Benchmarking the American Society of Breast Surgeon Member Performance for More Than a Million Quality Measure-Patient Encounters

Jeffrey Landercasper, Oluwadamilola M. Fayanju, Lisa Bailey, Tiffany S. Berry, Andrew J. Borgert, Robert Buras, Steven L. Chen, Amy C Degnim, Joshua Froman, Jennifer Gass, Caprice Greenberg, Starr Koslow Mautner, Helen Krontiras, Luis D. Ramirez, Michelle Sowden, Barbara Wexelman, Lee Wilke, Roshni Rao

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background: Nine breast cancer quality measures (QM) were selected by the American Society of Breast Surgeons (ASBrS) for the Centers for Medicare and Medicaid Services (CMS) Quality Payment Programs (QPP) and other performance improvement programs. We report member performance. Study Design: Surgeons entered QM data into an electronic registry. For each QM, aggregate “performance met” (PM) was reported (median, range and percentiles) and benchmarks (target goals) were calculated by CMS methodology, specifically, the Achievable Benchmark of Care™ (ABC) method. Results: A total of 1,286,011 QM encounters were captured from 2011–2015. For 7 QM, first and last PM rates were as follows: (1) needle biopsy (95.8, 98.5%), (2) specimen imaging (97.9, 98.8%), (3) specimen orientation (98.5, 98.3%), (4) sentinel node use (95.1, 93.4%), (5) antibiotic selection (98.0, 99.4%), (6) antibiotic duration (99.0, 99.8%), and (7) no surgical site infection (98.8, 98.9%); all p values < 0.001 for trends. Variability and reasons for noncompliance by surgeon for each QM were identified. The CMS-calculated target goals (ABC™ benchmarks) for PM for 6 QM were 100%, suggesting that not meeting performance is a “never should occur” event. Conclusions: Surgeons self-reported a large number of specialty-specific patient-measure encounters into a registry for self-assessment and participation in QPP. Despite high levels of performance demonstrated initially in 2011 with minimal subsequent change, the ASBrS concluded “perfect” performance was not a realistic goal for QPP. Thus, after review of our normative performance data, the ASBrS recommended different benchmarks than CMS for each QM.

Original languageEnglish (US)
Pages (from-to)1-11
Number of pages11
JournalAnnals of Surgical Oncology
DOIs
StateAccepted/In press - Nov 22 2017

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Benchmarking
Centers for Medicare and Medicaid Services (U.S.)
Breast
Registries
Anti-Bacterial Agents
Surgical Wound Infection
Needle Biopsy
Surgeons
Breast Neoplasms

ASJC Scopus subject areas

  • Surgery
  • Oncology

Cite this

Benchmarking the American Society of Breast Surgeon Member Performance for More Than a Million Quality Measure-Patient Encounters. / Landercasper, Jeffrey; Fayanju, Oluwadamilola M.; Bailey, Lisa; Berry, Tiffany S.; Borgert, Andrew J.; Buras, Robert; Chen, Steven L.; Degnim, Amy C; Froman, Joshua; Gass, Jennifer; Greenberg, Caprice; Mautner, Starr Koslow; Krontiras, Helen; Ramirez, Luis D.; Sowden, Michelle; Wexelman, Barbara; Wilke, Lee; Rao, Roshni.

In: Annals of Surgical Oncology, 22.11.2017, p. 1-11.

Research output: Contribution to journalArticle

Landercasper, J, Fayanju, OM, Bailey, L, Berry, TS, Borgert, AJ, Buras, R, Chen, SL, Degnim, AC, Froman, J, Gass, J, Greenberg, C, Mautner, SK, Krontiras, H, Ramirez, LD, Sowden, M, Wexelman, B, Wilke, L & Rao, R 2017, 'Benchmarking the American Society of Breast Surgeon Member Performance for More Than a Million Quality Measure-Patient Encounters', Annals of Surgical Oncology, pp. 1-11. https://doi.org/10.1245/s10434-017-6257-9
Landercasper, Jeffrey ; Fayanju, Oluwadamilola M. ; Bailey, Lisa ; Berry, Tiffany S. ; Borgert, Andrew J. ; Buras, Robert ; Chen, Steven L. ; Degnim, Amy C ; Froman, Joshua ; Gass, Jennifer ; Greenberg, Caprice ; Mautner, Starr Koslow ; Krontiras, Helen ; Ramirez, Luis D. ; Sowden, Michelle ; Wexelman, Barbara ; Wilke, Lee ; Rao, Roshni. / Benchmarking the American Society of Breast Surgeon Member Performance for More Than a Million Quality Measure-Patient Encounters. In: Annals of Surgical Oncology. 2017 ; pp. 1-11.
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abstract = "Background: Nine breast cancer quality measures (QM) were selected by the American Society of Breast Surgeons (ASBrS) for the Centers for Medicare and Medicaid Services (CMS) Quality Payment Programs (QPP) and other performance improvement programs. We report member performance. Study Design: Surgeons entered QM data into an electronic registry. For each QM, aggregate “performance met” (PM) was reported (median, range and percentiles) and benchmarks (target goals) were calculated by CMS methodology, specifically, the Achievable Benchmark of Care™ (ABC) method. Results: A total of 1,286,011 QM encounters were captured from 2011–2015. For 7 QM, first and last PM rates were as follows: (1) needle biopsy (95.8, 98.5{\%}), (2) specimen imaging (97.9, 98.8{\%}), (3) specimen orientation (98.5, 98.3{\%}), (4) sentinel node use (95.1, 93.4{\%}), (5) antibiotic selection (98.0, 99.4{\%}), (6) antibiotic duration (99.0, 99.8{\%}), and (7) no surgical site infection (98.8, 98.9{\%}); all p values < 0.001 for trends. Variability and reasons for noncompliance by surgeon for each QM were identified. The CMS-calculated target goals (ABC™ benchmarks) for PM for 6 QM were 100{\%}, suggesting that not meeting performance is a “never should occur” event. Conclusions: Surgeons self-reported a large number of specialty-specific patient-measure encounters into a registry for self-assessment and participation in QPP. Despite high levels of performance demonstrated initially in 2011 with minimal subsequent change, the ASBrS concluded “perfect” performance was not a realistic goal for QPP. Thus, after review of our normative performance data, the ASBrS recommended different benchmarks than CMS for each QM.",
author = "Jeffrey Landercasper and Fayanju, {Oluwadamilola M.} and Lisa Bailey and Berry, {Tiffany S.} and Borgert, {Andrew J.} and Robert Buras and Chen, {Steven L.} and Degnim, {Amy C} and Joshua Froman and Jennifer Gass and Caprice Greenberg and Mautner, {Starr Koslow} and Helen Krontiras and Ramirez, {Luis D.} and Michelle Sowden and Barbara Wexelman and Lee Wilke and Roshni Rao",
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AU - Landercasper, Jeffrey

AU - Fayanju, Oluwadamilola M.

AU - Bailey, Lisa

AU - Berry, Tiffany S.

AU - Borgert, Andrew J.

AU - Buras, Robert

AU - Chen, Steven L.

AU - Degnim, Amy C

AU - Froman, Joshua

AU - Gass, Jennifer

AU - Greenberg, Caprice

AU - Mautner, Starr Koslow

AU - Krontiras, Helen

AU - Ramirez, Luis D.

AU - Sowden, Michelle

AU - Wexelman, Barbara

AU - Wilke, Lee

AU - Rao, Roshni

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