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Background: Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy., Methods: Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression., Results: A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers., Conclusions and Relevance: Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

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: Interest in comparing hospital surgical quality continues to increase, particularly with respect to examining certain hospital designations such as National Cancer Institute-designated Cancer Centers (NCI-CC). Our objectives were to compare patients, surgical complexity, and risk-adjusted 30-day outcomes following major cancer surgery at NCI-CC versus non-NCI centers., Methods: From the American College of Surgeons National Surgical Quality Improvement Program, patients were identified who underwent colorectal, pancreatic, or esophagogastric resection for cancer (2007-2011). Regression methods were used to evaluate characteristics associated with undergoing treatment at NCI-CCs and surgical-complexity-adjusted 30-day morbidity, mortality, and prolonged length-of-stay at NCI-CC versus non-NCI centers., Results: NCI-CCs performed 20.2% of colorectal (10,555/52,265), 53.5% of pancreatic (6335/11,838), and 49.8% of esophagogastric (1596/3208) operations for cancer. NCI-CCs were more likely to treat patients who were younger, white, and with fewer comorbidities, but were more likely to perform more complex procedures including synchronous liver resection (eg, colorectal), adjacent organ resections (rectal cancer), and vascular reconstructions (eg, pancreas) (all P<0.05). NCI-CCs had a lower mortality rate for colorectal surgery only (1.2% vs. 1.9%) and increased rates of superficial surgical site infection (SSI) for colorectal (9.8% vs. 7.1%) and pancreatic (10.7% vs. 8.8%) surgery. No differences existed for the remaining complications by NCI-CC designation status. NCI-CCs were distributed throughout hospital quality rankings for all procedures and complications assessed., Conclusions: NCI-CCs treated younger, healthier patients, but performed more complex procedures. Patients treated at NCI-CCs had a lower risk of mortality for colorectal resection, but morbidity was similar to non-NCI centers. Comparison of cancer surgery hospital quality is feasible and should adjust for differences in patient demographics, comorbidities, and surgical complexity.

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.

Background: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) generally has not collected cancer-specific variables. Because increasing numbers of studies are using ACS NSQIP data to study cancer surgery, the objectives of the current study were 1) to examine differences between existing ACS NSQIP variables and cancer registry variables, and 2) to determine whether the addition of cancer-specific variables improves modeling of short-term outcomes., Methods: Data from patients in the ACS NSQIP and National Cancer Data Base (NCDB) who underwent colorectal resection for cancer were linked (2006-2008). By using regression methods, the relative importance of cancer staging and neoadjuvant therapy variables were assessed along with their effects on morbidity, serious morbidity, and mortality., Results: From 146 hospitals, 11,405 patients were identified who underwent surgery for colorectal cancer (colon, 85%; rectum, 15%). The NCDB metastatic cancer variable and the ACS NSQIP disseminated cancer variables agreed marginally (Cohen kappa coefficient, 0.454). For mortality, only the ACS NSQIP disseminated cancer variable and the NCDB stage IV variable were identified as important predictors; whereas the variables stage I through III, tumor (T)-classification, and lymph node (N)-classification were not selected. Cancer stage variables were inconsistently important for serious morbidity (stage IV, T-classification), superficial surgical site infection (N-classification), venous thromboembolism (metastatic cancer), and pneumonia (T-classification). With respect to neoadjuvant therapy, ACS NSQIP and NCDB variables agreed moderately (kappa, 0.570) and predicted superficial surgical site infection, serious morbidity, and organ space surgical site infection. The model fit was similar regardless of the inclusion of stage and neoadjuvant therapy variables., Conclusions: Although advanced disease stage and neoadjuvant therapy variables were predictors of short-term outcomes, their inclusion did not improve the models., (Copyright © 2012 American Cancer Society.)

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.