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Adequacy of Lymph Node Examination in Colorectal Surgery: Contribution of the Hospital Versus the Surgeon

Rhoads, Kim F. MD, MS, MPH, FACS*,†; Ackerson, Leland K. ScD, MPH; Ngo, Justine V. MHA*; Gray-Hazard, Florette K. MD§; Subramanian, S. V. PhD; Dudley, R. Adams MD, MBA

doi: 10.1097/MLR.0b013e3182a53d72
Original Articles

Background: Examination of at least 12 lymph nodes (LNs) in the staging of colon cancer (CC) was recommended by the National Comprehensive Cancer Network in 2000; however, rates of an adequate examination remain low. This study compares the impact of the hospital contextual variance against that of the operating surgeon on delivery of an adequate LN examination.

Study Design: Retrospective analysis of California Cancer Registry data for all CC operations (2001–2006). Hierarchical models predicted the adequacy of LN examination as a function of patient, surgeon, and hospital characteristics. Models were created using penalized quasi-likelihood approximation with second order Taylor linearization as implemented in MLwiN 2.15.

Results: A total of 25,606 resections involving 3376 surgeons operating in 346 hospitals were analyzed. Half of cases had an adequate examination. Hierarchical models showed the median odds of an adequate examination associated with the hospital context [(MORhosp 2.05; 95% confidence interval, 1.9–2.2) was much higher than that associated with the surgeon (MORsurg 1.34; 95% confidence interval, 1.2–1.4)]. Hospital characteristics teaching and high volume predicted higher odds of an adequate examination. There was no association with hospital revenue.

Conclusions: Approximately half of patients undergoing surgery for CC received an adequate LN examination. Hospital contextual factors had a stronger association with receipt of an adequate examination than surgeon factors. Our results suggest that quality improvement initiatives and incentives should be targeted at the hospital level to achieve the highest impact. Furthermore, we have identified nonteaching and low volume settings as rational targets for these efforts.

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*Section of Colon and Rectal Surgery, Department of General Surgery, Stanford University School of Medicine

Stanford Cancer Institute, Stanford, CA

Department of Community Health and Sustainability University of Massachusetts Lowell, Lowell, MA

§Department of Pathology, Stanford University School of Medicine, Stanford, CA

Department of Society, Human Development, and Health, Harvard University School of Public Health, Boston, MA

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA

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Presented at the American Society of Colon and Rectal Surgeons Annual Meeting, Vancouver, Canada, May 12–14, 2011.

Dr Rhoads' work on the project was supported by a Harold Amos Medical Faculty Development Program Award from the Robert Wood Johnson Foundation, Princeton NJ. Other authors have no conflict of interest to declare.

Reprints: Kim F. Rhoads, MD, MS, MPH, FACS, Section of Colon and Rectal Surgery, Department of General Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680F, Stanford, CA 94305. E-mail:

© 2013 by Lippincott Williams & Wilkins.