Quality Improvement in the Surgical Approach to Advanced Ovarian Cancer: The Mayo Clinic Experience

BACKGROUND: After observing disparate rates of cytoreduction, we initiated efforts to improve outcomes through feedback and education, and we reassessed outcomes. STUDY DESIGN: Outcomes from group A (2006 and 2007, n = 105) were compared with those from the cohort predating quality-improvement efforts (group B, 2000 to 2003, n = 132). All stage IIIC ovarian cancer patients at our institution were evaluated for tumor dissemination, age, performance status, surgical complexity, residual disease (RD), morbidity, and mortality. A surgical complexity score previously described was used to categorize extent of operation. RESULTS: No significant differences in age, performance status, or extent of disease were observed between cohorts. Surgical complexity increased after initiation of quality improvement (mean surgical complexity score, 5.5 to 7.1; p < 0.001), rates of optimal RD (< 1 cm) improved from 77% to 85% (p = 0.157), and rates of complete resection of all gross disease rose from 31% to 43% (p = 0.188). In the subset of patients with carcinomatosis most likely to benefit from extended surgical resection, radical procedures were used more frequently (63% versus 79%; p = 0.028), rates of optimal debulking (RD < 1 cm) increased ( 64% to 79%), and the rate of RD = 0 increased from 6% to 24% ( p = 0.006). When disease was noted on the diaphragm, procedures to remove the disease were more frequently used (38% to 64%; p = 0.001). The rates of major perioperative morbidity (group B, 21% versus group A, 20%; p = 0.819) and 3-month mortality (8% versus 6%; p = 0.475) were not affected despite this more aggressive surgical approach. CONCLUSIONS: Analysis of outcomes with appropriate feedback and education is a powerful tool for quality improvement. We observed improvements in rates of cytoreduction and use of specific radical procedures, with no increase in morbidity as a result of this process. (J Am Coll Surg 2009;208:614-620. (C) 2009 by the American College of Surgeons)