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Original Investigation
February 20, 2019

Evaluation of Access to Hospitals Most Ready to Achieve National Accreditation for Rectal Cancer Treatment

Author Affiliations
  • 1University of Michigan Medical School, Ann Arbor
  • 2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
  • 3Department of Surgery, University of Michigan, Ann Arbor
JAMA Surg. 2019;154(6):516-523. doi:10.1001/jamasurg.2018.5521
Key Points

Question  How do outcomes of hospitals eligible for the American College of Surgeons National Accreditation Program for Rectal Cancer compare with those of hospitals less likely to be accredited?

Findings  This cohort study of 1315 American College of Surgeons Commission on Cancer–accredited hospitals found that those most prepared for accreditation are usually academic institutions with the best survival outcomes. These hospitals more often serve affluent populations.

Meaning  The current standards and scope of the National Accreditation Program for Rectal Cancer may not reach hospitals and patients most in need of improvement and could exacerbate disparities in access to high-quality care, which may be mitigated by quality improvement interventions and redirection of socioeconomically disadvantaged patients to high-quality accredited institutions.


Importance  The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities.

Objectives  To characterize hospitals’ readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation.

Design, Setting, and Participants  A total of 1315 American College of Surgeons Commission on Cancer–accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018.

Exposures  Hospitals’ readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards.

Main Outcomes and Measures  Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital.

Results  Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence.

Conclusions and Relevance  Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.

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