Introduction: Despite the use of quality indicators (QIs) as markers of high-quality surgical care, minimal data exist to inform their most effective implementation into real-world quality improvement programs. The objective of this study was to determine whether variance in kidney cancer surgery QIs is most impacted by surgeon-level or hospital-level factors in order to inform quality improvement initiatives.

Methods: The ICES and Veterans Affairs (VA) databases were queried for patients undergoing surgery for kidney cancer. Kidney cancer surgery QIs were defined within each cohort. Quality of care was benchmarked at a surgeon- vs. hospital-level to identify statistical outliers, using available clinicopathological data to adjust for differences in case-mix. The variance between surgeons and hospitals was calculated for each QI using a random-effects model.

Results: The QI with the greatest amount of variance explained by hospital- and surgeon-level factors was the proportion of cases performed with minimally invasive surgery (MIS). The majority of this variance was due to surgeon-level factors for both the VA and ICES cohorts (Figure 1). The proportion of MIS cases was also the QI with the greatest number of outlier hospitals and surgeons compared to the average performance. The proportion of partial nephrectomies performed for patients at risk of chronic kidney disease was the QI with the greatest amount of variance due to hospital-level factors for the ICES cohort.

Conclusions: The proportion of localized kidney cancer cases performed using an MIS approach is the QI requiring the greatest attention. Quality improvement initiatives should focus on surgeon-level factors to increase the number of MIS cases being performed for patients with localized renal masses.