Dr. Gore states that the time for health care delivery reform is now. In the past, health care was typically producer-centered, incentivized for volume, unsustainable, and fragmented. The present and future platform is patient-centered, incentivized for outcomes, sustainable, and coordinated. Past systems and policies were fee-for-service payments, whereas the present and future policies include value-based purchasing, Accountable Care Organizations, bundled payments, medical homes, quality/cost transparency, and population-based payments. Health care quality, according to Dr. Gore, stems from the structure, a process, and outcomes.
Specific to kidney cancer, Dr. Gore notes that there are several quality metrics in kidney cancer:
- Negative surgical margins in patients undergoing partial nephrectomy pT1 or pT2 renal cortical tumors
- Establish nodal status for patients undergoing extirpative surgery for clinical N+M0 renal cortical tumors
- Biopsy before ablation for a renal cortical tumor
- Nephrectomy or biopsy (of the primary site or another site) prior to initiating systemic therapy in metastatic renal cell carcinoma
Previous work from the NCDB has been used to determine hospital-level variations in RCC surgical quality after adjusting for differences in patient- and tumor-specific factors . Over 1100 hospitals were benchmarked for quality, with 10-31% identified as providing poor care for a given quality indicator. To evaluate hospitals, the authors utilized a Renal Cancer Quality Score, derived of (i) the percentage of T1a tumors undergoing partial nephrectomy, (ii) Percentage of T1-T2 tumors undergoing MIS for radical nephrectomy, (iii) Percentage of positive surgical margins following partial nephrectomy, (iv) length of stay after radical nephrectomy, and (v) percentage of 30-day readmissions after radical nephrectomy. Lower Renal Cancer Quality Score hospitals had smaller referral volumes and were less academic compared with higher Renal Cancer Quality Score hospitals (p<0.001). Higher Renal Cancer Quality Score was independently associated with lower 30-day, 90-day, and overall mortality (aOR 0.92, CI 0.90-0.95); aOR 0.94, CI 0.91-0.96; aHR: 0.97, CI 0.96-0.98, respectively], per unit increase. The authors concluded that superior quality is associated with improved patient outcomes, including mortality benefit.
Dr. Gore concluded with several take-home messages from his talk:
- Quality measurement promotes clinical standards and is critical to assigning value-based incentives for health care delivery
- There are no endorsed quality metrics in kidney cancer
- Constructing composite measures may better align performance measurement with tangible patient outcomes
- Unintended punitive consequences to hospital-based quality measurement may disproportionately impact safety net hospitals
Presented by: John L. Gore, University of Washington Medical Center, Seattle, Washington
Written By: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md at the 2019 American Society of Clinical Oncology Genitourinary Cancers Symposium, (ASCO GU) #GU19, February 14-16, 2019 - San Francisco, CA
- Gore JL, Wright JL, Daratha KB, et al. Hospital-level variation in the quality of urologic cancer surgery. Cancer 2012 Feb 15;118(4):987-996.
- Lawson KA, Saarela O, Abouassaly R, et al. The impact of quality variations on patients undergoing surgery for renal cell carcinoma: A National Center Database study. Eur Urol 2017 Sep;72(3):3790386.