Assessing whether cancer stage is needed to evaluate measures of hospital surgical performance

Abstract

Rational, aims, and objectives: While public reports of hospital-level surgical quality measures are becoming increasingly common in health care, a comprehensive national assessment of surgical quality across multiple cancer sites has yet to be developed.Fee-for-service (FFS) Medicare claims present a potential resource from which to measure outcomes following cancer surgery given the national scope of patients and providers.However, due to the administrative nature of the data, clinical cancer information such as stage is not recorded. Leveraging the Surveillance, Epidemiology, and End Results (SEER) registry linked to FFS Medicare claims to analyse outcomes for patients whom we ultimately know stage information, we determined whether Medicare claims are suitable for measuring provider quality following cancer surgery by assessing the extent to which the lack of stage information modifies assessments of provider performance. Methods:We identified patients aged 66 and older undergoing cancer surgery between 2011 and 2013 from SEER-Medicare. We compared the changes in the risk-standardized rates (RSRs), decile rankings, and c-statistics with and without risk adjustment for cancer stage for three measures of hospital performance: 30-day mortality, surgical complications, and unplanned readmissions. Results:The RSR changed by at most 11.4% for mortality and by less than 4% for complications and readmissions, indicating that measures of hospital performance were stable with and without adjustment for stage. The relative performance of hospitals was also stable, as demonstrated by fewer than 20% of hospitals changing decile rank. The c-statistic declined by less than 2% across all measures, indicating that model fit was not substantially worsened without this information.Conclusion: These findings support the use of FFS Medicare claims for hospital-level analyses of short-term outcomes following cancer surgery. Quality reporting based on these analyses can be used to help patients choose among hospitals and for evaluating policies to improve surgical cancer care.

Assessment of variation in 30‐day mortality following cancer surgeries among older adults across US hospitals

“…The advantage of the FFS Medicare claims dataset is that it comprehensively covers the entire United States. A shortcoming is that it does not have the type of detailed information about cancer site that cancer registries contain, but prior analyses demonstrate that risk‐adjusted surgical outcome assessment is robust to the exclusion of these SEER variables . While we relied on the Charlson comorbidity index for our risk adjustment, which is a widely accepted method in the field, all risk adjustment can be criticized for being incomplete .…”

“…Although FFS Medicare claims do not include clinical information regarding cancer stage, we previously demonstrated that risk adjustment was not sensitive to the inclusion or absence of this information. 31 Hospital characteristics came from the AHA database including hospitals' location (rural/urban), organizational control (not-for-profit, private, government), and teaching status (defined as a member of the council of teaching hospitals of the American Medical Association). 28 These characteristics were not available for 84 hospitals (2.2% of the sample) and were excluded from analyses that depended on these characteristics.…”

“…A shortcoming is that it does not have the type of detailed information about cancer site that cancer registries contain, but prior analyses demonstrate that risk-adjusted surgical outcome assessment is robust to the exclusion of these SEER variables. 18,24,31 While we relied on the Charlson comorbidity index for our risk adjustment, which is a widely accepted method in the field, all risk adjustment can be criticized for being incomplete. 29,30,41 There is controversy over the inclusion of additional information in analyses of outcome variation and in the field of quality measurement more generally.…”

High hospital volume is associated with more consistent long-term mortality rates

“…Patients treated with chemotherapy, radiotherapy, or surgery at an acute care or critical access hospital in 2006, 2011, 2012, and 2013 (index years) were in the analysis and we obtained 4-year mortality ratios for each hospital in 2010, 2015, 2016, and 2017 respectively (data available from our previous studies (3)(4)(5). Hospitals were identified across index years via the Centers for Medicare and Medicaid Services Certification Numbers.…”

“…Hospitals were then divided into quartiles based on their total FFS Medicare patient volume combined across index years. As per prior work, Medicare FFS beneficiaries were included if they initiated cancer treatment or management of recurrent disease in the index year indicated by an absence of claims for cancer in the previous year (3)(4)(5)(6).…”