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A Statewide Approach to Reducing Re-excision Rates for Women with Breast Conserving Surgery
Jessica Schumacher1, Elise Lawson1, Joseph Weber3, Amanda Kong4, Jeanette May1, Nicholas Marka5, Bret Hanlon1, Manasa Venkatesh1, Randi Cartmill1, Caprice C. Greenberg2
1University of Wisconsin-Madison, Madison, Wisconsin, United States, 2Medical College of Georgia, Augusta University, Augusta, Georgia, United States, 3Aurora Medical Center - Grafton, Grafton, Wisconsin, United States, 4Medical College of Wisconsin, Milwaukee, Wisconsin, United States, 5University of Minnesota, Minneapolis, Minnesota, United States

Objective: Statewide surgical quality collaboratives have demonstrated improved quality and decreased cost, but require significant resources limiting generalizability. The Surgical Collaborative of Wisconsin (SCW) is a consortium of 85 hospitals and 224 surgeons and quality leaders, that sought to utilize existing administrative data and obviate the need for resource-intensive primary data collection.
Breast conserving surgery (BCS) to treat cancer is a common operation performed across hospital settings, from small rural hospitals to large academic centers. Previous studies demonstrate significant variation in re-excision rates following BCS, identifying it asa high-value target for improvement. We sought to test the effectiveness of benchmarked performance reports based on discharge data paired with an intervention to implement evidence-based strategies to decrease post-BCS re-excision rates.

Methods: Wisconsin Hospital Association discharge data from calendar year 2017 through 2019 were used to compare 60-day re-excision rates following BCS for breast cancer. SCW and control group differences in baseline re-excision rates and patient case-mix (age, payer) were assessed using T-tests and Chi-Square tests. The primary analysis estimated the difference in the average change pre-to post-intervention between SCW hospitals and non-participating hospitals (difference-in-difference approach) using a multivariable logistic mixed effects model with repeated measures, adjusting for age, payer, and including hospitals as random effects.
The intervention included 5 in-person and virtual collaborative meetings. Surgeon champions shared guideline updates and facilitated table discussions to share challenges, best practices, action planning, and guideline implementation experiences. Confidential reports containing risk- and reliability-adjusted surgeon and hospital-level re-excision rates benchmarked against statewide performance were provided.

Results: In 2017, 2,592 procedures were performed in SCW hospitals and 883 in non-participating hospitals. Baseline hospital-level re-excision rates ranged from 5% to over 50% (statewide mean=16.3%). No statistically significant difference in re-excision rates existed between SCW and non-participating hospitals at baseline (16.1% v 17.1%, p = 0.47). Following the intervention period, there was a decrease in re-excision rates for SCW but not non-participating hospitals (Figure). The OR from the adjusted model predicting re-excision was 0.68 (95% CI=0.52-0.89).

Conclusions: Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excision, increasing quality and decreasing cost. Importantly, our study demonstrates the effective use of administrative data as a platform for a statewide quality collaborative. The use of existing data requires fewer resources and offers a new paradigm for statewide quality collaboratives that promotes participation across practice settings.

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