Quality Metrics for Bladder Cancer Surgery that Actually Measure Up

Meaningful scoring system correlates quality metrics and patient mortality

Urologists, like many other surgeons across the nation, are subjected to quality scoring systems that may be arbitrary or irrelevant for patients. These metrics are often created with little input from physicians on the front-line. Further, many quality metrics are process-related, and may not have much impact on real-world patient outcomes.

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Abhinav Khanna, MD, MPH, urologic surgery resident, and Robert Abouassaly, MD, staff urologic oncologist at Glickman Urological & Kidney Institute, recognized a lack of validated quality scoring systems specifically tailored to bladder cancer surgery, one of the most complex and costly surgeries performed in all of urology. So they decided to develop a novel hospital quality scoring system that is predictive of death following radical cystectomy. The researchers presented their study results at the American Urological Association’s 2018 Annual Meeting.

“Our study is exciting because it proposes a quality scoring system that is actually meaningful for bladder cancer patients,” says Dr. Khanna. “It also brings urologic surgeons into the conversation about surgical quality, which is significant because the surgeon plays a vital role in the delivery of high quality care.”

Bladder cancer quality score

The researchers used the National Cancer Database, one of the largest cancer registries in the world, to gather data on hospitals performing radical cystectomy from 2004 to 2014 across the U.S. Dr. Khanna’s team applied sophisticated statistical modeling techniques to measure hospital performance across several different quality metrics. Then, the team created a composite hospital quality score for radical cystectomy, which was subsequently shown to correlate with 30-day, 90-day and overall mortality.

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A Bladder Cancer Quality Score (BC-QS) was created based on the performance of lymph node dissection during radical cystectomy, rate of positive surgical margins and delivery of neoadjuvant chemotherapy for eligible patients before surgery. The overall score was then correlated to patient mortality. The study showed that patients undergoing surgery at high-scoring hospitals are less likely to die — both in the short and long term.

Improvements in health policy and surgical outcomes

The impact of this study is primarily related to health policy. “Our hope is that one day, surgical quality will be measured in a meaningful, thoughtful way that leads to improved outcomes for patients,” says Dr. Khanna. “Our scoring system is an important step toward this goal.” Next-generation quality metrics may be used by insurers and regulators to better discern hospital quality for patients undergoing radical cystectomy.

Future research to improve surgical quality metrics

Cleveland Clinic is developing better ways to measure hospital quality. “Instead of being told by insurers or regulators how our quality is to be measured, we are working to establish an evidence-based reciprocal dialogue in which we are key participants,” notes Dr. Khanna.

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“We hope that other researchers across the country will use our scoring system as a foundation for continued efforts to improve surgical quality measurement,” says Dr. Khanna. “We want others to build upon and refine our system in the future as well as validate our metrics in other large datasets.”

View Dr. Khanna’s biography and those of our other residents and fellows.