Elsevier

Gynecologic Oncology

Volume 107, Issue 1, October 2007, Pages 99-106
Gynecologic Oncology

A new frontier for quality of care in gynecologic oncology surgery: Multi-institutional assessment of short-term outcomes for ovarian cancer using a risk-adjusted model

https://doi.org/10.1016/j.ygyno.2007.05.032Get rights and content

Abstract

Objective

To test the feasibility and utility of a risk-adjusted, multicenter outcomes model for ovarian cancer surgery as a tool for quality improvement.

Methods

Patient characteristics, intra-operative findings, procedures, and outcomes were assessed in primary advanced stage ovarian cancer cases from 3 independent centers. A surgical complexity score (SCS) was developed to adjust for extent of surgery. Outcomes measures were: 30-day morbidity (sepsis, thrombo-embolic, cardiac, readmission or re-operation), 3-month mortality, length of stay (LOS), and ability to receive chemotherapy. A multivariable risk-adjusted model was developed for all the outcomes. Observed-to-expected (O/E) outcome ratios were calculated from all data.

Results

564 consecutive patients from 3 centers were analyzed. The strongest predictors of 30-day morbidity were endogenous [albumin (p < 0.001) and ASA (p = 0.008)] and complexity of surgery [SCS (p < 0.001)]. Age (p = 0.002) and ASA (p = 0.001) independently predicted mortality. LOS independently correlated with age (p = 0.007), albumin (p = 0.004), SCS (p = 0.002), and stage (p = 0.024). ASA (p < 0.001) and SCS (p = 0.003) both impacted ability to receive chemotherapy. Observed to expected (O/E) ratios for dependent outcome variables were similar for all 3 institutions.

Conclusions

We demonstrate the benefits of a national system for studying outcomes in gynecologic surgery using a risk-adjusted model. We specifically find that endogenous patient factors and complexity of surgery are primary drivers of morbidity in ovarian cancer surgery. These data can successfully be used to formulate expected, risk-adjusted rates of complications thus providing a meaningful mechanism to identify areas ripe for quality improvement.

Introduction

In 1999 the Institute of Medicine (IOM) raised concerns about quality of care in cancer patients, and lack of standardized systems to assess quality [1], [2], [3]. To begin to answer these concerns, the American Society of Clinical Oncology (ASCO) started the “Quality Oncology Practice Initiative” (QOPI). This gathered a group of oncologists who devised medical record abstraction measures based upon published practice guidelines and consensus-derived indicators of quality care. The QOPI system allows rapid feedback of performance data for each indicator, which can be compared with aggregate results [4].

The National Initiative for Cancer Care Quality (NICCQ) [5] focused its attention on breast and colon cancer patients, analyzing five different metropolitan statistical areas (MSAs). They found that patients with breast cancer received 86% of recommended care and patients with colorectal received 78% of recommended care. Adherence to quality measures was less than 85% for 18 of the 36 breast cancer measures, and significant variation across the different MSAs was observed for seven quality measures. For colorectal cancer measures, the adherence rate was less than 85% for 14 of the 25, and one quality measure demonstrated statistically significant variation across the MSAs. They concluded that while reporting a substantial consistency with evidence-based practice, substantial variation in adherence to some quality measures point to significant opportunities for improvement.

From October 1991 to December 1993, the Veterans Health Administration (VHA) conducted the National VA Surgical Risk Study (NVASRS), validating a risk-adjustment model for surgical morbidity and mortality. This model allowed participating centers to monitor and compare their results to other centers. Data are transmitted electronically to a coordination/analysis center, which periodically generates observed/expected (O/E) ratios for 30-day outcomes for all operations in a hospital. Significantly low O/E ratio is indicative of relatively superior quality of care, while a high O/E ratio is indicative of relatively inferior quality of care. Periodic comparative reports show the O/E ratios for all hospitals that aid care providers in identifying structures and processes that need to be improved at the local level. Following these results, the National VA Surgical Quality Improvement Program was started in January 1994 [6]. This has since evolved into the National Surgical Quality Improvement Program (NSQIP) to involve non-VA centers under the direction of the American College of Surgeons (ACS) [7]. Since the program started the 30-day morbidity rate after major surgery decreased by 45% and 30-day mortality rate by 31%. The program underscored the importance of center-specific systems as principal determinants of quality of care: the tool of Observed/Expected ratio is reflective of the quality of these systems [7].

We currently know of no mechanisms to allow for risk-adjusted assessment of quality of care in gynecologic cancer surgery. We sought to test the relevance of a model for ovarian cancer surgical outcomes by applying NSQIP methodology. We identified factors predictive of the following outcomes: 30-day morbidity, 3-month mortality, ability to receive chemotherapy, and length of hospitalization. We demonstrate the relevance of this risk-adjusted model and use of O/E ratios as a useful tool for quality improvement. We strongly believe that development of a nationally validated system to track surgical outcomes in gynecologic cancer will result in improved overall care.

Section snippets

Methods

Institutional Review Board approval was obtained at all participating institutions.

Patients’ characteristics

A total of 564 patients diagnosed with epithelial ovarian cancer (446 with stage IIIC and 118 with stage IV) were included in the study. Two hundred and forty-four patients (43%) were enrolled from Mayo Clinic (reference center), 105 patients (19%) from Johns Hopkins Medical Center, and 215 (38%) from Memorial Sloan Kettering Cancer Center. Some aspects of Mayo Clinic patients have previously been reported [10], [11].

All patients underwent primary exploratory laparotomy to diagnose stage and

Discussion

Surgery is learned progressively by studying and practicing during the years of training. Mentors guide the trainee in the achievement of required objectives. During this training period, the physician has objective observers who serve to increase his/her knowledge and skills. However, this scenario is not translated after the completion of the above-mentioned training. It is difficult to objectively define surgical outcomes or complication rates in ones practice. Furthermore, it is impossible

References (12)

There are more references available in the full text version of this article.

Cited by (0)

View full text