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High-volume, NCI-designated centers not associated with greater value in pancreatic cancer care
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High-value care appeared associated with important patient, tumor and treatment characteristics among patients with early-stage pancreatic cancer who underwent curative resection, according to results of a retrospective study published in JAMA Surgery.
NCI-designated and high-volume centers, however, did not appear associated with greater value, suggesting a need for targeted measures to increase value at these centers, researchers noted.
“Value in cancer care has become increasingly important in the age of ever-rising health care costs and increasing incidence of cancer,” Sarah B. Bateni, MD, of the department of surgery at UC Davis Health System, and colleagues wrote. “Unfortunately, the rising costs of cancer and surgical care coincide with the rising incidence of cancer in the population. Hence, studies regarding the value of health care are essential.”
Regionalization of pancreatic cancer surgical care has been studied as a method to improve perioperative outcomes. However, investigations have not explored long-term outcomes in relation to health care costs.
In the current study, Bateni and colleagues sought to identify patient and hospital characteristics that correlated with improved OS, decreased costs and increased value among patients with pancreatic cancer undergoing curative resection.
Researchers used the California Cancer Registry to identify 2,786 patients (mean age, 67 years; 50% men; 82.8% white) with stage I or stage II pancreatic cancer who underwent resection at 157 hospitals in California between 2004 and 2012. Slightly more than half (51.3%) of patients underwent treatment at a teaching hospital, whereas 46.6% received care at high-volume pancreatic surgery center and 40.5% at an NCI-designated cancer center. Fewer than half of the patients (44.4%) received postoperative chemotherapy, and 31.4% received radiotherapy.
OS, surgical hospitalization costs and value served as the study’s primary endpoints.
Researchers defined high-value care as the fourth quintile or higher for survival (26 months or longer) and the second quintile or less for costs ($40,674 or less).
Median follow-up was 20 months (interquartile range [IQR], 10-35).
Most patients (74%) died of pancreatic cancer.
Results showed associations between longer OS and postoperative chemotherapy (adjusted HR [aHR] = 0.71; 95% CI, 0.64-0.79) and high-volume surgical centers (aHR = 0.78; 95% CI, 0.61-0.99). Median OS was 23 months (IQR, 11-46) for high-volume centers vs. 18 months (IQR, 10-35) for low-volume centers (P < .001).
Mean surgery hospitalization cost, including index surgical hospitalization and readmissions within 30 days, was $60,939 (standard deviation, $56,779).
Higher Elixhauser comorbidity index scores (estimate, 0.006; 95% CI, 0.003-0.008), complications (estimate, 0.22; 95% CI, 0.17-0.27), readmissions (estimate, 0.34; 95% CI, 0.29-0.39) and longer lengths of stay (estimate, 0.03; 95% CI, 0.03-0.04) appeared associated with higher costs (P < .001), whereas postoperative chemotherapy appeared associated with lower costs (estimate, 0.06; 95% CI, 0.11 to 0.02; P = .006).
Researchers observed no association between NCI-designated and high-volume centers and costs.
Grade 3 and grade 4 tumors (OR = 0.65; 95% CI, 0.39-0.91), T3 category disease (OR = 0.71; 95% CI, 0.46-0.95), complications (OR = 0.68; 95% CI, 0.49-0.86), readmissions (OR = 0.64; 95% CI, 0.44-0.84) and length of stay (OR = 0.82; 95% CI, 0.78-0.85) were inversely significantly associated with high-value care. NCI designation (OR = 1.07; 95% CI, 0.66-1.49) and high-volume centers (OR = 1.08; 95% CI, 0.54-1.61) were not associated with high-value care.
The study’s retrospective nature served as its primary limitation. Future studies should itemize costs for each step of therapy to identify potential savings, researchers wrote.
“These data suggest that although regionalization of pancreatic cancer surgical care may lead to improvements in patient survival, regionalization is not associated with decreased costs or high value,” Bateni and colleagues wrote. “Therefore, targeted measures to enhance value are needed at high-volume and NCI-designated cancer centers, because these centers already treat a significant fraction of patients with pancreatic cancer and are likely to bear an increasing demand for the care of these patients.”
Physicians must actively educate themselves on cost and value to help improve patient care at an affordable cost, Roxanne L. Massoumi, MD, of the department of surgery at David Geffen School of Medicine at University of California, Los Angeles, and O. Joe Hines, MD, professor and chief of the Geffen School of Medicine’s division of general surgery, wrote in an accompanying editorial.
“There is a dire need for robust, validated pathways in pancreatic cancer treatment designed to save resources while maintaining a high standard of care,” Massoumi and Hines wrote. “As treatment options become more effective for pancreatic cancer, it will be important for NCI-designated cancer centers to take leadership roles in developing these high-quality, cost-efficient pathways to realize value for patients with this serious diagnosis.” – by John DeRosier
Disclosures: Bateni reports grants from the Agency for Healthcare Research and Quality outside of the submitted work. All other study authors, Massoumi and Hines report no relevant financial disclosures.
Perspective
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Sanjay S. Reddy, MD, FACS
Defining value of pancreatic surgery for those with any stage of pancreatic cancer addresses an important topic in health care. This study by Bateni and colleagues focused on those with early-stage disease, specifically stage I and stage II. The definition of value is quality relative to cost of care. Pancreatic cancer serves as a good surrogate to interrogate this, because management of this disease is highly complex. Although it is well-known that high-volume centers typically perform better in terms of outcomes, the metric of decreasing costs and improving survival is simple to follow. This article highlights that high-volume centers and/or those with NCI designation were, in fact, associated with better survival. However, they were not associated with improved health care cost or value. In the current health care climate, this is a legitimate concern.
Issues that drive cost are complications and readmissions, and among patients in this cohort, 37% experienced at least one complication within 30 days of surgery and 20% were readmitted. Work continues on reducing rates of complications and shortening length of stay to limit costs. Enhanced recovery pathways have been implemented in many high-volume, teaching and NCI-designated cancer centers. The goal is to standardize delivery of care and thus standardize costs. Although surgery hasn’t changed much, advances in laparoscopic and robotic surgical techniques certainly add cost, with much debate on the added value.
This study is limited primarily because it relied upon retrospective, observational data. Details of where the costs were accrued are not clearly defined, and these measures are important.
This study serves as a broad look into optimizing high-value care without compromising results. This is a fine balance, and through better standardization of care, and protocol-driven management of patients, enhancing high-value care should be an attainable goal.
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