title: Risk-adjusted pathologic margin positivity rate as a quality indicator in rectal cancer surgery.
abstract: OBJECTIVE
  Margin positivity after rectal cancer resection is associated with poorer outcomes. We previously developed an instrument for calculating hospital risk-adjusted margin positivity rate (RAMP) that allows identification of performance-based outliers and may represent a rectal cancer surgery quality metric.
  
  
  METHODS
  This was an observational cohort study of patients with rectal cancer within the National Cancer Data Base (2003 to 2005). Hospital performance was categorized as low outlier (better than expected), high outlier (worse than expected), or non-RAMP outlier using standard observed-to-expected methodology. The association between outlier status and overall risk of death at 5 years was evaluated using Cox shared frailty modeling.
  
  
  RESULTS
  Among 32,354 patients with cancer (mean age, 63.8 +/-13.2 years; 56.7% male; 87.3% white) treated at 1,349 hospitals (4.9% high outlier, 0.7% low outlier), 5.6% of patients were treated at high outliers and 3.0% were treated at low outliers. Various structural (academic status and volume), process (pathologic nodal evaluation and neoadjuvant radiation therapy use), and outcome (sphincter preservation, readmission, and 30-day postoperative mortality) measures were significantly associated with outlier status. Five-year overall survival was better at low outliers (79.9%) compared with high outliers (64.9%) and nonoutliers (68.9%; log-rank test, P < .001). Risk of death was lower at low outliers compared with high outliers (hazard ratio [HR], 0.61; 95% CI, 0.50 to 0.75) and nonoutliers (HR, 0.69; 95% CI, 0.57 to 0.83). Risk of death was higher at high outliers compared with nonoutliers (HR, 1.12; 95% CI, 1.03 to 1.23).
  
  
  CONCLUSIONS
  Hospital RAMP outlier status is a rectal cancer surgery composite metric that reliably captures hospital quality across all levels of care and could be integrated into existing quality improvement initiatives for hospital performance.
authors.forename: Nader N
authors.initials: NN
authors.lastname: Massarweh
authors.forename: Chung-Yuan
authors.initials: CY
authors.lastname: Hu
authors.forename: Y Nancy
authors.initials: YN
authors.lastname: You
authors.forename: Brian K
authors.initials: BK
authors.lastname: Bednarski
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Rodriguez-Bigas
authors.forename: John M
authors.initials: JM
authors.lastname: Skibber
authors.forename: Scott B
authors.initials: SB
authors.lastname: Cantor
authors.forename: Janice N
authors.initials: JN
authors.lastname: Cormier
authors.forename: Barry W
authors.initials: BW
authors.lastname: Feig
authors.forename: George J
authors.initials: GJ
authors.lastname: Chang
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery; D002288:Adenocarcinoma, Mucinous / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018279:Carcinoma, Signet Ring Cell / Q000473:pathology / Q000601:surgery; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D016017:Odds Ratio; D059351:Organ Sparing Treatments; D010359:Patient Readmission / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery*; D012306:Risk; D014481:United States / Q000453:epidemiology
references.citation: N Engl J Med. 2004 Oct 21;351(17):1731-40
references.pmid: 15496622
references.citation: Med Care. 2003 Oct;41(10):1111-7
references.pmid: 14515105
references.citation: Health Aff (Millwood). 2010 Jan-Feb;29(1):182-7
references.pmid: 19897509
references.citation: Br J Surg. 2002 Mar;89(3):327-34
references.pmid: 11872058
references.citation: J Clin Oncol. 2009 Sep 1;27(25):4177-81
references.pmid: 19636004
references.citation: Ann Surg Oncol. 2013 Jun;20(6):1759-65
references.pmid: 23475400
references.citation: Cancer. 1994 Jan 15;73(2):499-504
references.pmid: 8293419
references.citation: Med Care. 1994 Apr;32(4):390-400
references.pmid: 8139303
references.citation: Ann Surg Oncol. 2010 Jan;17(1):4-7
references.pmid: 19847564
references.citation: JAMA. 2010 Jun 23;303(24):2479-85
references.pmid: 20571014
references.citation: JAMA Surg. 2013 Aug;148(8):769-77
references.pmid: 23803722
references.citation: J Clin Oncol. 2005 Dec 20;23(36):9257-64
references.pmid: 16361623
references.citation: Lancet. 1994 Sep 10;344(8924):707-11
references.pmid: 7915774
references.citation: J Clin Epidemiol. 1992 Jun;45(6):613-9
references.pmid: 1607900
references.citation: N Engl J Med. 2006 Feb 23;354(8):864-70
references.pmid: 16495401
references.citation: Ann Surg. 2009 Sep;250(3):363-76
references.pmid: 19644350
references.citation: Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1311-20
references.pmid: 12654443
references.citation: CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29
references.pmid: 22237781
references.citation: Lifetime Data Anal. 1995;1(3):255-73
references.pmid: 9385105
references.citation: Lancet. 2009 Mar 7;373(9666):821-8
references.pmid: 19269520
references.citation: World J Surg. 2005 Oct;29(10):1241-4
references.pmid: 16136280
references.citation: Ann Surg. 2011 Sep;254(3):494-9; discussion 499-501
references.pmid: 21817889
references.citation: Colorectal Dis. 2003 Sep;5(5):471-7
references.pmid: 12925083
references.citation: Ann Surg Oncol. 2008 Mar;15(3):683-90
references.pmid: 18183467
references.citation: JAMA. 2012 Feb 1;307(5):509-10
references.pmid: 22298680
references.citation: Surgery. 2002 Jan;131(1):16-8
references.pmid: 11812958
references.citation: JAMA. 2004 Aug 18;292(7):847-51
references.pmid: 15315999
references.citation: Acad Med. 2007 Dec;82(12):1178-86
references.pmid: 18046123
references.citation: JAMA Surg. 2013 Aug;148(8):778
references.pmid: 23803771
references.citation: N Engl J Med. 2001 Aug 30;345(9):638-46
references.pmid: 11547717
references.citation: JAMA. 1988 Sep 23-30;260(12):1743-8
references.pmid: 3045356
references.citation: Stat Med. 2008 Dec 30;27(30):6310-31
references.pmid: 19021241
references.citation: Surgery. 2012 Feb;151(2):146-52
references.pmid: 22129638
references.citation: J Am Coll Surg. 2004 Apr;198(4):626-32
references.pmid: 15051016
references.citation: Stat Methods Med Res. 2007 Jun;16(3):277-98
references.pmid: 17621472
references.citation: Arch Surg. 2010 Oct;145(10):999-1004
references.pmid: 20956770