title: Nationwide Outcomes Measurement in Colorectal Cancer Surgery: Improving Quality and Reducing Costs.
abstract: BACKGROUND
  Recent literature suggests that focus in health care should shift from reducing costs to improving quality; where quality of health care improves, cost reduction will follow. Our primary aim was to investigate whether improving the quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs.
  
  
  METHODS
  This was a retrospective analysis of clinical and financial outcomes after colorectal cancer surgery in 29 Dutch hospitals (9,913 patients). Detailed clinical data were obtained from the 2010 to 2012 population-based Dutch Surgical Colorectal Audit. Patient-level costs were measured uniformly in all participating hospitals and based on time-driven, activity-based costing. Odds ratios (OR) and relative differences (RD) were risk adjusted for hospitals and differences in patient characteristics.
  
  
  RESULTS
  Over 3 consecutive years, severe complications and mortality declined by 20% (risk-adjusted OR 0.739, 95% CI 0.653 to 0.836, p < 0.001), and 29% (risk-adjusted OR 0.757, 95% CI 0.571 to 1.003, p = 0.05), respectively. Simultaneously, costs during primary admission decreased 9% (risk-adjusted RD -7%, 95% CI -10% to -5%, p < 0.001) without an increase in costs within the first 90 days after discharge (RD -2%, 95% CI -10% to 6%, p = 0.65). An inverse relationship (at hospital level) between severe complication rate and hospital costs was identified (R = 0.64). Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs; hospitals with declining severe complication rates were associated with cost reduction.
  
  
  CONCLUSIONS
  This report presents evidence for simultaneous quality improvement and cost reduction. Participation in a nationwide quality improvement initiative with continuous quality measurement and benchmarked feedback reveals opportunities for targeted improvements, bringing the medical field forward in improving value of health care delivery. The focus of health care should shift to improving quality, which will catalyze costs savings as well.
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Groene Hart Ziekenhuis, Gouda, The Netherlands. Electronic address: j.a.govaert@lumc.nl.
authors.forename: Johannes A
authors.initials: JA
authors.lastname: Govaert
authors.affiliation: Performation, Bilthoven, The Netherlands; X-IS, Delft, The Netherlands.
authors.forename: Wouter A
authors.initials: WA
authors.lastname: van Dijk
authors.affiliation: Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands; Mathematical Institute, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Marta
authors.initials: M
authors.lastname: Fiocco
authors.affiliation: Performation, Bilthoven, The Netherlands.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Scheffer
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Lieke
authors.initials: L
authors.lastname: Gietelink
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Michel W J M
authors.initials: MW
authors.lastname: Wouters
authors.affiliation: Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Rob A E M
authors.initials: RA
authors.lastname: Tollenaar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000191:economics / Q000401:mortality / Q000601:surgery*; D017046:Cost Savings / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data / Q000639:trends*; D019984:Quality Indicators, Health Care / Q000191:economics / Q000706:statistics & numerical data / Q000639:trends*; D012189:Retrospective Studies