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Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?
  1. Ryan J Ellis1,2,
  2. Cary Jo R Schlick1,
  3. Joe Feinglass3,
  4. Mary F Mulcahy4,5,
  5. Al B Benson4,5,
  6. Sheetal M Kircher4,5,
  7. Tony D Yang1,4,
  8. David D Odell1,4,
  9. Karl Bilimoria1,2,4,
  10. Ryan P Merkow1,2,4
  1. 1 Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  2. 2 Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
  3. 3 Division of General Internal Medicine and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4 Robert H Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
  5. 5 Department of Medicine, Northwestern University Division of Hematology/Oncology, Chicago, Illinois, USA
  1. Correspondence to Dr Ryan P Merkow; ryan.merkow{at}


Background Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.

Methods Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.

Results A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers.

Conclusions and relevance Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.

  • quality measurement
  • surgery
  • health services research

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  • Contributors Study conception and design: RJE, CJRS, MFM, ABB, SMK, TY, DDO, KB and RPM. Acquisition of data: RJE and CJRS, Feinglass Analysis and Interpretation of data: RJE, CJRS, JF and RPM. Drafting of manuscript: RJE and RPM. Critical revision: RJE, CJRS, JF, MFM, ABB, SMK, TY, DDO, KB and RPM.

  • Funding This study was funded by Center for Strategic Scientific Initiatives, National Cancer Institute grant no: K07CA216330; American Cancer Society grant no: IRG-18-163-24; National Heart, Lung and Blood Institute grant no: K08HL145139; Agency for Healthcare Research and Quality grant no: 5T32HS000078, K12HS026385.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was considered non-human subjects research by the Northwestern institutional review board and exempt from approval.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available.

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