Hospital Variation in Cancer Treatments and Survival OutComes of Advanced Melanoma Patients: Nationwide Quality Assurance in The Netherlands

BACKGROUND

To assure a high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes is evaluated in the Dutch Melanoma Treatment Registry. The aim of this study was to assess center variation in treatments and 2-year survival probabilities of patients diagnosed between 2013 and 2017 in the Netherlands.

METHODS

We selected patients diagnosed between 2013 and 2017 with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers' performance on 2-year survival was evaluated using Empirical Bayes estimates calculated in a random effects model. Treatment patterns of the centers with the lowest and highest estimates for 2-year survival were compared.

RESULTS

For patients diagnosed between 2014 and 2015, significant center variation in 2-year survival probabilities was observed even after correcting for case-mix and treatment with new systemic therapies. The different use of new systemic therapies partially explained the observed variation. From 2016 onwards, no significant difference in 2-year survival was observed between centers.

CONCLUSION

Our data suggest that between 2014 and 2015, after correcting for patient case-mix, significant variation in 2-year survival probabilities between Dutch melanoma centers existed. The use of new systemic therapies could partially explain this variation. In 2013 and between 2016 and 2017, no significant variation between centers existed.

Center-Effect of Incident Hemodialysis Vascular Access Use: Analysis of a Bi-national Registry

Background

Commencing hemodialysis (HD) with an arteriovenous access is associated with superior patient outcomes compared with a catheter, but the majority of patients in Australia and New Zealand initiate HD with a central venous catheter. This study examined patient and center factors associated with arteriovenous fistula/graft access use at HD commencement.

Methods

We included all adult patients starting chronic HD in Australia and New Zealand between 2004 and 2015. Access type at HD initiation was analyzed using logistic regression. Patient-level factors included sex, age, race, body mass index (BMI), smoking status, primary kidney disease, late nephrologist referral, comorbidities, and prior RRT. Center-level factors included size; transplant capability; home HD proportion; incident peritoneal dialysis (average number of patients commencing RRT with peritoneal dialysis per year); mean weekly HD hours; average blood flow; and achievement of phosphate, hemoglobin, and weekly Kt/V targets. The study included 27,123 patients from 61 centers.

Results

Arteriovenous access use at HD commencement varied four-fold from 15% to 62% (median 39%) across centers. Incident arteriovenous access use was more likely in patients aged 51-72 years, males, and patients with a BMI of >25 kg/m2 and polycystic kidney disease; but use was less likely in patients with a BMI of <18.5 kg/m2, late nephrologist referral, diabetes mellitus, cardiovascular disease, chronic lung disease, and prior RRT. Starting HD with an arteriovenous access was less likely in centers with the highest proportion of home HD, and no center factor was associated with higher arteriovenous access use. Adjustment for center-level characteristics resulted in a 25% reduction in observed intercenter variability of arteriovenous access use at HD initiation compared with the model adjusted for only patient-level characteristics.

Conclusions

This study identified several patient and center factors associated with incident HD access use, yet these factors did not fully explain the substantial variability in arteriovenous access use across centers.

Patient and center characteristics associated with kidney transplant outcomes: a binational registry analysis

This registry-based study evaluated the contribution of center characteristics to kidney transplant outcomes in adult first kidney transplant recipients in Australia and New Zealand between 2004 and 2014. Primary outcomes were mortality and graft failure, and secondary outcomes were transplant complications. Overall, 6970 transplants from 17 centers were included. For deceased donor transplants, 5-year patient and graft survival rates varied considerably (81.0-93.9% and 72.2-88.3%, respectively). Variations in mortality and graft failure were partially reduced after adjustment for patient characteristics (1% and 20% reductions) and more markedly reduced after adjustment for center characteristics (41% and 55% reductions). For living donor transplants, 5-year patient and graft survival rates varied (89.7-100% and 79.2-96.9%, respectively). Centers with high average total ischemic times (>14 h) were associated with higher mortality for both deceased (adjusted hazard ratio [(AHR] 2.24, 95% CI 1.21-4.13) and living donor transplants (AHR 1.76, 95% CI 1.02-3.04). Small center size (<35 new kidney transplants/year) was associated with a lower hazard of mortality for living donor kidney transplants (AHR 0.48, 95% CI 0.28-0.81). No center characteristic was associated with graft failure. The appreciable variations in deceased donor kidney transplant recipient and graft survival outcomes across centers were attributable to center effects.

The Effect of Transplant Volume and Patient Case Mix on Center Variation in Kidney Transplantation Outcomes

Background

Kidney transplantation is the optimal treatment for patients with end-stage renal disease; however, long-term outcomes remain suboptimal.

Objective

The objectives of our study were to examine the variation in survival rates and determine whether center volume and case mix are associated with transplant outcomes and explain the variation across kidney transplant centers in Ontario, Canada.

Design

This was a population-based cohort study using health care administrative databases.

Setting

A total of 5 transplant centers across Ontario, Canada.

Patients

We included adults (≥18 years) undergoing primary, solitary kidney transplantation between January 1, 2000 to December 31, 2013.

Measurements

The co-primary outcomes were death-censored graft loss and total mortality.

Methods

Multivariable Cox proportional hazards regression was used to assess potential associations and describe variation, using hazard ratios (HRs) with 95% confidence intervals (CIs) for each center relative to the average across all centers.

Results

The study cohort included 5037 patients followed for a median of 5.3 years, interquartile range (2.7-8.6). In multivariable models, recipient age, body mass index, Charlson Index, time on dialysis, donor type, and age were found to be significantly associated with death-censored graft loss, and recipient age and sex, Charlson Index, time on dialysis, donor age, and time era of transplant were associated with total mortality. There was statistically significant variation across centers observed for death-censored graft loss (P = .04) with HRs ranging from 0.72 to 1.22. However, neither adjusting for case mix nor center volume meaningfully changed the HRs reflecting each center-specific effect. There was a tendency toward reduced risk of graft loss (HR, per additional 25 patients, 0.90 [95% CI, 0.78-1.04]) in centers with higher volumes. For total mortality, there was statistically significant variation across centers with HRs ranging from 0.82 to 1.13 (P = .04); however, neither adjusting for case mix or center volume meaningfully changed the HRs. Center volume was not significantly associated with total mortality (HR, per additional 25 patients, 1.04 [95% CI, 0.90-1.20]).

Limitations

This study was limited by the small number of centers included.

Conclusions

Outcomes differ across the 5 transplant centers in Ontario. We did not find any strong support for our hypotheses that case mix or center volume is responsible for these differences.

Case Mix, Patterns of Care, and Inpatient Outcomes Among Ontario Kidney Transplant Centers: A Population-Based Study

Background:

Significant variation in both patient case mix and the structure of care in kidney transplantation has been previously described in the United States.

Objective:

The objective of our study was to characterize patient case mix, patterns of care, and inpatient outcomes across 5 kidney transplant centers in the province of Ontario, Canada.

Design:

This was a retrospective population-based cohort study using health care administrative databases.

Setting:

The setting is Ontario, Canada.

Patients:

We included adult (≥18 years) transplant recipients who received a primary, solitary kidney between January 1, 2000, and December 31, 2013 (N = 5037).

Methods:

Using linked administrative health care databases, we characterized kidney transplant recipient and donor factors, center characteristics, provider characteristics, and inpatient outcomes across transplant centers in Ontario. To compare case mix–adjusted differences in length of stay across centers, multivariable Cox proportional hazards regression was used to obtain hazard ratios (HRs) for each center relative to the average across all centers. Center volume and provider characteristics were added to the models to examine whether these factors explain differences in length of stay across centers.

Results:

We noted significant differences across transplant centers in patient race, cause of end-stage renal disease, body mass index, comorbidities, time on dialysis, and donor type. Mean annual transplant center volumes during the study period ranged between 51.5 (9.3) and 101.7 (23.9) transplants/year across centers (P < .0001). Physician specialty most responsible for in-hospital transplant care varied significantly across centers with the most common combination being nephrologist and urologist. Less than 31 deaths occurred in hospital during the index transplant admission but mortality risk did not differ significantly between centers. Overall, 25.1% of recipients required dialysis in hospital post transplantation (range across centers 18.3%-33.5%, P < .0001) and 24.7% of recipients spent time in the intensive care unit (ICU; range across centers: 5.7%-58.0%, P < .0001). The proportion of participants requiring dialysis did not change with time (P = .12), whereas the proportion staying in the ICU increased steadily over time (P < .0001). The median length of stay in hospital after transplantation ranged from 7 to 9 days across centers (P < .0001) and decreased significantly over time. After adjusting for patient case mix as well as center and provider factors, HRs for length of stay censored at the time of death ranged between 0.75 (95% confidence interval [CI]: 0.69-0.82) and 1.29 (95% CI: 1.20-1.38) across centers. Center volume and provider experience were not independently associated with length of hospital stay.

Limitations:

Data were missing (0.8%-18.4%) for certain covariates of interest.

Conclusions:

This study found significant heterogeneity across kidney transplant centers in case mix, practice patterns, and inpatient outcomes. Future studies are needed to examine the influence of length of stay and practice patterns on long-term outcomes such as patient/graft survival and quality of life.

Center Variation and the Effect of Center and Provider Characteristics on Clinical Outcomes in Kidney Transplantation: A Systematic Review of the Evidence

Background

Kidney transplantation is the best treatment option for patients with end-stage renal disease. While patient-level factors affecting survival are established, the presence of variation in the management of transplant recipients remains unknown.

Objective

The objective of this study was to examine center variation in kidney transplantation and identify center and provider characteristics that may be associated with clinical outcomes.

Design

This is a systematic review.

Data sources

Ovid Medline, Embase, and Cochrane library from inception to June 2016 were used.

Study eligibility

Any study examining the association between center or provider characteristics and graft or patient survival, quality of life, or functional status were included.

Results

We identified 6327 records and 24 studies met eligibility. Most studies used data registries. Characteristics evaluated include center volume (n = 17), provider volume (n = 2), provider experience (n = 1), center type (n = 2), and location of follow-up (n = 1). Outcomes assessed included graft survival (n = 24) and patient survival (n = 9). Significant center variation was described in 12 of 15 and 5 of 7 studies for graft and patient survival. There was a significant and positive association between center volume and graft and patient survival in 8 and 2 studies, respectively. Provider experience and volume were significantly associated with less allograft loss and provider volume with lower risk of death. There was no association between graft survival and location of follow-up or center type.

Limitations

There was substantial heterogeneity in the variables assessed and methodology used to analyze associations.

Conclusion

This systematic review found center variation in kidney transplantation. Future studies in the current era are necessary to better evaluate this important topic.

Center Variation in the Delivery of Indicated Late Preterm Births

Objective Evidence for optimal timing of delivery for some pregnancy complications at late preterm gestation is limited. The purpose of this study was to identify center variation of indicated late preterm births. Study design We performed an analysis of singleton late preterm and term births from a large U.S. retrospective obstetrical cohort. Births associated with spontaneous preterm labor, major congenital anomalies, chorioamnionitis, and emergency cesarean were excluded. We used modified Poisson fixed effects logistic regression with interaction terms to assess center variation of indicated late preterm births associated with four medical/obstetric comorbidities after adjusting for socio-demographics, comorbidities, and hospital/provider characteristics. Results We identified 150,055 births from 16 hospitals; 9,218 were indicated late preterm births. We found wide variation of indicated late preterm births across hospitals. The extent of center variation was greater for births associated with preterm premature rupture of membranes (risk ratio [RR] across sites: 0.45-3.05), hypertensive disorders of pregnancy (RR across sites: 0.36-1.27), and placenta previa/abruption (RR across sites: 0.48-1.82). We found less center variation for births associated with diabetes (RR across sites: 0.65-1.39). Conclusion Practice variation in the management of indicated late preterm deliveries might be a source of preventable late preterm birth.