American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Study Finds Overall Hospital Quality Performance Differs

Surgeons say quality measurement should consider cancer surgical procedure indication when rating hospital outcomes


SAN DIEGO (July 18, 2013): New research findings released earlier this week at the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) National Conference in San Diego, Calif., show that hospital quality measurement specific to cancer versus noncancer care provides a more accurate assessment of a hospital’s overall quality performance.  

Currently, programs used to measure surgical quality report outcomes based on operation type, (e.g., colon and pancreas resection), but do not report outcomes based on different patient groups, such as cancer verses noncancer patients. In order to determine if patient type can influence hospital performance, the study looked at whether a hospital’s ranking would change when taking into consideration cancer status. 

“Understanding the factors that contribute to complications is critical to finding ways to prevent complications from occurring,” said lead study author Jennifer L. Paruch, MD, general surgery resident at the University of Chicago and ACS surgical oncology scholar-in-residence. “Cancer can affect patients in complex ways, and our goal was to determine whether cancer impacts how different hospitals perform for these operations.” 

For the study, researchers reviewed clinical data from the ACS NSQIP database to identify patients at 309 hospitals who had undergone colon (n=93,846), rectum (n=13,477), pancreas (n=14,570), liver (n=7,912), esophagus (n=2,226), and stomach (n=5,534) or lung (n=3,947) resections over a four-year period (2007-2011). Investigators found 55 percent of these operations were performed for cancer indications, with the largest contributor to the cancer group coming from colon resections (58 percent of cancer cases).
Investigators developed hierarchical models to generate two observed-to-expected event rates (O:E ratios) for each hospital for performance based on procedures performed on cancer patients and non-cancer patients. O:E ratios are a measure of how many complications occurred (observed) compared to how many complications would be expected based on the patients’ risk factors and the difficulty of the procedure (expected).

The study examined whether there was a significant difference between the cancer O:Es and noncancer O:Es as a whole and then whether the difference between the O:Es for each hospital was more than expected based on chance variation between the different groups of patients.

Researchers found hospital mean O:E for cancer patients was significantly different from mean O:E for noncancer patients (p=0.0139). Variance in difference for noncancer O:E and cancer O:E also was significantly different from variation expected by chance from different patient populations (p < .0001). In total, 41.1 percent of hospitals (127 of 309) performed differently for cancer and noncancer patients.

Study results suggest that hospitals that performed well for noncancer patients may not perform as well for patients with cancer and vice versa. To accurately assess quality performance based on the surgical care provided to cancer patients, the study’s researchers recommend collecting robust data specific to cancer patients in order to fully understand complications and what factors impact surgical outcomes, as well as to target quality improvement efforts.  

“These results demonstrate that in order to get a true picture of a hospital’s quality performance, quality programs must take into consideration patients who have certain diseases, such as cancer,” said Clifford Y. Ko, MD,  FACS, director of the ACS Division of Research and Optimal Patient Care. “Hospitals aiming to improve cancer care should look specifically at cancer outcomes, independent from non-cancer procedures because certain aspects of cancer affect surgical outcomes.” 

A model for outcomes-based quality improvement, ACS NSQIP collects clinical, risk-adjusted, 30-day outcomes data in a nationally benchmarked database. The program is currently used by approximately 500 hospitals across the U.S.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit


Sally Garneski
Dan Hamilton