The Impact of Quality Variations on Patients Undergoing Surgery for Renal Cell Carcinoma: A National Cancer Database Study.

Abstract

Despite efforts to define metrics assessing hospital-level quality for renal cell carcinoma (RCC) surgical care there remains a paucity of real-world data validating their ability to benchmark performance. Consequently, whether poor performance on hospital-level quality indicators is associated with inferior patient outcomes remains unknown. To determine hospital-level variations in RCC surgical quality after adjusting for differences in patient- and tumor-specific factors. Further, to determine associations between hospital-level quality performance and surgical volume, academic affiliation, and patient mortality. RCC patients undergoing surgery in the USA and Puerto Rico (2004-2014) were identified from the National Cancer Database. Hospital-level quality of care was assessed according to disease-specific process and outcome quality indicators. Case-mix adjusted hospital benchmarking was performed using indirect standardization methodology and multivariable regression models. A composite measure of quality, the Renal Cancer Quality Score (RC-QS), was subsequently derived and associations between RC-QS and surgical volume, academic affiliation, and patient mortality were determined. Over 1100 hospitals were benchmarked for quality, with 10-31% identified as providing poor care for a given quality indicator. Lower RC-QS hospitals had smaller referral volumes and were less academic compared with higher RC-QS hospitals (p<0.001). Higher RC-QS was independently associated with lower 30-d, 90-d, and overall mortality (adjusted odds ratio [confidence interval]: 0.92 [0.90-0.95], odds ratio: 0.94 [0.91-0.96], hazard ratio: 0.97 [0.96-0.98] per unit increase, respectively). These data are retrospective and it is unknown whether improvement in the RC-QS improves outcomes. Widespread hospital-level variations in RCC surgical quality exist, as captured by the RC-QS. Superior quality is associated with improved patient outcomes, including mortality benefit. The RC-QS serves as a benchmarking tool for RCC quality that can provide audit level feedback to hospitals and policymakers for quality improvement. We benchmarked hospital performance across quality indicators for kidney cancer surgical care. Overall, large variations in quality exist, with high volume academic hospitals demonstrating superior performance and improved patient survival. These data can inform hospitals and policymakers for quality improvement initiatives.