Jun 30, 2014
By Shira Klapper, Senior Writer/Editor
A research team in Michigan showed it was possible to successfully link a statewide registry that collects data on surgical quality with the tumor registries of 10 hospitals. The robust database created from the linkage will serve as a platform for a quality assessment program for rectal cancer surgery. The study, “Implementation of a Hospital-Based Quality Assessment Program for Rectal Cancer,” was published in the May 2014 Journal of Oncology Practice (JOP).
Study first author, Samantha Hendren, MD, MPH, said the study was inspired by European initiatives to improve the quality of rectal cancer surgery. Those initiatives had been successful, in large part, due to Europe’s centralized health care systems, which meant that all data was in one place and could be easily combed through to identify areas in need of improvement. In Norway alone, a surgical quality improvement program resulted in local rectal cancer recurrence rates dropping from 12 to 6%, and four-year survival rates increasing from 60 to 73%.
Dr. Hendren and her colleagues at the University of Michigan and Munson Medical Center thought that American surgeons could benefit from similar quality assessment programs, but there was an obstacle: Since the American health care system is decentralized, data on specific diseases is often spread out across multiple databases.
“The United States does have large, national databases such as SEER Medicare and the National Cancer Database,” said Dr. Hendren. “But none of them have sufficient enough detail to assess the quality of rectal surgery.” Even surgery-specific registries, such as the nationwide American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP), do not include cancer-specific variables.
Motivated by this lack of data, Dr. Hendren and her co-authors designed a study to assess whether it was possible to compile a large data set on rectal cancer surgery by linking the tumor registries with an existing registry created for surgical quality improvement, the Michigan Surgical Quality Collaborative. The data were also enriched with details from the pathology and operative reports specific to rectal cancer care. Since those reports can be quite technical, an integral part of the study was assessing whether nurses could be trained to read the pathology and operative reports in order to cull specific data-points.
The findings? The study reported that it was possible to link the tumor registries and other records, thereby producing a more complete data platform than either source alone could have generated. Furthermore, nurses who received training were able to pull information from the tumor registries and medical records with 90% accuracy.
When designing the study, Dr. Hendren and the research team chose to use both hospital medical records and tumor registries as data sources since each contained a trove of quality indicators.
“The medical record includes indicators such as—was the surgery done using minimally invasive techniques, was it done using an anastomosis, was there an ostomy done, did the patient see an ostomy nurse?” said Dr. Hendren. “It also includes the clinical stage, which captures what the true stage was before any treatment was given, and which is how we measure whether people who should have got neoadjuvant treatment actually received that treatment.”
The tumor registry, for its part, served to augment, and complement, the data in the medical record.
“Nearly every state has a state tumor registry since cancer, like TB, is a reportable illness, which means hospitals are required to report data about their cancer cases,” said Dr. Hendren. “We really wanted to get the stage information from the tumor registry because we felt like that’s the ultimate gold-standard in staging.”
Training nurses to glean 66 variables
The success of the study hinged on successfully training the nurses to decipher the hospital medical records.
“The nurses were terrific and knew the ins and outs of the electronic medical records in each of their hospitals, so that was a big advantage for us,” said Dr. Hendren. “But they had not really been looking at pathology reports before, so we had to spend a lot of time talking about the technical jargon in those reports.”
The nurses were asked to abstract 44 variables from the medical records and 22 variables from the hospital tumor registrars. In order to learn how to slice through the jargon and complexity of the pathology reports, the nurses underwent a six-week training that included explanations of variables, three sample test cases, and conference calls with clinical specialists. To test the nurses’ readiness to abstract data, they were given a final test case in which they had to identify variables with at least 90% accuracy; nine out of the ten nurses met this requirement.
Applying the data
After completing the study, Dr. Hendren and her co-authors reviewed the 66 abstracted variables and identified 32 (11 from the tumor registry and 21 from the medical record) to serve as the basis for future data collection and quality assessment programs in Michigan. The researchers thought those 32 variables merited wider use because they met three criteria: they were strong indicators of the quality of the surgery, they were verified as accurate by nurses and experts, and they were not overly difficult to abstract.
In addition to showing that these kinds of data-linkages are possible, Dr. Hendren and her co-authors are also using the data to create real-world quality improvement initiatives.
“We’re taking the information that we’re learning and putting together a report showing how each hospital compares to all the other hospitals in the quality of their rectal cancer surgery,” said Dr. Hendren. “We hope that the surgeons and nurses will present the report within their surgery departments and discuss how they can improve. And that’s our ultimate goal.”
(The American Society of Clinical Oncology (ASCO) has several Quality initiatives, including The Quality Oncology Practice Initiative® (QOPI®), which allows oncology practices to measure and evaluate their performance, and CancerLinQ™, which will aggregate a massive amount of data on the national level in order to uncover patterns to improve care and provide real-time quality feedback to providers).
Samantha Hendren, MD, PhD, is a general and colorectal surgeon and an Assistant Professor in the University of Michigan Department of Surgery.
Hendren S, McKeown E, Morris AM, et al. Implementation of a hospital-based quality assessment program for rectal cancer. J Oncol Pract. 2014;10(3);e120-e129.
The Exclusive Coverage series on ASCO.org highlights selected research from the Journal of Clinical Oncology (JCO) and the Journal of Oncology Practice (JOP) with additional perspective provided by the lead or corresponding author.
@ 2014 American Society of Clinical Oncology