title: National assessment of margin status as a quality indicator after pancreatic cancer surgery.
abstract: BACKGROUND
  Surgical margin involvement is an important outcome after pancreatic cancer surgery; however, variation in pathologic review practices may limit its use as a quality indicator. Our objectives were to assess variation in hospital performance and the reliability of margin involvement after pancreatic cancer surgery.
  
  
  METHODS
  From the National Cancer Data Base, patients who underwent pancreatic resection for stage I to III adenocarcinoma were identified. Risk-adjusted surgical margin involvement was evaluated using hierarchical regression methods, and variation in hospital performance and reliability was determined.
  
  
  RESULTS
  From 1,002 hospitals, 14,889 patients underwent pancreatic resection for adenocarcinoma, and 3,573 (24.0 %) had an involved surgical margin (R1 22.8 %; R2 1.2 %). The strongest predictors associated with margin involvement were T stage [T3: odds ratio (OR) 2.08, 95 % confidence interval (CI) 1.68-2.59; T4: OR 7.26, 95 % CI 5.50-9.60; vs. T1] and tumor size (2-3.9 cm: OR 1.66, 95 % CI 1.39-1.98, ≥ 4 cm: OR 2.28, 95 % CI 1.90-2.74; vs. <2 cm). Factors associated with a decreased likelihood of margin involvement were the use of neoadjuvant therapy and hospital type (academic and National Cancer Institute-designated comprehensive cancer centers vs. community). At the hospital level, the mean risk-adjusted surgical margin involvement rate was 25.9 % and ranged 10.1 to 50.5 %. Twenty-one (2.1 %) hospitals had lower-than-expected and 17 (1.7 %) had higher-than-expected margin involvement. A minimum acceptable reliability of 0.4 was met after 13 cases and was achieved by 249 hospitals that performed 79 % of pancreatic resections assessed.
  
  
  CONCLUSIONS
  Despite differences in pathologic evaluation practices, hospitals can be feasibly and reliably provided comparative data on surgical margin status after resection for pancreatic cancer.
authors: Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA, RMerkow@facs.org.
authors: Ryan P
authors: RP
authors: Merkow
authors: Karl Y
authors: KY
authors: Bilimoria
authors: David J
authors: DJ
authors: Bentrem
authors: Henry A
authors: HA
authors: Pitt
authors: David P
authors: DP
authors: Winchester
authors: Mitchell C
authors: MC
authors: Posner
authors: Clifford Y
authors: CY
authors: Ko
authors: Timothy M
authors: TM
authors: Pawlik
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology* / Q000601:surgery; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery; D011379:Prognosis; D019984:Quality Indicators, Health Care / Q000592:standards*