Association of Quality and Technology with Patient Mobility for Colorectal Cancer Surgery

In the inaugural event of the Global Cancer Movement, hosted by OncoDaily, Dr. Ajay Aggarwal presented an insightful exploration of patient choice within healthcare systems, with a particular focus on colorectal cancer surgery. This engaging session delved into how policies promoting choice and competition influence patient decisions, healthcare quality, and technological adoption in the UK’s National Health Service (NHS).

Thank you very much, OncoDaily, for the invitation. Great to see you, Jemma. And to the audience so far, I hope you find this talk interesting.

And it really is around patients and the expectations in some health systems that patients will travel for their care, where they’ll choose their care, where they have the right to choose their care, and what they decide or what decisions they make is based on quality, reputation, is it technology? And this is looking particular focus at colorectal cancer surgery, but I also want to give an idea of the policy that informs this behind it. So the policy really is around choice and competition policy.

Now we always think of the US, I’m based in the UK, I’m an oncologist, and also a health services researcher, but we always think of healthcare markets and competitions as being a US based thing, often, people can choose on the basis of price, people can choose on the basis of differences in quality for their care, not just for not just for non-cancer treatments, but for also cancer treatments.

The fundamental aim of it is to drive healthcare performance. I’ve got a picture of someone called Julian LeGrand, who was very influential, he was at the London School of Economics, and he was a tutor of mine, about 15 years ago, and one of the things that he was involved in, in the NHS, was driving a change in the policy to improve standards or quality of care.

And he said, look, health systems have targets, you need to do better. And if you don’t do better, we’ll tell you that you’re not doing better, and you keep punching and punching and punching, but there’s very often very little improvement. The other option that they try as well, the doctors think that they know best, let the doctors decide how much money we need, and they will improve care.

But actually, unfortunately, in most health systems, when that happens, there’s a lot of wastage of money, it becomes inefficient, and there’s lots of perverse incentives.

So his idea was that actually, look, you have the National Health Service here in the UK, care is free, it’s reimbursed by the social health insurance or the NHS. However, if we allow someone to choose where they have their health care, and if they choose on the basis of outcome measures that this hospital is better than another, the idea is that the patient moves to that centre, money follows the patient, and the other hospital loses income.

If they lose income, they think, well, we’re losing income, because people think that other hospitals better, we need to get better. And the idea is meant to drive up the standard. So it’s like a nudge, basically, or a market phenomenon where there’s not price competition, it’s a fixed price.

But the movement of patients in these markets is meant to drive health care performance because of the threat of losing patients or money. Now, this happened and started in the NHS in the 2000s. And a piece of work, a three year project that I had was to try and see, well, in the National Health Service in the UK, do people shop around for their cancer care?

Are they prepared to travel for their treatment? When I was developing the project, most people said, well, no one travels, maybe 5% of people, everybody has their local care. But I sought to start to investigate that.

And I think the first piece of work I did was actually based in prostate cancer. And one of the things that I asked, I had a data set for all patients treated with prostate cancer surgery over a five year period between 2000 and 2015. And the first question was, do patients travel to centres other than their nearest prostatectomy centre for treatment?

As I said, the hypothesis of others was very few, maybe 5%. I thought maybe a bit more. So this is the first map I’m going to show you.

So here we have a map of England. You’ll see the coloured dots on the right hand side. Those green dots tell you that those are patients who live near the cancer centre there, who had their treatment there.

The orange dots are people who actually lived close to that centre, but went to another centre. And the red dots are patients who lived closer to another centre, but travelled to the centre of those green dots. What that basically tells us is that actually, as expected, most people are having local care.

But I investigated other hospitals. And at the time, you’ll see these crosses here. There were 65 hospitals providing prostate cancer surgery.

You’ll see a cross on the left hand side in a sea of green. That’s a hospital in a place called Bristol. And the green dots are all the patients who live close to Bristol who had their treatment there.

All the blue dots are patients who actually had another prostate cancer surgery centre much closer to them, but they travelled to this centre in Bristol for their care. No one had seen anything like this before. So we were finding within the NHS for prostate cancer surgery, where care is meant to be free at the point of access, people were choosing to go to the centre.

But it wasn’t just this centre. It was other centres as well. We found that one in three men were shopping around for their prostate cancer care.

They were younger, fitter and more affluent. But the question is, why were they going to that centre? If you take all of those 65 centres, there were some centres, as you can see on the left side, who gained more patients than they lost.

And on the right hand side, there were some patient centres that were losing lots of patients to these other centres. So there was a winners and losers phenomenon. But if you look at the centres gaining patients, these were all the early adopters of robotic surgery.

These were all the centres, these 12 centres were all the early adopters and they gained patients. So what happened to the other centres? Well, the centres losing patients were not doing a minimum volume of patients.

They had to do 50 a year. So a lot of those centres closed. So you have patients moving, moving for robotics, most likely.

Other centres losing patients, not doing enough volume and were closing down. So centres were actively closing. So what would you do if you were a centre in the middle, neither gaining or losing, but you can see what’s happening?

You would naturally get a robot. So we saw this phenomenal diffusion of technology where only 15 percent of centres had robotic surgery and by 2016, 85, 90 percent. Everyone has robotic surgery.

And one of the biggest drivers was this competition. But the question that someone then has, well, if robotics was one of the major factors in driving this movement of patients, what has been the impact on outcomes? Well, we weren’t collecting outcome measures at these hospitals, but we do now.

And what this graphic basically shows you from the NHS and within our only 50 centres providing prostate cancer surgery. And this is a funnel plot and the Y axis is basically rates of complications from prostate cancer surgery, severe incontinence, bleeding. And you can see despite all of these centres having robotic surgery, there’s still a huge variation in the quality of care in the National Health Service.

So you have this situation where patients move, centres lost patients, some closed, some got robots, but ultimately there’s been no improvement in the quality of care. So that’s the prostate cancer surgery story. But I was very interested to know, well, what’s the story in other cancer types?

And in the UK, we have 10 audits or registers of cancer. So bowel, breast, ovarian, lung. And we cover all patients treated in the National Health Service.

We have a population of 55 million people. And we look at, we collect measures of quality at the individual centres and those can be outcomes, so mortality, they can be toxicity after treatment, they can be complications after treatment, but they can also be, did this patient receive evidence-based care or not? And these outcomes are now being reported through the centre, the National Cancer Audit Collaborating Centre and are available publicly.

So we have a public system where a patient, public clinician can go onto a website, click on the hospital and they can compare themselves to every other hospital in the country for outcome measures. So which leads us on to colorectal cancer. And as many of us know, within colorectal cancer, despite some large randomised control trials being done, we know that there are increasingly surgeons who are using robotic surgery.

But colorectal cancer was also interesting because it was one of the few cancers where outcome measures were also being published by the NHS. So we had things like two year mortality rates after bowel cancer surgery was one of the measures that we had.

So the question was in this particular study, which was published in the Journal of Surgery, was actually for all the patients receiving colorectal cancer surgery, so 44,000 in this period of time, so a large number of patients who had a choice of 163 hospitals offering this, was there any evidence that patients were shopping around or deciding to not go to their local centre and going elsewhere?

The factors that we were looking at to decide what could be the benefits of going to other hospitals. So we had two year colorectal cancer outcomes, so that was mortality. We designated whether the centres were a comprehensive cancer centre, so 51 of those, 163 were comprehensive cancer centres.

There is an overall hospital rating that we have in our health service, good, bad, inadequate, and 12 were rated as inadequate. We also looked at the specialisation of the unit, so only 31 of these 163 centres performed pelvic exenteration and would be a very highly specialised centre. And although we weren’t looking at people having this surgery, those centres that did provide it were seen as being of the highest level, potentially from a skill perspective.

We had 22 robotic surgery centres and we also looked at research activity. So I talked about prostate cancer, where one in three patients were moving, and we have here something very different, because in prostate cancer there were only 65 units, there are 163 in the NHS. We found that one in four patients were bypassing their nearest centre, so 25%, that was up to 30% for rectal cancer.

And you can just see in the map, those blue dots, so you’ll see a little tinge of green, it’s magnified, so we’re looking at a centre, my own centre in London, and our hospital has lots of patients, these blue dots coming from all over, different parts of the south of England, despite those crosses, other bowel cancer surgery centres were there, and these patients were younger, more affluent patients.

So the question that I wanted to ask was, well, what are the factors associated with that? And very clearly, we found that if you’re a specialist colorectal cancer surgeon, you should be able to do this.