Communicating Value: Use of a Novel Framework in the Assessment of an Enhanced Recovery Initiative

The United States is transitioning to a value-incentivized healthcare system [1]. As originally proposed by Porter and Teisberg, “value” for patients is determined by assessing the relationship between the outcomes that matter to them and the cost incurred to deliver those outcomes across the full cycle of care [2]. The University of Texas MD Anderson Cancer Center has favored a definition that integrates the outcomes component of the value framework with traditional quality, safety, and patient experience measures [3]. It also prefers to expand the definition of cost to include the costs to both payers and patients (Figure 1A). Historically, it has been difficult to effectively visualize and communicate all of the value framework’s outcomes and cost components. It has also been difficult to summarize value using metrics across multiple dimensions. A standard framework for this purpose has been described only in a limited context [4, 5].

Figure 1.

A: The Value Equation at MD Anderson. B: Radar chart comparing value before and after implementation of risk-stratified clinical care pathways for patients undergoing pancreatectomy for pancreatic adenocarcinoma. Post-implementation metrics are displayed using relative change from an index value. Blue depicts quality metrics, green depicts cost metrics, and orange depicts harm/safety metrics.

The determination of value is prominent in the setting of pancreatic cancer surgery. Although pancreatectomy can be curative for well-selected patients with pancreatic adenocarcinoma, less than one-third of patients who undergo potentially curative operations live 5 years [6]. Moreover, pancreatic surgery is associated with significant perioperative morbidity [7], and the arduous recovery further impacts patients’ quality-of-life (QOL) [8]. Finally, the costs of these treatments are significant [9]. Because it is associated with such physical, emotional, and financial demands, yet offers prolonged survival to so few, the treatment of patients with pancreatic cancer offers an important clinical context in which to study value.

Our surgical department recently implemented a set of clinical care pathways for patients undergoing pancreatectomy. These pathways direct patients’ postoperative care on the basis of a preoperative clinical assessment of the patients’ risk of postoperative pancreatic fistula. We showed that these risk-stratified pathways decreased length-of-stay (LOS) and costs without affecting rates of adverse events (AEs) [7]. This initiative provides an ideal opportunity to demonstrate the utility of a framework to simultaneously visualize and communicate a wide range of outcomes and cost metrics. Herein, we describe the use of a radar chart depicting metrics of AEs, survival, functional outcomes, patient experience, and costs to illustrate a comprehensive definition of value.

MEASURING VALUE

Our risk-stratified clinical pathways were developed and implemented in October, 2016. For this study, we compared all 42 patients with pancreatic adenocarcinoma treated in the 12 months preceding pathway implementation with the 62 patients treated in the 12 months following implementation. The groups’ clinico-demographic profiles, including disease stage, did not differ significantly (p<0.05; data not shown).

Postoperative AEs

We use a prospective surveillance program to report all AEs within 90 days after surgery [10]. Following pathway implementation, median LOS decreased from 8 to 6 days (p < 0.001). The incidence of at least one postoperative AE (73% to 63%, p = 0.29) and the readmission rate (14% vs 12%, p = 1.00) did not change significantly.

Survival

The median disease-free survival of the pre-implementation group (14 [9 - 19] months) and post-implementation group (16 [13 - 19] months) did not differ significantly (p=0.63).

QOL and Functional Recovery

QOL and functional recovery were assessed using the Function Assessment of Cancer Therapy–General (FACT-G), a 27-item questionnaire that measures QOL in multiple domains. As this survey is not routinely administered to patients, we obtained all available FACT-G data from patients treated with pancreatectomy. Intermediate-term survey data (3 - 12 months postoperative) were available for 35 patients, of whom 18 and 17 were treated before and after pathway implementation, respectively. Overall QOL was similar (86 ± 25 vs. 86 ± 10, p = 0.98); scores were similar across all subdomains including functional well-being (22 ± 5 vs. 22 ± 4, p = 0.60).

Patient Experience

Patient experience was determined using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a national, standardized, publicly reported survey of patients’ perspectives of their overall care [11]. Our institution began administering the survey 5 months preceding pathway implementation. Therefore, we compared aggregated HCAHPS results from before the implementation to those obtained within 5 months following implementation. Because patient-level data are proprietary information, we report the results as a percentage difference. HCAHPS scores increased by 24% following pathway implementation.

Costs

Costs within 90 days of surgery were specified as either institutional costs (defined as all direct hospital and physician costs) or third-party payer/patient costs (all hospital and physician charges). The institutional gross margin was calculated as the difference between institutional costs and total collections received. Cost data are proprietary information thus reported as a percentage difference. Following pathway implementation, institutional costs decreased by 30% (p < 0.001), and the payer/patient costs decreased by 21% (p < 0.001). The institutional gross margin shifted from negative to positive.

Radar Chart

A radar chart is a graphical method of displaying data in which quantitative variables are represented on multiple axes that originate from the same point. We constructed a radar chart to simultaneously present each value metric. More favorable outcomes are plotted farther from the center on each axis; metrics for which a negative change is favorable (i.e. costs, complications, LOS) are plotted inversely. The relative change in each metric is displayed against an index value. Figure 1B reflects the change in value that occurred following implementation of the care pathways. This tool enables us to visualize and communicate how the pathway implementation provides an overall value advantage by improving several metrics.

DISCUSSION

Although the data reported herein demonstrate the potential benefit of an enhanced recovery program, the purpose of this analysis was not to assess the value of one single initiative, but rather to demonstrate the use of a novel analytic framework in which multiple domains of health care value are simultaneously quantified and communicated. This framework has important clinical utility given that comparative studies of health care processes, specifically in the surgical literature, have generally evaluated only a limited number of the components of the value equation [3].

The simple radar chart is a practical tool with which to improve dialogue between stakeholders as it provides clinicians, patients, administrators, and policy makers with a readily understandable snapshot that can facilitate value assessment. They may have particular utility in the context of shared decision-making between patient and provider, as they can reflect both costs that may be incurred and outcomes that may be achieved across two or more treatment possibilities. Institutions may also find this framework useful as they develop and prioritize specific workflows, pathways, and algorithms, or to support value-based reimbursement models.

Other frameworks have been developed to provide a comprehensive measure of health care value. The American Society of Clinical Oncology (ASCO) has proposed assigning a numeric Net Health Benefit (NHB) score to cancer treatments based on an assessment of their clinical benefit, side effects, associated symptoms, effect on QOL, and costs [12]. The extent to which value can be summarized by a single number using data generated across multiple dimensions, however, is unclear. Furthermore, there is currently no reason to believe that total value would be accurately represented by the linear sum of such metrics. The NCCN Evidence Blocks (NEB) proposed by the National Comprehensive Cancer Network (NCCN) may address these limitations by presenting assessments of efficacy, safety, quality of evidence, and costs of treatments as a visual matrix [13]. However, the blocks quantify expert opinion about specific recommendations, not data. And, neither of these frameworks is optimized to allow visualization of value from the perspective of different stakeholders. The radar chart is different in that it facilitates intuitive understanding of value differences through robust graphic depiction of actual data across multiple metrics. Future work may help to guide not only the selection of metrics used by different stakeholders, but also how stakeholders’ preferences may be reflected into more aggregate indexes of value.

Although this case study illustrates the potential utility of a novel framework, it also exposes important limitations to our current abilities to measure value. For example, many domains can be measured using data readily available in electronic medical records, data registries, and/or financial systems. Other metrics, however -- especially patient-reported outcomes such as pain measures, functional outcomes, QOL, and measures of financial toxicity -- may not be routinely available. To the extent that patients are increasingly taking greater responsibility for their health care [14], it is critical that the patient perspective is accurately reflected by any value measurement. Until we have access to multiple disparate outcomes, each measured routinely and reliably, it will be difficult to assess the total value of any care process.

As we develop better data, our ability to effectively communicate value will facilitate shared decision-making among all stakeholders involved in value-based health care.