Hospital Quality Indicator For Lymph Node Exam After Colon Cancer Surgery Is Not Associated With Survival

Examining a specific number of lymph nodes after colon cancer surgery, a measurement that has been recommended as a quality indicator for hospitals, is not associated with length of patient survival, according to a study in the November 14 issue of JAMA.

Several studies have suggested improved survival among patients in whom a higher number of nodes are examined after colectomy for colon cancer (part or all of the colon is removed). Several organizations recently endorsed a 12-node minimum as a standard for hospital-based performance, according to background information in the article. Large private payers have already begun incorporating this measure into their pay-for-performance programs. Whether such efforts will improve outcomes for patients with colon cancer remains unclear, as is whether node counts are useful as an indicator of hospital quality.

Sandra L. Wong, MD, MS, of the University of Michigan, Ann Arbor, and colleagues, using data from the national Surveillance Epidemiology and End Results (SEER)-Medicare linked database (1995-2005), assessed whether hospitals’ lymph node examination rates were associated with cancer staging, use of adjuvant (supplemental) chemotherapy (indicated for patients with node-positive disease), and five-year survival. The study included 30,625 patients undergoing colectomy for nonmetastatic colon cancer. Hospitals were ranked according to the proportion of their patients in whom 12 or more lymph nodes were examined and then were sorted into four groups. Late survival rates were assessed for each hospital group, adjusting for potentially confounding patient and clinician characteristics.

Hospitals with the highest proportions of patients with 12 or more lymph nodes examined tended to treat lower-risk patients and had substantially higher procedure volumes. After adjusting for these and other factors, there remained no statistically significant relationship between hospital lymph node examination rates and survival after surgery. Although the four hospital groups varied widely in the number of lymph nodes examined, they were equally likely to find node-positive tumors. There were no clinically important differences in the use of adjuvant chemotherapy, either overall (unadjusted rates of 26 percent for the highest hospital quartile vs. 25 percent for the lowest hospital quartile) or within cancer stage subgroups.

"Our study raises questions about the importance of examining a large number of lymph nodes in patients with colon cancer," the authors write.

Regarding the finding of no evidence of higher five-year survival at hospitals with higher lymph node examination rates, the authors say, "Our analyses also suggest a simple explanation for these null findings. Regardless of how many lymph nodes hospitals examined, they tended to find the same number of node-positive ones. As a result, higher hospital lymph node examination rates did not result in greater detection of patients with node-positive tumors or higher rates of adjuvant chemotherapy.

"Using lymph node counts as a hospital quality indicator is gaining momentum from stakeholders in the healthcare community," the researchers write. "The number of lymph nodes hospitals examine following colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention."

Editorial: Lymph Node Counts in Colon Cancer Surgery -- Lessons for Users of Quality Indicators
In an accompanying editorial, Marko Simunovic, MD, MPH, of McMaster University, Hamilton, Ontario, Canada, and Nancy N. Baxter, MD, PhD, of the University of Toronto, Ontario, Canada, comment on the findings of Wong and colleagues.

"Researchers should not abandon efforts to identify potentially useful quality indicators through various study designs," they say. "Those who use such measures and endorsing agencies must recognize the inherent weaknesses of quality indicators derived from observational data; the potential for unintended consequences as clinicians and hospitals respond in varying ways to meet perceived indicator benchmarks; and should guard against the carrot or stick use of indicators. Using quality indicators as one part of a comprehensive, supportive, incremental quality-improvement project, such as those included under the rubric of total quality management or continuous quality improvement, is likely to be more constructive —although even these strategies currently lack a compelling evidence base."

Source: American Medical Association (AMA)

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