EURURO Vol. 72 No. 3

387 476

Platinum Priority – Editorial
Referring to the article published on pp. 379–386 of this issue
Improving Quality in Renal Cell Carcinoma Care:
Bridging the Gap Between Measurement and Meaning
Anobel Y. Odisho John L. Gore
Department of Urology, University of Washington, Seattle, WA, USA
As we continue to investigate quality and performance
measures in health care, the national landscape has shifted
dramatically, forcing us to re-evaluate why, how, and what
we measure.
Early efforts in quality measurement were founded in
the academic and altruistic desire of providers to improve
the quality of care they delivered to patients . Although
good intentions persist, they have been buttressed with
financial incentives, with the most recent incarnation
being the Medicare Access and CHIP Reauthorization Act
(MACRA), which consolidates multiple quality programs
into the Merit Based Incentive Payment System (MIPS).
This program adjusts reimbursement according to four
performance categories: resource use, quality, advancing
care information, and clinical practice improvement.
Starting in 2017, the quality metric accounts for 60% of
the total MIPS score, which can result in up to a 9% payment
adjustment.
Investigators and policymakers have developed innu-
merable quality measures following the Donabedian model
of structure, process, and outcome. However, early measure
development was limited by data availability, which
consisted of administrative data collected primarily for
billing purposes. As a result, early measures were defined by
ease of collection rather than relevance to true clinical
outcomes. Process measures, such as adherence to common
screening recommendations or timing of care delivery, and
crude outcome measures, such as readmission or mortality
rates, were among the first implemented because they
could be easily ascertained from claims data. Initial
measures were aimed at large and broad patient cohorts,
such as all surgical patients or patients with acute
myocardial infarction. Now, attention is being turned to
more select cohorts, such as patients with prostate cancer,
and measures targeted at subgroups (eg, appropriateness of
adjuvant hormone therapy in high-risk prostate cancer
patients receiving external beam radiation; avoidance of
bone scans in low-risk prostate cancer). These more
granular measures are more actionable but must be proven
to impact patient outcomes.
There remains a disconnect between process measures as
indicators of some important underlying behavior and the
tangible outcomes experienced by patients, such as adher-
ence to surgical-site infection measures and incidence of
surgical site infections As our data sources continue to
improve and include data prospectively collected for the
explicit purpose of quality improvement (such as the
American College of Surgeons National Surgical Quality
Improvement Program), we can turn our attention to more
pertinent measures.
In this issue of European Urology, Lawson and colleagues
report on the development and validation of a composite
metric of quality outcomes for patients undergoing surgery
for renal cell carcinoma (RCC). Their composite metric,
called the Renal Cancer Quality Score (RC-QS), consists of
three process measures (patients with T1a tumors under-
going partial nephrectomy, patients with T1–2 tumors
undergoing minimally invasive surgery, positive margin
rates in partial nephrectomy) and two outcome measures
(length of stay and 30-d unplanned readmission rate after
radical nephrectomy). Importantly, using the National
Cancer Database (NCDB), they validated their composite
measure with tangible patient outcomes, 30-d and 90-d
mortality at the hospital level.
ava ilable at
journal homepage:
DOI of original article: .
* Corresponding author. Department of Urology, University of Washington, Box 356510, 1959 NE Pacific Street, Seattle, WA 98195, USA.
Tel. +1 206 2216430.
E-mail address: (A.Y. Odisho).
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.