EURURO Vol. 72 No. 3

379 476

Platinum Priority – Kidney Cancer
Editorial by Anobel Y. Odisho and John L. Gore on pp. 387–388 of this issue
The Impact of Quality Variations on Patients Undergoing Surgery
for Renal Cell Carcinoma: A National Cancer Database Study
Keith A. Lawson Olli Saarela Robert Abouassaly Simon P. Kim Rodney H. Breau
Antonio Finelli
a Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada; bDalla Lana School of Public
Health, University of Toronto, Toronto, ON, Canada; cUrology Institute, University Hospitals Case Medical Center, Cleveland, OH, USA; d Division of Urology,
Department of Surgery, University of Ottawa, Ottawa, ON, Canada
ava ilable at
journal homepage:
Article info
Article history:
Accepted April 27, 2017
Associate Editor:
Giacomo Novara
Keywords:
Renal cell carcinoma
Quality
Quality indicators
Performance measures
Benchmarking
Abstract
Background: 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.
Objectives: 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.
Design, setting, and participants: RCC patients undergoing surgery in the USA and Puerto Rico
(2004–2014) were identified from the National Cancer Database.
Outcome measures and statistical analysis: 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.
Results and limitations: 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-QSwas independently associatedwith 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.
Conclusions: 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.
Patient summary: 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.
# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Division of Urology, Department of Surgery, Princess Margaret Hospital,
3–130, 610 University Avenue, Toronto, ON M5G 2M9, Canada. Tel. +1-416-946-2851;
Fax: +1-416-946-6590.
E-mail addresses: , (A. Finelli).
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.