Hospital Characteristics Associated With Maintenance or Improvement of Guideline-recommended Lymph Node Evaluation for Colon Cancer

Background: Over the past 20 years, surgical practice organizations have recommended the identification of >= 12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines. Research Design: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (>= 12) lymph node evaluation compared with initial evaluation levels (1996-1998) using chi(2) tests and multivariate logistic regression analysis, adjusting for patient case-mix. Results: We identified 228 hospitals that performed >= 6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n = 60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance. Conclusions: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.