A Multimodal Intervention to Increase Total Mesorectal Excision Grading for Rectal Cancer in Michigan: A Randomized Controlled Trial.

Abstract

Background: The total mesorectal excision technique is associated with improved outcomes for rectal cancer, and grading the total mesorectal excision specimen is recommended. We implemented a multimodal intervention in Michigan Surgical Quality Collaborative hospitals to increase total mesorectal excision grading.

Objective: To compare total mesorectal excision grading rates over time between hospitals that received the intervention early and late in the study.

Design: Stepped wedge randomized controlled trial with hospitals randomized to receive the education intervention early in the trial or one year later. We used a generalized linear mixed model to compare rates of total mesorectal excision grading over time between groups, adjusting for hospital characteristics.

Setting: Twelve hospitals within the Michigan Surgical Quality Collaborative.

Patients: Adult patients undergoing total mesorectal excision for rectal cancer from 2014 to 2021.

Intervention: A multimodal educational intervention consisting of a webinar about total mesorectal excision grading, a pre- and post-webinar quiz, and site visits.

Main outcome measures: Total mesorectal excision grading rate for each hospital over time.

Results: From 2014 to 2021, 560 patients underwent total mesorectal excision in participating hospitals, 350 at early intervention hospitals and 210 in late intervention hospitals. The early intervention began August 2018, and the late intervention began June 2019. Based on the mixed model, grading in early hospitals increased from 8.1% to 99.7% at the end of the study (p < 0.001). In the late group, grading increased from 47.8% to 94.0% (p < 0.001). The intervention was not associated with a change in total mesorectal excision grading in either group; rather, the increase in grading corresponded with a statewide collaborative presentation on this topic in December 2016.

Limitations: Selection bias, as hospitals recruited to participate were already participating in colorectal cancer quality improvement and may reflect greater commitment to high-quality rectal cancer care.

Conclusions: Our findings show an increase in total mesorectal excision grading in Michigan from 2014-2021 that preceded the dates of our intervention. These results highlight the importance of accounting for secular trends in measuring healthcare quality improvement interventions. See Video Abstract.