Measuring Quality Care in Localized Renal Cell Cancer: Use of Appropriate Preoperative Investigations in a Population-Based Cohort

Moideen, Nikitha; Marzouk, Karim; Matheson, Kara; Wood, Lori

doi:10.3747/co.24.3290

Cited by 4 publications

(4 citation statements)

References 4 publications

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“…For example, one study in the US defined hypercalcemia at serum calcium > 10.1 mg/dL (2.5 mmol/L) 14 , whereas our study in Canadian centres defined hypercalcemia at serum calcium > 2.7 mmol/L to capture more clinically significant hypercalcemia. The lower prevalence of hypercalcemia may also be due to a high proportion of patients (84%) from current study who did not have a preoperative calcium level recorded which is often due to one not being drawn as shown in other studies 19 . The implications of PNS from this study should be further evidence for urologists to ensure a full preoperative chemistry panel is obtained.…”

Section: Discussionmentioning

confidence: 69%

Prognostic impact of paraneoplastic syndromes on patients with non-metastatic renal cell carcinoma undergoing surgery: Results from Canadian Kidney Cancer information system

Sun

Breau

Mallick

et al. 2020

CUAJ

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Introduction: The impact of paraneoplastic syndromes (PNS) on survival in patients with renal cell carcinoma (RCC) is uncertain. This study was conducted to analyze the association of PNS with recurrence and survival of patients with non-metastatic RCC undergoing nephrectomy. Methods: The Canadian Kidney Cancer information system is a multi-institutional cohort of patients started in January 2011. Patients with nephrectomy for non-metastatic RCC were identified. PNS included anemia, polycythemia, hypercalcemia, and weight loss. Associations between PNS and recurrence or death were assessed using Kaplan-Meier curves and multivariable analysis. Results: Of 4337 patients, 1314 (30.3%) had evidence of one or more PNS. Patients with PNS, were older, had higher comorbidity, and had more advanced clinical and pathological tumor characteristics as compared to patients without PNS (all p<0.05). Kaplan-Meier five-year estimated recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were significantly worse in patients with PNS (63.7%, 84.3%, and 79.6%, respectively for patients with PNS vs. 73.9%, 90.8%, and 90.1%, respectively for patients without PNS, all p<0.005). On univariable analysis, presence of PNS increased risk of recurrence (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.48–1.90, p<0.0001) and cancer-related death (HR 1.85, 95% CI 1.34–2.54, p=0.0002). Adjusting for known prognostic factors, PNS was not associated with recurrence or survival. Conclusions: In non-metastatic RCC patients undergoing surgery, presence of PNS is associated with older age, higher Charlson comorbidity index score, advanced tumor stage, and aggressive tumor histology. Following surgery, baseline PNS is not strongly independently associated with recurrence or death.

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Section: Discussionmentioning

confidence: 69%

Prognostic impact of paraneoplastic syndromes on patients with non-metastatic renal cell carcinoma undergoing surgery: Results from Canadian Kidney Cancer information system

Sun

Breau

Mallick

et al. 2020

CUAJ

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“…In this single institution study by Moideen et al, only 39.0% of patients who were stage II or above had a CT chest within 3 months of surgery. 15 When looking at all patients in clinical stage I, II, or III groups, the percentage of patients who had chest imaging of any type within 3 months of surgery was 61.6%; even when looking only at stage II, the percentage of patients with imaging of any type was only 74.0%, meaning roughly a quarter of patients with high-risk clinical presentation did not receive appropriate preoperative staging.…”

Section: Discussionmentioning

confidence: 99%

Guideline Compliance Regarding Chest Imaging of Suspicious cT1 Renal Masses in MUSIC-KIDNEY

Semerjian

Ginsburg

et al. 2023

Urology Practice

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Introduction:Multiple urological societies recommend chest imaging for suspicious renal masses using chest x-ray or CT as clinically indicated. The purpose of chest imaging is to assess for thoracic metastasis at the time of renal mass diagnosis. Ideally, imaging use and type are commensurate with risk related to tumor size and clinical stage. We examined current practice patterns with chest imaging compliance in the state of Michigan and implemented clinician education and value-based reimbursement incentivization on guideline adherence.Methods:MUSIC (Michigan Urological Surgery Improvement Collaborative)-KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) is a statewide initiative focusing on quality improvement for patients with cT1 renal masses. Data regarding chest imaging in MUSIC and panel discussion occurred at an in-person MUSIC meeting in October 2019. Adherence to chest imaging guidelines was made a value-based reimbursement metric at the triannual MUSIC meeting in January 2020. Adherence was defined as optional in renal masses <3 cm (CT not indicated), recommended in renal masses 3-5 cm (chest x-ray preferred), and required in renal masses >5 cm (CT preferred). The MUSIC registry was queried for percentage of patients receiving chest imaging by type. Factors associated with adherence were assessed.Results:There was significant practice-level variation in chest imaging rates across the 14 contributing practices, ranging from 11% to 68%. Compliance with MUSIC guidelines for chest imaging during evaluation of T1 renal masses was 81.8% overall, with only 61.8% of patients with masses >5 cm meeting the guideline requiring imaging with preference for CT. Factors associated with increased adherence included larger tumor size (T1b vs T1a) and solid (vs cystic or indeterminate) tumor (P < .05 for each). Prior to value-based reimbursement introduction, 46.7% of patients underwent imaging of either type, compared to 49.0% post-intervention. Imaging rates only slightly increased in masses >5 cm (58.3% before value-based reimbursement vs 61.2% after, P = .56) and 3-5 cm (50.0% before value-based reimbursement vs 56.2% after, P = .0585).Conclusions:Chest imaging guideline adherence during the initial evaluation of cT1 renal masses is acceptable, particularly given that most masses are <3 cm, for which metastatic risk is low. However, despite consensus from major urological societies regarding imaging for masses >4-5 cm, imaging rates were low across MUSIC. After educational and value-based reimbursement incentive initiation, rates of imaging for 3-5–cm and >5-cm masses changed only slightly. There remains significant practice variability and room for improvement.

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“…Many different metrics remain available as potential indicators of quality surgical care in kidney cancer and other subspecialty surgical fields. 3,5–10,16,25,30 Further assessment of these unevaluated metrics warrants consideration in an effort to further refine our compound metric score, which was conceived as a dynamic rather than static process for quality improvement. Importantly, the CQS evaluated in this study makes use of administrative data easily collected with queries of existing hospital data sets.…”

Section: Discussionmentioning

confidence: 99%

“…1–4 However, examples of these initiatives in urology remain uncommon or in early stages of development. 5–10 This is despite the increasing and concerning evidence that significant variations exist in the quality of surgical care at the hospital level nationwide. 11–15 Importantly, this has been shown for subspecialty urological care and patients with kidney cancer in particular.…”

mentioning

confidence: 99%

A Novel Metric for Hospital Quality in Kidney Cancer Surgery: A Veterans Affairs National Health System Validation of Concept

et al. 2022

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Introduction:We aimed to develop and validate a Compound Quality Score (CQS) as a metric for hospital-level quality of surgical care in kidney cancer at the Veterans Affairs National Health System.Methods:A retrospective review of 8,965 patients with kidney cancer treated at Veterans Affairs (2005–2015) was performed. Two previously validated process quality indicators (QIs) were explored: the proportion of patients with 1) T1a tumors undergoing partial nephrectomy and 2) T1-T2 tumors undergoing minimally invasive radical nephrectomy. Demographics/comorbidity/tumor characteristics/treatment year were used for case mix adjustments at hospital level. The predicted versus observed ratio of cases was calculated per hospital to generate QI scores using indirect standardization and multivariable regression models. CQS represents the sum of both scores. A total of 96 hospitals were grouped by CQS, and short-term patient-level outcomes were regressed on CQS levels to assess for length of stay (LOS), 30-day complications/readmission, 90-day mortality and total cost of surgical admission.Results:CQS identified 25/33/38 hospitals with higher/lower/average performance, respectively. High performance hospitals had higher nephrectomy volumes (p <0.01). Total CQS independently associated with LOS (β=−0.04, p <0.01, predicted LOS 0.84 days shorter for CQS=2 versus CQS=−2), 30-day surgical complications (OR=0.88, p <0.01) or 30-day medical complications (OR=0.93, p <0.01) and total cost of surgical admission (β =−0.014, p <0.01, predicted 12% lower cost for CQS=2 versus CQS=−2). No association was found between CQS and 30-day readmissions or 90-day mortality (all p >0.05), although low event rates were observed (8.9% and 1.7%, respectively).Conclusions:Variability in quality of surgical care at hospital level can be captured with the CQS among patients with kidney cancer. CQS is associated with relevant short-term perioperative outcomes and surgical cost. QIs should be used to identify, audit and implement quality improvement strategies across health systems.

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Measuring Quality Care in Localized Renal Cell Cancer: Use of Appropriate Preoperative Investigations in a Population-Based Cohort

Abstract: IntroductionObtaining appropriate preoperative risk-specific staging investigations for localized renal cell

Cited by 4 publications

References 4 publications

Prognostic impact of paraneoplastic syndromes on patients with non-metastatic renal cell carcinoma undergoing surgery: Results from Canadian Kidney Cancer information system

Prognostic impact of paraneoplastic syndromes on patients with non-metastatic renal cell carcinoma undergoing surgery: Results from Canadian Kidney Cancer information system

Guideline Compliance Regarding Chest Imaging of Suspicious cT1 Renal Masses in MUSIC-KIDNEY

A Novel Metric for Hospital Quality in Kidney Cancer Surgery: A Veterans Affairs National Health System Validation of Concept

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