title: Implementation of a Surgeon-Level Comparative Quality Performance Review to Improve Positive Surgical Margin Rates during Radical Prostatectomy.
abstract: Success in the era of value-based payment will depend on the capacity of health systems to improve quality while controlling costs. Comparative quality performance review can be used to drive improvements in surgical outcomes and thereby reduce costs. We sought to determine the efficacy of a comparative quality performance review to improve a surgeon-level measure of surgical oncologic quality, that is the positive surgical margin rate at the time of radical prostatectomy.
  
  
  
  Eight surgeons who performed consecutive radical prostatectomies at a single high volume institution between January 1, 2015 and December 31, 2015 were included in analysis. Individual surgeons were provided with confidential report cards every 6 months detailing their case mix, case volume and pT2 radical prostatectomy positive surgical margin rate relative to 1) their own self-matched data, 2) the de-identified data of their colleagues and 3) institutional aggregate data during the study period. Positive surgical margin rates were compared before and after intervention. Hierarchal logistic regression analysis was used to examine the association of study period on the odds of positive surgical margins, adjusted for prostate specific antigen level and National Comprehensive Cancer Network® risk group.
  
  
  
  Overall, 1,822 (1,392 before and 430 after intervention) radical prostatectomies were performed that met study inclusion criteria. The aggregate departmental unadjusted positive surgical margin rates were 10.6% and 7.4% in the pre-intervention and post-intervention groups, respectively. After adjusting for higher risk cancer in the post-intervention group, there was a significant protective association of post-intervention status on positive margins (OR 0.64, 95% CI 0.43-0.97, p = 0.03). All 5 surgeons with positive surgical margin rates higher than the aggregate department rate in the pre-intervention period showed improvement after intervention.
  
  
  
  Comparative quality performance review can be implemented at the surgeon level and can promote improvement in an objective measure of surgical oncology quality.
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Matulewicz
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Tosoian
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: C J
authors.initials: CJ
authors.lastname: Stimson
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Ashley E
authors.initials: AE
authors.lastname: Ross
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Meera
authors.initials: M
authors.lastname: Chappidi
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Tamara L
authors.initials: TL
authors.lastname: Lotan
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Humphreys
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Alan W
authors.initials: AW
authors.lastname: Partin
authors.affiliation: Department of Urology, Northwestern University Feinberg School of Medicine (RSM, EMS), Chicago, Illinois; The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland. Electronic address: E-Schaeffer@northwestern.edu.
authors.forename: Edward M
authors.initials: EM
authors.lastname: Schaeffer
mesh_terms: D000368:Aged; D002983:Clinical Competence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D011467:Prostate / Q000473:pathology / Q000601:surgery; D011468:Prostatectomy / Q000592:standards*; D011471:Prostatic Neoplasms / Q000601:surgery*; D011785:Quality Assurance, Health Care / Q000379:methods; D058996:Quality Improvement; D011787:Quality of Health Care / Q000592:standards*; D066231:Surgeons / Q000706:statistics & numerical data
keywords: margins of excision; prostate; prostatectomy; quality improvement; surgeons