To risk adjust or not to risk adjust for sociodemographics—that is the question, so what is the answer?

© Journal of Hospital Management and Health Policy. All rights reserved. J Hosp Manag Health Policy 2020;4:1 | http://dx.doi. org/10.21037/jhmhp.2020. 03.01 It is estimated that 606,880 people died from cancer in the United States in 2019 (1). Three of the most commonly diagnosed malignancies include breast, colon, and lung cancer which have well defined treatment modalities that often includes the use of chemotherapy. The National Quality Forum (NQF) and the Commission on Cancer (CoC) of the American College of Surgeons have developed and endorsed several guidelines and metrics involving the rate of appropriate administration of chemotherapy (2,3) among eligible cancer patients. Hospitals are rated and accredited based on thresholds of compliance for these chemotherapy metrics and which are used as a measure of hospital quality. Thus, understanding how these metrics are calculated and used in practice has important ramifications for benchmarking cancer care quality at the hospital-level. Currently, the NQF and the CoC measures consider a hospital compliant if chemotherapy was recommended to a patient but they did not receive it because they either refused or were lost to follow-up. In their article (4), Ellis et al. argue that while this appropriately does not penalize hospitals for not offering appropriate chemotherapy, it may mask a true gap in cancer care quality that may be associated with socioeconomic disparities. Whether to adjust for and incorporate measures of socioeconomic factors in quality measures has been a controversial policy topic. In particular, it has been argued that social risk adjustment may obscure true performance by not penalizing providers who deliver low quality care to disadvantaged populations, whereas others argue that it may inappropriately penalize providers who work for safety net hospitals with a large proportion of socially disadvantaged patients (5,6). To this end, the objectives of the study conducted by Ellis et al. were to identify patient-level factors associated with failure to receive recommended chemotherapy and to characterize hospital-level variation in failure to administer chemotherapy without a documented contraindication separately for breast, colon, and lung cancer patients. The study identified patients diagnosed with colon, breast, and lung cancer from 2005 to 2015 in the United States using the National Cancer Database (NCDB), a hospital-based registry that capture approximately 70% of all newly diagnosed cancers. In total, 183,148 patients treated at 1,281 hospitals met inclusion criteria for the study. The rate of failure to receive chemotherapy for breast (n=82,598), colon (n=90,077), and lung cancer (n=8,473) was 3.5%, 6.6%, and 10.7%, respectively. By cancer type, investigators used multivariable logistic regression models accounting for hospital clustering in order to identify independent patient-level characteristics associated with failure to receive chemotherapy. In general, socioeconomic disparities were reported. For example, non-Hispanic black compared to white breast and colon cancer patients had 26% and 38% increased odds of failing to receive chemotherapy, respectively. Insurance status also predicted failure to receive chemotherapy. For example, among lung Editorial Commentary