title: Hospital characteristics associated with maintenance or improvement of guideline-recommended lymph node evaluation for colon cancer.
abstract: BACKGROUND
  Over the past 20 years, surgical practice organizations have recommended the identification of ≥12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines.
  
  
  METHODS
  Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (≥12) lymph node evaluation compared with initial evaluation levels (1996-1998) using χ tests and multivariate logistic regression analysis, adjusting for patient case-mix.
  
  
  RESULTS
  We identified 228 hospitals that performed ≥6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance.
  
  
  CONCLUSIONS
  Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.
authors.affiliation: Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA. parsonsh@uthscsa.edu
authors.forename: Helen M
authors.initials: HM
authors.lastname: Parsons
authors.forename: James W
authors.initials: JW
authors.lastname: Begun
authors.forename: Patricia M
authors.initials: PM
authors.lastname: McGovern
authors.forename: Todd M
authors.initials: TM
authors.lastname: Tuttle
authors.forename: Karen M
authors.initials: KM
authors.lastname: Kuntz
authors.forename: Beth A
authors.initials: BA
authors.lastname: Virnig
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000601:surgery*; D005260:Female; D006742:Hospital Bed Capacity; D006761:Hospitals / Q000592:standards*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D010067:Ownership; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D012111:Residence Characteristics; D018426:SEER Program / Q000706:statistics & numerical data; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data*; D014481:United States