Colorectal cancer quality improvement in a statewide surgical collaborative

The Michigan Surgical Quality Collaborative began measuring quality of care for colorectal cancer in 2014, and findings showed significant variation in performance. This report describes a 2-year quality improvement project including data collection, process and outcome measure targets, and multidisciplinary case review among participating Michigan Surgical Quality Collaborative hospitals and analyzes their narratives regarding positive margins on colorectal cancer resection.

This was a retrospective analysis of quantitative and qualitative data from voluntarily participating hospitals (2021-2022). Adherence to process and outcome measures was reported as rates, and changes in rates were assessed using Wilcoxon matched-pairs signed-rank tests. Qualitative data were extracted from written reports describing project implementation at each site and multidisciplinary case review of colorectal cancer cases noted to have a positive margin on the pathology report. Written data were reviewed by 2 study team members using a combined approach of inductive and deductive analysis to identify codes and aggregate them into themes.

Nine metropolitan hospitals with >250 beds participated in the project (7 for both years). A significant improvement in use of oral antibiotic and mechanical bowel preparation was demonstrated (from 94% to 98%; P = .04). Hospitals' median colorectal cancer resection positive margin rates were 3.5% (range: 0%-11.5%) in 2021 and 3% (range: 0%-4.9%) in 2022 (P = .24). Hospitals described the use of continuous plan-do-check-act cycles and implementation strategies such as audit and feedback, distribution of education, templated documentation, and tailoring of colorectal pathways for cancer as tools for improvement. Five hospitals contributed summaries of case reviews from colorectal cancer resections resulting in a positive margin. Themes were aggregated into preoperative, intraoperative, and postoperative opportunities to mitigate the occurrence and sequelae of positive margins. Nearly all cases with positive margins were described by the hospitals as "unavoidable."

This multihospital quality improvement project for colorectal cancer surgery provides insight into the conduct of cancer surgery-focused quality improvement across diverse hospital settings. Although participating hospitals were already high performing, some improvements were objectively noted. Novel findings from this project include specific opportunities to address and mitigate the occurrence of positive surgical margins in colorectal cancer resections, including high-quality preoperative staging studies, standardized pathologic definitions for positive margins, and utilization of multidisciplinary review.