Commentary and Complementary Data to Add to “Compliance with Cancer Quality Measures Over Time and Their Association with Survival Outcomes: The Commission on Cancer’s Experience with the Quality Measure Requiring at Least 12 Regional Lymph Nodes to be Removed and Analyzed with Colon Cancer Resections”

To the editor-

We read with great interest the recently published article “Compliance with Cancer Quality Measures Over Time and Their Association with Survival Outcomes: The Commission on Cancer’s Experience with the Quality Measure Requiring at Least 12 Regional Lymph Nodes to be Removed and Analyzed with Colon Cancer Resections.” This large study of colon cancer patients diagnosed 2003–2015 in the National Cancer Database (NCDB) showed hospitals with Commission on Cancer (CoC) accreditation increased compliance over time with the CoC quality measure requiring 12 lymph nodes be removed and examined during colon cancer resection.¹ They also demonstrated variation in compliance by cancer program type. Importantly, risk-adjusted hazard of death followed the same pattern.

The findings of this study raised several questions. While the majority of colon cancer patients are treated in CoC-accredited hospitals (71%)², there remains a substantial proportion receiving surgery in non-accredited hospitals, which may be higher in rural states. These hospitals are not collecting and submitting data to the NCDB so little is known about their quality of cancer care. As this quality measure has been in existence since 2003 and is endorsed by the National Quality Forum, it is possible through diffusion of practice, compliance with this standard would be comparable in non-CoC hospitals.

To answer this, we used data from the Iowa Cancer Registry, an original member of the NCI Surveillance, Epidemiology and End Results (SEER) program. We found 40% of 7,408 resected colon cancer patients diagnosed from 2008–2015 and eligible for the CoC quality measure received surgery in hospitals that were not CoC-accredited. We then assigned patients to hospitals and assessed compliance to the same quality measure, shown as the two dashed lines (Figure 1). For every year examined there was a significant difference between compliance rates in Iowa hospitals with and without CoC accreditation (e.g., 95% vs 85% in 2015, p<0.0001). Based on the authors’ findings, these differences likely translate into poorer outcomes as well. Of note, non-accredited hospitals did improve compliance over time, suggesting diffusion of CoC quality measures beyond accredited hospitals.

Figure 1.

Percent of compliant cases by hospital category for CoC-accredited hospitals and Iowa hospitals by CoC accreditation status (adapted from Shulman et al).

Iowa is a largely rural state, so our estimates may not generalize to other more urban, geographic areas. Nonetheless, our findings highlight the importance of monitoring cancer quality measures. Rural hospitals face significant resource challenges, which can prevent them from pursuing accreditation; yet they care for a sizable proportion of patients with colon cancer. Our previous research indicates rural cancer patients value being able to receive treatment in a local hospital familiar to them,³ suggesting centralization is unlikely to be successful.

Our results support the authors’ findings demonstrating the critical role of collecting and monitoring quality measures in changing practice and improving outcomes for cancer patients. They also suggest that disparity in access to CoC accreditation may contribute to poorer cancer outcomes in rural populations. We encourage CoC leadership to consider new initiatives, engaging non-accredited hospitals in collecting and submitting their cancer data to the NCDB so they too can monitor and benchmark their performance. State-based registries such as ours may be able to assist in these efforts.