Improving Value in Surgery

Opportunities in Rectal Cancer Care. A Surgical Perspective

A radical and essential transformation in health care delivery is underway. Fee-for-service (FFS) has long held sway as the primary payment model in the United States, rewarding providers and hospitals for volume but not for quality or costs of services provided, and is largely responsible for the staggering growth of health care spending. The Affordable Care Act, enacted in 2010, is shifting incentives away from volume and toward a Triple Aim of better care, improved health, and reduced spending. Likewise, patients are becoming more sophisticated consumers of their health care, and payers are aggressively seeking new payment models that incentivize health systems to improve outcomes, enhance patient experience, and lower costs.

Whereas much of this effort has focused on primary care providers (eg, accountable care organizations and patient-centered medical homes), surgeons have a critical role in improving the value of health care in the United States. Costs of surgical procedures far outweigh primary care services, accounting for nearly half of all Medicare spending.¹ In addition, surgeons often lead the management of patients with complex, potentially costly medical problems. Every surgeon can readily identify defects in value, which are occurrences in the management of their patients who compromise quality and patient experience and increase costs. Examples of defects in value are abundant across health care, accounting for at least $1.3 trillion in wasted spending.² Opportunities for improvement in surgery are emerging related to avoidable complications, readmissions, overtreatment, no-value-added technology, and lack of specialist care.³

DEFECTS IN VALUE IN RECTAL CANCER CARE AND OPPORTUNITIES FOR REVERSAL

Perhaps no other area within the field of surgery has as much opportunity to eliminate defects and, thereby, improve the value of care as rectal cancer treatment. Rectal cancer is a complex disease. It is best managed by a multidisciplinary team (MDT) of expert providers using an array of treatment modalities aimed at maximizing oncologic benefit while minimizing adverse treatment effects. Innovations in the past several decades in neoadjuvant therapy, surgery, and imaging have undoubtedly improved overall patient outcomes. Nonetheless, they have also created treatment algorithms with convoluted options that have differences in benefit, harm, patient inconvenience, and cost.

Providers caring for rectal cancer patients will be increasingly asked to not only create a treatment plan focused on cancer outcomes, but 1 that incorporates the value equation variables−patient goals/experience and treatment costs. Figure 1 illustrates 8 defect domains in rectal cancer treatment, creating no-value care (no clinical benefit and may harm the patient) and low-value care (higher cost with little-to-no clinical benefit or decreases in both cost and quality-adjusted life years). By no means all-inclusive, these examples are meant to stimulate rectal cancer providers to critically assess the cost–benefit ratio of each step of treatment algorithms with the goal of providing the highest value care possible for each patient. Below we discuss several of these defects in rectal cancer care and the potential cost savings if they were eliminated (Table 1^4–12).

FIGURE 1: The figure shows the domains of defects in rectal cancer treatment, situated on a cost-effectiveness plane relative to high-value, low-value, or no-value care. Value is considered on a sliding scale based on clinical benefit, cost, and quality-adjusted life years (QALY), in which the greater the clinical benefit and QALY for the patient and the lower the cost, the higher the value.

TABLE 1 - Value Defects in Rectal Surgery and Potential US Health Care Cost Impact

Rectal Cancer Value Defect	Domain(s)	US Societal Cost
Overtreatment with neoadjuvant therapy	Inappropriate care	$166,078,880* 4,5
	Difficulty supporting shared decision-making
Loop ileostomy	Inappropriate care	$18,001,170*,† 5–7
	Preventable postdischarge care
Anastomotic leaks	Care with avoidable complications	$23,343,450* 8,9
	Preventable postdischarge care
Robotic surgery	Low-value care	$5,888,938*,‡ 10,11
Care by nonspecialist provider in low-volume hospital	Difficulty accessing specialty care	$2,512,602* 12
	Care at low-volume hospital by low-volume surgeon

^*Applied procedure estimates from the American College of Surgeons National Cancer Database from cases diagnosed January 1, 2021, https://www.facs.org/-/media/files/quality-programs/cancer/ncdb/store_manual_2021.ashx.

^†Used 24,750 loop ileostomy estimate, given NCCN guideline recommendations for neoadjuvant therapy for all clinical stage II and III patients and a mandatory policy of fecal diversion in treated patients.

^‡Cost of a laparoscopic procedure served as the comparator.

NEOADJUVANT THERAPY

It is well-accepted that neoadjuvant therapy in addition to surgery reduces the overall incidence of local tumor recurrence in rectal cancer patients compared with surgery alone. However, the absolute risk reduction is highly dependent on tumor stage and location in the rectum, varying from <1% in early-stage upper rectal cancers to up to 10% in stage III tumors in the lower rectum.¹³ This variation translates into a wide range (10–>100) of the number needed to treat to see a benefit from neoadjuvant therapy. This variability in efficacy along with the associated morbidity, inconvenience, and cost makes the limited use of neoadjuvant therapy to only patients who will derive meaningful clinical benefit an ideal strategy to improve value in rectal cancer care.

Radiation and chemotherapy account for nearly 40% of the total cost of treatment for rectal cancer.¹⁴ Standard courses of neoadjuvant chemoradiation therapy and adjuvant chemotherapy are estimated to cost $25,000 and $20,000, respectively. Overtreatment not only wastes costs on neoadjuvant therapy, but also costs for subsequent, mandatory adjuvant chemotherapy administered to patients whose initial tumor may have been over-staged. Recent studies suggest that magnetic resonance imaging–based classification of rectal cancers into low-risk and high-risk tumors may eliminate neoadjuvant therapy in up to 40% of clinical stage II and III patients without compromising outcomes.^15,16 This would generate an annual cost saving of $166 million.

LOOP ILEOSTOMY

Fewer patients treated with neoadjuvant therapy can also reduce the number of loop ileostomies created, as most surgeons consider fecal diversion mandatory in radiated patients. Loop ileostomies cause defects in value from hospital readmissions, expenses for nursing support and stoma supplies, and decreased quality of life.¹⁴ Costs for subsequent loop ileostomy closures are also significant (Table 1). On the basis of National Comprehensive Cancer Network guideline recommendations for neoadjuvant therapy for all clinical stage II and III patients and mandatory fecal diversion in treated patients, 24,750 loop ileostomies would be created annually. Applying a selective approach for neoadjuvant therapy, but still assuming surgeons would divert nonradiated patients with middle or lower third tumors, would decrease annual loop ileostomies to 21,780. The calculated costs of loop ileostomy closure in each patient group yields an estimated annual savings of over $18 million.

ANASTOMOTIC LEAKS

Anastomotic leaks are a catastrophic complication of rectal cancer surgery and make negative contributions to all facets of the value equation. Anastomotic leaks may increase local recurrence rates and decrease survival.¹⁷ This complication can also adversely impact patient experience such as increase the length of hospital stay, extend time in a skilled nursing facility, require revision surgery, prolong the time with a temporary stoma, or worse yet, lead to a permanent stoma, and add financial and social hardships for patients and their families. Costs of care are also dramatically increased. One study used Medicare FFS and commercial claims data from a large US-based health plan and found that costs for the index hospitalization alone were > $30,000 higher for patients experiencing an anastomotic leak.¹⁸ Total costs are likely much higher given this figure excludes costs related to readmissions, home health care, skilled nursing facility care, and revision surgeries. On the basis of these data alone, a reduction in the anastomotic leak rate after restorative rectal cancer surgery from 15% to 10% would save nearly $15 million annually and a further reduction from 10% to 8% would save an additional, nearly $6 million in costs of care.

ROBOTIC-ASSISTED RECTAL CANCER SURGERY

New technologies are abundant in surgery, and many have been adopted to treat rectal cancer patients. Although studies examining these new devices and techniques have reported efficacy, in many cases, they increase the costs of treatment, positioning technological innovation in direct conflict with efforts to improve health care value. The widespread adoption of robotics for rectal cancer surgery is 1 example of how technology can create significant friction in the shift toward value-based care. Proponents of robotics cite many anecdotal advantages to this surgical approach and its acceptance and utilization in the treatment of rectal cancer continues to grow worldwide. Two randomized trials comparing the robotic approach to conventional laparoscopy in the treatment of rectal cancer have been published. The US-based ROLLAR (Robotic-assisted surgery compared with laparoscopic resection surgery for rectal cancer)trial¹⁹ failed to demonstrate any significant clinical advantage, whereas the recently published REAL study²⁰ from China was able to report improved outcomes in several end points. Although some of the differences between the robotic and laparoscopic groups were relatively minor and of questionable clinical significance (10 mL blood loss, 1 day length of stay), others measuring quality of the resection specimen, APR rate, and conversion to open surgery portend a genuine advantage, especially if they ultimately translate into lower recurrence rates and improved survival with longer patient follow-up.

The only study specifically examining the value of robotic surgery in rectal cancer was published by Silva-Velazco et al.¹⁰ They compared both oncologic outcomes and costs for 3 approaches to curative proctectomy in 488 patients treated at a high-volume rectal cancer hospital. They reported outcomes and costs for the index surgical hospitalization and costs for subsequent readmissions and loop ileostomy closures. The proportions of patients treated using the robotic, laparoscopic, and open approach were 14%, 24%, and 62%, respectively. Groups were similar in demographics, tumor characteristics, and neoadjuvant treatment. Differences in outcomes were found in operating room time (longer in the robotic group) and in blood loss, transfusions, length of stay, and complications (all higher in the open group). No differences were found in short-term oncologic outcomes, including the circumferential resection margin-positivity rate, lymph node harvest, and mesorectal grade. Although costs were similar in the open and laparoscopic groups, the index surgical admission cost was 38% higher for patients treated robotically, and this proportional cost increase persisted after including 30-day readmissions and subsequent loop ileostomy closures.

More information is clearly needed to define the role of robotic surgery in rectal cancer treatment, especially in health care systems that are focusing on high-value care. The reality, however, is that value means different things to different people–administrator versus surgeon versus patient. Although robotic surgery may prove to be the way of the future, assuming the identified advantages are real and are sustained, but that does not mean that such technology dissemination is practical, viable, or affordable for anything other than the most fortunate health care systems.

CURRENT AND FUTURE OF RECTAL CANCER CARE IN THE UNITED STATES

Recent studies have highlighted the variability in treatment and outcomes for US patients with rectal cancer. Examination of the Commission on Cancer’s National Cancer Database, which captures ~70% of all invasive cancer cases treated annually in the United States, reveals that most patients with rectal cancer are cared for in low-volume hospitals by nonspecialist providers.²¹ In addition, well-accepted and important quality indicators for rectal cancer treatment, such as lymph node yield, adherence to evidence-based guidelines, accuracy of clinical staging, colostomy rates, and circumferential resection margin status have been found to be substandard.²²

The current state of US rectal cancer care is similar to care that existed 20 years ago in several European countries. National efforts to improve the quality of care through provider training, followed by consolidation and standardization of care, have decreased local recurrence rates by ~50% and raised 5-year survival rates by up to 60% in Sweden, Norway, the Netherlands, and Denmark. This remarkable success is the inspiration behind the Commission on Cancer’s National Accreditation Program for Rectal Cancer, which aims to improve US rectal cancer outcomes through the principles of multidisciplinary-based and guideline-based care.²¹ Architects of National Accreditation Program for Rectal Cancer estimate that achieving similar improvements as the European countries here in the United States could reduce total costs of rectal cancer care by 16%, or $528 million annually, and save 6000 patient-lives per year.

The important work to tackle defects must start as a grassroots effort on the institutional level, led by individuals who are deeply committed to improving the value of rectal cancer care. However, the motivation to embark on the journey is not purely altruistic as there are tangible benefits for every institution. The US health care system is slowly transitioning away from the predominant FFS model and toward a value-based reimbursement system. Hospitals who can demonstrate high-value care, transparent reporting of outcomes, and aggressive cost management will be in the strongest position to compete for contracts with value-seeking payers, employers, and patients.

Modern rectal cancer care is conducted by an MDT of specialist providers collaborating to design and deliver an individualized evidence-based treatment plan for each rectal cancer patient. We propose that the rectal cancer MDT is the ideal vehicle for beginning the journey toward value-based care. Rectal cancer treatment is complex. Each patient can often be offered several treatment options, and each option may be supported by high-quality evidence. It is logical that the MDT could also consider the costs of each option in their deliberations and, thus, arrive at a final plan that would deliver both optimal outcomes at a minimum cost. Inserting the patient’s goals and expectations in these discussions would be the “icing on the cake,” allowing us to reach the pinnacle of high-value rectal cancer care where superb outcomes, outstanding patient experience, and tightly controlled costs all come together.

CONCLUSIONS

The US health care system is beginning its transition from FFS to value-based care. Although current efforts primarily focus on primary care, surgeons will have an important role to play if the full potential of this transformation is to be realized. We recognize that many barriers exist, and the task may seem overwhelming. However, we also have great faith in the unique talents of surgeons, in particular their dogged commitment to improving patient outcomes and their ability to innovate to solve difficult problems. The treatment of patients with rectal cancer provides only 1 example of the opportunities standing in front of us. We are confident that once committed, surgeons in all fields will find numerous other areas where the value of patient care can be improved.