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Original Investigation
November 2017

Measuring Institutional Quality in Head and Neck Surgery Using Hospital-Level DataNegative Margin Rates and Neck Dissection Yield

Author Affiliations
  • 1Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
  • 2Motility Doc, San Jose, California
  • 3Division of Head and Neck Surgery, Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
JAMA Otolaryngol Head Neck Surg. 2017;143(11):1111-1116. doi:10.1001/jamaoto.2017.1694
Key Points

Question  Can 2 surgical quality metrics that have been validated at the patient level in head and neck surgery (negative margins and lymph node yield from a neck dissection) be used to identify higher quality hospitals with improved outcomes?

Findings  Patients treated at hospitals that achieved the combined metric of 90% or higher negative margins and 80% or more of cases with lymph node yields of 18 or more experienced a significant reduction in mortality. Importantly, this survival benefit was independent of previously reported measures of institutional quality, such as hospital volume and teaching status.

Meaning  These 2 surgical quality metrics may be a surrogate measure of the quality of oncology care in head and neck surgery and should be considered when identifying hospitals for quality improvement initiatives.


Importance  Negative margins and lymph node yields (LNY) of 18 or more from neck dissections in patients with head and neck squamous cell carcinomas (HNSCC) have been associated with improved patient survival. It is unclear whether these metrics can be used to identify hospitals with improved outcomes.

Objective  To determine whether 2 patient-level metrics would predict outcomes at the hospital level.

Design, Setting, and Participants  A retrospective review of records from the National Cancer Database (NCDB) was used to identify patients who underwent primary surgery and concurrent neck dissection for HNSCC between 2004 and 2013. The percentage of patients at each hospital with negative margins on primary resection and an LNY 18 or more from a neck dissection was quantified. Cox proportional hazard models were used to define the association between hospital performance on these metrics and overall survival.

Main Outcomes and Measures  Margin status and lymph node yield at hospital level. Overall survival (OS).

Results  We identified 1008 hospitals in the NCDB where 64 738 patients met inclusion criteria. Of the 64 738 participants, 45 170 (69.8%) were men and 19 568 (30.2%) were women. The mean SD age of included patients was 60.5 (12.0) years. Patients treated at hospitals attaining the combined metric of a 90% or higher negative margin rate and 80% or more of cases with LNYs of 18 or more experienced a significant reduction in mortality (hazard ratio [HR] 0.93; 95% CI, 0.89-0.98). This benefit in survival was independent of the patient-level improvement associated with negative margins (HR, 0.73; 95% CI, 0.71-0.76) and LNY of 18 or more (HR, 0.85; 95% CI, 0.83-0.88). Including these metrics in the model neutralized the association of traditional measures of hospital quality (volume and teaching status).

Conclusions and Relevance  Treatment at hospitals that attain a high rate of negative margins and LNY of 18 or more is associated with improved survival in patients undergoing surgery for HNSCC. These surgical outcome measures predicted outcomes independent of traditional, but generally nonmodifiable characteristics. Tracking of these metrics may help identify high-quality centers and provide guidance for institution-level quality improvement.