 2.2 % (±2.7 %) for mortality and 17.2 % (±8.7 %) for serious morbidity. After rectal cancer resection, complication rates were 0.9 % (±3.8 %) for mortality and 22.3 % (±20.4 %) for serious morbidity. When cancer-specific variables were included in risk-adjustment, outlier agreement was very good (kappa >0.85), and hospital odds ratio correlations were nearly identical (R > 0.98) for all outcomes assessed. Median changes in hospital rankings with the addition of the cancer-specific variables ranged from 1 to 2 after colon resection to 2-4 after rectal resection., Conclusions: Addition of the available cancer-specific variables to risk-adjustment models did not affect hospital quality rankings for cancer surgery. Existing ACS NSQIP risk-adjustment variables appears to be sufficient for accurate comparisons of hospital quality.

Objective: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure., Background: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target., Methods: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds., Results: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008., Conclusions: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Background: Reoperation rate has gained increasing attention as a potential indicator of surgical quality. Objectives of this study were to examine the feasibility of assessing reoperation rates at 182 hospitals to identify institutions with outlying performance, to examine potentially modifiable factors that are associated with reoperations, and to determine if a more parsimonious logistic regression model effectively predicts reoperations., Study Design: Patients were identified who underwent colorectal procedures at 182 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program in 2006-2007. Risk-adjusted regression models for reoperation were developed to identify hospitals that had ratios of observed-to-expected events that were substantial outliers., Results: Of 23,098 patients identified, 1,320 (5.7%) required reoperations. Reoperation occurred significantly more often than expected in 16 hospitals and less often than expected in 7 hospitals (p < 0.05). Factors that were associated with an increased risk of reoperation were advanced American Society of Anesthesiologists class, male gender, contaminated wounds, surgical extent, surgical indication, smoking, poor functional status, disseminated cancer, COPD, steroid dependence, anemia, body mass index (calculated as kg/m(2)) >35 or < or = 18.5, and hypertension. Compared with the full logistic regression model, there was a high degree of correlation with the more parsimonious logistic model containing only the first six variables (r = 0.996)., Conclusions: There is considerable variability in reoperation rates at American College of Surgeon's National Surgical Quality Improvement Program hospitals. American College of Surgeon's National Surgical Quality Improvement Program data can be used to provide individual hospitals with risk-adjusted self-assessment data on reoperations to potentially identify quality-improvement opportunities.