National Quality Forum Colon Cancer Quality Metric Performance: How Are Hospitals Measuring Up?
To evaluate the impact of care at high-performing hospitals on the National Quality Forum (NQF) colon cancer metrics.



The NQF endorses evaluating ≥12 lymph nodes (LNs), adjuvant chemotherapy (AC) for stage III patients, and AC within 4 months of diagnosis as colon cancer quality indicators. Data on hospital-level metric performance and the association with survival are unclear.



Retrospective cohort study of 218,186 patients with resected stage I to III colon cancer in the National Cancer Data Base (2004-2012). High-performing hospitals (>75% achievement) were identified by the proportion of patients achieving each measure. The association between hospital performance and survival was evaluated using Cox shared frailty modeling.



Only hospital LN performance improved (15.8% in 2004 vs 80.7% in 2012; trend test, P < 0.001), with 45.9% of hospitals performing well on all 3 measures concurrently in the most recent study year. Overall, 5-year survival was 75.0%, 72.3%, 72.5%, and 69.5% for those treated at hospitals with high performance on 3, 2, 1, and 0 metrics, respectively (log-rank, P < 0.001). Care at hospitals with high metric performance was associated with lower risk of death in a dose-response fashion [0 metrics, reference; 1, hazard ratio (HR) 0.96 (0.89-1.03); 2, HR 0.92 (0.87-0.98); 3, HR 0.85 (0.80-0.90); 2 vs 1, HR 0.96 (0.91-1.01); 3 vs 1, HR 0.89 (0.84-0.93); 3 vs 2, HR 0.95 (0.89-0.95)]. Performance on metrics in combination was associated with lower risk of death [LN + AC, HR 0.86 (0.78-0.95); AC + timely AC, HR 0.92 (0.87-0.98); LN + AC + timely AC, HR 0.85 (0.80-0.90)], whereas individual measures were not [LN, HR 0.95 (0.88-1.04); AC, HR 0.95 (0.87-1.05)].



Less than half of hospitals perform well on these NQF colon cancer metrics concurrently, and high performance on individual measures is not associated with improved survival. Quality improvement efforts should shift focus from individual measures to defining composite measures encompassing the overall multimodal care pathway and capturing successful transitions from one care modality to another.
*Houston VA Center for Innovations In Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX †Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX ‡Departments of Surgical Oncology and Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX §Department of Medicine, Baylor College of Medicine, Houston, TX.
Meredith C
MC
Mason
George J
GJ
Chang
Laura A
LA
Petersen
Yvonne H
YH
Sada
Hop S
HS
Tran Cao
Christy
C
Chai
David H
DH
Berger
Nader N
NN
Massarweh
D000368:Aged; D017024:Chemotherapy, Adjuvant; D003110:Colonic Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D005260:Female; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D009367:Neoplasm Staging; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D016019:Survival Analysis; D014481:United States