“Intuitively we would expect the opposite; specifically, that hospitals which performed better on process of care measures would also perform better on outcomes,” said Dr. Ryan Merkow a surgery resident at the University of Chicago and study co-author.
“This highlights the limitations of publicly reported outcome measures based on administrative data that are intrinsically more challenging to accurately measure,” he said.
The study, published this week in the Annals of Surgery, compared results from more than 3,500 facilities, including 56 National Cancer Institute-designated cancer centers, 1112 American College of Surgeon Commission on Cancer (CoC) accredited hospitals, and 2395 hospitals with no accreditation.
Among the findings, CoC hospitals had the highest cost per Medicare beneficiary overall. When compared with non-accredited hospitals, they performed worse on 5 out of 10 measures, including serious post-op complications; catheter-associated bloodstream and urinary tract infections; and glycemic control. At the same time, they did better than non-accredited hospitals on five out of 10 patient satisfaction measures.
Overall NCI-designated cancer centers had the lowest cost per Medicare beneficiary, which the study says may mean they perform more efficient care. But the centers also performed worse than both the non-accredited and CoC hospitals on eight out of 10 outcome measures, including deaths following surgery; post-operative blood clots; serious post-op complications; both central line and urinary tract infections; wounds opening following surgery; glycemic control of surgical patients and colon surgical site infections.
Looking at patient satisfaction, the NCI cancer centers outperformed non-accredited hospitals on five out of 10 measures, including cleanliness, physician communication; responsiveness to patients; communicating about medications; and quietness.
The NCI responded in an email saying its designation is for research support.
“We are not in a position to judge the outcomes of the centers, but rather their research portfolio,” the agency said.
Dr. Lawrence Shulman, chair of the quality integration committee for the Commission on Cancer, which oversees the quality of cancer care in CoC-accredited hospitals, says the study offers a good start in use available data to compare quality. But part of the problem, he says, is that many of these metrics would not necessarily apply to cancer patients.
“Urinary catheter infection and poor glycemic control are important medical issues, but in a different patient population,” said Shulman, who also serves as chief of the division of general oncology at Dana-Farber Cancer Institute, one of 11 NCI-designated comprehensive cancer centers. There are cancer-specific safety metrics that more appropriately apply, he said, providing examples such as the use of breast-conserving surgery for breast cancer patients, knowing if a patient should have radiation as part of their treatment, and knowing which colon cancer patients would qualify for chemotherapy following surgery.
“It's a challenge to the medical community to come up with better metrics for quality for cancer programs,” he said noting that the CoC is in the process of developing new measures.
Researchers from the University of Chicago (which is an NCI-designated cancer center), Northwestern (which is both NCI-designated and CoC-accredited center) and the VA Medical Center of Chicago, used data from Medicare's Hospital Compare, the American Hospital Association annual survey and the CMS Inpatient Prospective Payment System. They agree that much of the confusion lies within the available metrics.
“ [Outcome measures] not only require complex risk adjustment methods to account for differences in patients and procedures performed, they are more likely to be subject to biases in their identification.”
For example, Merkow notes that patients at cancer centers may have more comorbidities and complex disease processes, and therefore might be at higher risk for complications. Risk adjustment may not fully account for the differences.
One of the measures included in the study was for post-operative blood clots, or venous thromboembolism (VTE). Previous studies have questioned whether that factor should even be considered on metrics of hospital quality, because bias can occur in hospitals that have more expansive VTE screening criteria for the condition.
Accreditation bodies should take an active role in developing cancer care specific quality measures that can be used by patients to help choose a hospital for their care, Merkow recommends.
That sentiment was mimicked in another recent report looking at the proliferation of hospital report cards, ratings and rankings, which have sprung out of the growing movement for improved quality and patient satisfaction, lower costs and greater accountability and transparency.
Hospital quality and reporting sites told Modern Healthcare that hospitals (all of them, not just cancer centers) should develop deliberate and thoughtful strategic plans for quality and safety, taking the lead in disclosing quality and cost information in a clear and useful way. “If they did that,” said Dr. Jeff Rice, CEO and founder of Healthcare Bluebook, which helps patients compare healthcare prices. “Then others wouldn't spend so much time trying to reinvent the wheel.”
Follow Sabriya Rice on Twitter: @MHSRice
