Using a Lymph Node Count Metric to Identify Underperforming Hospitals After Rectal Cancer Surgery

Mustafa Raoof, Syed Nabeel Zafar, Philip H.G. Ituarte, Robert S. Krouse, Kurt Melstrom

Research output: Contribution to journalReview articlepeer-review

6 Scopus citations


Background: Investigating methods to assess the quality of cancer surgery and then benchmarking hospitals on these quality indicators can lead to improvements in cancer care in the United States. We sought to determine the utility of lymph node count as a quality metric. Methods: We performed a retrospective analysis of the California Cancer Registry database (2004-2011) merged with Office of Statewide Health Planning and Development inpatient database. Patients with locally advanced rectal adenocarcinoma who underwent neoadjuvant therapy and resection were included. Hospital quality score was defined as the proportion of patients at a particular hospital that had adequate examination with at least nine lymph nodes. High-quality score hospitals were those that retrieved nine or more nodes among ≥25% of operations. A multivariate Cox proportional hazards (standard and shared frailty) model was used to determine differences in overall survival adjusting for age, hospital volume, race, sex, insurance, comorbidity, T-stage, response to neoadjuvant therapy, adjuvant chemotherapy, and teaching hospital status as covariates. Results: A total of 2704 patients were treated at 228 hospitals (low-scoring hospital = 85 and high-scoring hospital = 143). Patient- and disease-specific characteristics were similar between the groups. Socioeconomic status and hospital characteristics were strongly associated with score status. High-scoring hospitals had higher sphincter preservation (P = 0.004), lower complications (P = 0.021), and a trend toward lower mortality (P = 0.079). Care at high-scoring hospitals independently predicted overall survival (hazard ratio: 0.74; 95% confidence interval: 0.61-0.90; P = 0.003). Conclusions: This study demonstrates that hospital quality score based on lymph node count can be used to identify underperforming hospitals.

Original languageEnglish (US)
Pages (from-to)216-223
Number of pages8
JournalJournal of Surgical Research
StatePublished - Apr 2019


  • Cancer survival
  • Lymph nodes
  • Outcomes research
  • Quality improvement
  • Rectal cancer

ASJC Scopus subject areas

  • Surgery


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