In this episode, Tom Varghese, MD, FACS is joined by Calista M Harbaugh, MD, MSc, from the University of Michigan. They discuss Dr Harbaugh’s recent study, “Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery,” in which the authors found that hospitals accredited by the National Accreditation Program for Rectal Cancer are associated with lower short- and long-term morbidity and mortality, but few programs achieve accreditation status.
Disclosure Information: Drs Varghese and Harbaugh have nothing to disclose.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian Erdahl
and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, loyal listeners,
welcome to another episodeof The Operative Word,
the podcast of the Journalof the American College of Surgeons, where
we connect with amazing authorswho published recent articles in JACS.
I'm honored to be joined todayby Dr Calista Harbaugh,
(00:50):
who is a colorectal surgeonat the University of Michigan.
Dr Harbaugh, welcome to the show.
Thank you so much. I'm happy to be here.
The first question to ask
is, do you have any relevant disclosuresfor this article?
I do not for this article.
So, full disclosure to our audience members,
as many of you know, I did my CT surgeryfellowship at the University of Michigan.
(01:12):
So, if I have a partial,you know, favoritism towards Dr Harbaugh,
I don't apologize for that. Go blue.
So with that,we'll go ahead and get started.
Dr Harbaugh,thank you for joining us today,
because we're going to be discussing thisamazing article that was
published in the August issue of JACS,which is titled “Association
of National Accreditation Programfor Rectal Cancer Accreditation
(01:35):
with Outcomes after Rectal CancerSurgery.”
And this abstract was presented
at the American College of Surgeons109th Annual Clinical Congress
that took place in Bostonin October of 2023.
Dr Harbaugh, as a start,
why do we go and do thisproject in the first place?
Yeah,
rectal cancer treatment has really changeddramatically over the last few decades,
(01:59):
and it's gotten increasingly complexfor any patient with rectal cancer.
Depending on where the tumor is at,how locally advanced it
is, there are treatment optionsthat may span anything from chemotherapy,
chemoradiation, immunotherapy,and with or without surgery.
So, with all of that complexity,we also see a lot of variation in care.
And there are some basic standardsthat every patient
(02:21):
should have in the treatmentworkup and treatment planning.
With all of that
variation in treatment,we also see the variation in outcomes.
And so to address that,the American College of Surgeons
established NAPRC in 2017
with the goal of improving rectal cancer
(02:41):
treatment broadly at all hospitals.
The NAPRC standards
focus really on the multidisciplinary care
of patients, with careful attention
to data capture and auditing,making sure every patient is presented
and all of the multidisciplinaryproviders are involved.
(03:02):
It focuses less on what the actual treatments are.
You know, there's a lot of questionearly on, because all of this
multidisciplinary programmanagement can be very resource intensive.
And there were some early questionsabout whether the NAPRC
A) would be accessible for most hospitalsand most patients,
and B) whether it would have any impact on outcomes.
(03:24):
So there were some early preimplementation studies
that tried to predict what would happenafter the NAPRC was implemented,
but really no studies so farthat have looked at what happened
after hospitals startedachieving accreditation.
So that was really our goal with
this was to look at A) who achievedaccreditation and B) what happened.
Well, and so extending on that.
So right who meaning the characteristicsof the hospitals that are doing NAPRC.
(03:49):
That was really the goal, not theindividual surgeon practices per se.
Correct.
We focused at the hospitallevel. Okay.
And I thought it was very novelbecause you're right.
there was a lot of attention, potentiallyeven a little bit of controversy
when NAPRC was rolled outbecause you went in the direction
of the multidisciplinary teamin the processes, but unlike other
(04:14):
accreditation programs, volumewasn't a consideration in the first place.
Correct? Yeah.
You know, there's so much to debateand a lot of controversy around the idea
of centers of excellence, which, I knowthis isn't a center of excellence per se,
but you could draw a lot of corollariesbetween that concept and accreditation.
And we know that at centers of excellencefor some other conditions,
(04:37):
really, didn't, they, they didn'thave the same effect as they wanted.
And, some argue that perhaps using volumeas standard is the problem,
is that that now isn't necessarily a proxyfor all of the different aspects of care
that go on.
So that was the unique thing about NAPRC,is it drilled down so heavily
on all of these multidisciplinary aspects
(04:59):
that's different than a lot of otherprograms and standards.
And so let's now go deep diving into this article.
So, you, the methodology,
first, the the selection of the database,you know,
you use the MedPAR or Medicare provideranalysis and Review database.
is that because it was so comprehensivein terms of the information
(05:22):
you get acknowledgingit's a Medicare patient population,
is that the reason why that database waschosen?
Yeah, it's one of the few opportunities to look at
a more population-level group recognizingeverybody's over the age of 65.
But there's not as much biasin terms of who was included
in that, in terms of demographicsand other aspects.
(05:42):
And most hospitalshave a Medicare population.
And so it gives us sort ofa unique ability to have insight broadly.
There's some limitations to that too, that we can discuss.
But this was as a first stepwhere we decided to start.
Absolutely.
And then and obviously, as you correctlypointed out, the primary exposure
variable for all the analysis was NAPRCaccreditation.
(06:04):
Yes/No.Did they have accreditation or not?
But I thought the interesting thingis, you started,
the analysis, from 2017 to 2020.
and I think that you put in therethe comment that recognizing
you started like a yearbefore it officially came out, thinking
that a lot of these hospitals probablywere doing the work of getting accredited,
(06:28):
from that aspect.
And so that was a surrogate,
that was a reasonwhy the time period was chosen.
Exactly.
So NAPRC startedaccepting applications in 2017.
It's about a 12 month processto achieve accreditation.
So, in order to achieve accreditationin 2018, they had to be adhering to
that standards for the year before.
So another really important limitation iswe did reach out and try to get exact
(06:50):
dates of when hospitals got accredited,but we were not able to get that.
We could only accesspublicly available information,
which tells you at the time pointthat I opened the website,
these are the hospitalsthat were accredited.
And so that was another reasonto include back to 2017,
because that limitation really appliesthroughout the entire study period.
And again, these accreditationsare not things that change very quickly.
(07:13):
Like these are things that hospitals
have to adhereto for a long period of time.
And then the outcomes,you know, the outcomes
that you looked at were, you know, welldocumented, measures of surgical safety,
including in-hospitalmortality, 30-day mortality complications.
we say serious
complications re-operations, readmissions
(07:35):
and 1-year mortality.
that looks likea pretty comprehensive list.
any thoughts after after you didthe study,
was there something elsethat you would have loved to have done?
If you can do this analysis over again?
Yeah.
I mean, I think the thing we all want to know is
what's the effect on cancerand our survival and our, you know,
1-year survival is a very,
(07:57):
broad outcome, especially when you'relooking at a cohort of older patients.
There's a lot of reasons
that people can have 1-year mortalityoutside of their tumor, their cancer itself.
And that's \what we don't have in these databases is,
we don't have access to adherenceto standards like staging.
We don't have accessto whether their cancer recurred.
so these were kind of the bestyou can get in a client's database.
(08:20):
You know, we asked whether we should usesome other databases,
like, you know, there’s SEER Medicarethat might give some more insight to that.
again, this was a good place to startbecause it gave us a comprehensive view.
There are definitely limitationsto things like SEER Medicare
that don't necessarily capture broadly.
Everybody across the US.
So, so this was a good place to start,but definitely not the end.
(08:42):
Beautiful.
Well, let's go ahead and, keep going.
So, obviously, you compared hospital-and patient-level characteristics
and then you ultimately ended updoing multivariable logistic regression,
really trying to figure outwhat were the drivers
of the outcome resultsthat you're looking at.
And I was fascinated by this.
(09:03):
So, you identified 20,202 patients
in the Medicare patient populationthat is between 65 and 99 years of age,
who underwent proctectomyfor rectal cancer
at one of the 1,984 hospitalsthat were identified.
I guess your hypothesis going in was,
(09:25):
your thought was that NAPRC,the hospitals should have better outcomes
and were most likelyto be at academic centers.
When you looked at the findings, were itwere any of the findings surprising,
for you when you did the analysis? Yeah.
I think the most surprising thingfor the first objective.
So just understanding
what types of hospitals achievedaccreditation is that actually a large
(09:46):
proportion of them were small to moderatesize hospitals, like less than 500 beds,
we hypothesized, you know,they were mostly teaching hospitals.
Actually, I should actually correct that,they were all teaching hospitals.
But in terms of thebed size, I thought that was surprising.
I thought mostly that the large hospitals
would be the ones that would be ableto achieve accreditation.
(10:07):
But that being said, even thoughthere were many small hospitals
that achieved accreditation, it's still Imean, we have to look at the numbers.
And only about 3% of all hospitalsachieved accreditation and 10%
of all patients received treatmentat a total accredited center.
Right.
You...that's amazing.As you correctly point out.
Yeah. So 10%.
So about a little over2000 patients underwent
(10:30):
protectomy for a rectal cancerat an NAPRC-accredited hospital.
And then,
this probably wasn't too surprising.
The patients who were treated
at the accreditedhospital were less likely to be Hispanic.
But there were no significant differencesin age, demographics, or comorbidities
between NAPRC hospital patientsand non-NAPRC hospitals.
(10:52):
Maybe that's a little surprising, right?
You would have thought that maybe
then NAPRC hospitalsshould be treating more sicker patients.
But that that wasn't the finding.
Yeah.
It's hard to know what to make of that.
And I think we definitely would have todelve in a little bit more to understand.
I mean, again, like half of the hospitalswere smaller, moderate sized. So,
(11:13):
you know, I definitely think
we got to dig in a little bit deeperto understand the nuance of that.
Yeah.
And then some of the other findings,
I guess the other onesI wasn't too surprised about.
I mean, more likely...NAPRChospital patients were more likely
to receive a minimally invasive approach.
They were more likely to get surgerieswith sphincter preservation.
(11:35):
But, I guess this one,this is kind of the,
the one that, it's always been a concernabout when you're developing centers
of excellence, patientswho were treated at any NAPRC hospitals
were more likely to travelfurther distances to get their care.
But in the modern age,
when information is availableat our fingertips,
(11:55):
is that necessarilya bad thing that maybe patients
need to travel a little bit furtherto get high quality care?
No,
I mean, that's an interestingone to think about is with a lot of,
a lot of cancer, we think a lot aboutwhether we should be centralizing care.
And I think that measure gets into thatconcept is in some
to some extent, patientsmay be centralizing themselves.
(12:20):
You know, itruns a little bit against NAPRC's mission.
It's not so much to identify centers of excellence,
but try to raise thestandard of care everywhere.
and, and so I do think we have to,
to think about measures like thata little bit,
because when we're thinking aboutnot just high-quality care, but equitable,
high-quality care,we need to think about who can travel.
(12:41):
So it definitely is a measurethat is A) not surprising.
And B) maybe in some sensewe should be moving towards.
But C) is that maybe also we shouldn't.
And maybe there's opportunitiesto think about
what kind of care we can delivercloser to home at a high-quality level,
and how to make NAPRC really achievethat stated mission.
(13:02):
And so, I mean, obviously,the most important
outcome of the paperwas you successfully proved,
the primary outcome, that is, NAPRChospital patients had significantly lower
risk of,risk-adjusted rates of in-hospital
mortality,lower 30-day mortality and complications,
lower 1-year mortalityas compared to non-accredited hospitals.
(13:26):
And so, you know, coming back to that, 3main points that you had of the
with the paper,
better outcomes at the
NAPRC hospitals,but unfortunately, only 1 in 10 patients
in this Medicare patient populationreceived their care at an NAPRC hospital.
And and the outcomes are clear,
(13:46):
I guess, really the question comes, whatwhere is the hesitation in this?
I mean, is a little bit of speculationon that, you know, because to me,
in one sense,that seems to be a no-brainer, right?
It's like maybe we should getall the hospitals NAPRC accredited.
But I think you alluded to this.
It's very labor intensive to get to be and, you know,
(14:09):
if financially incentive, intensiveto get to be an NAPRC hospital
is that a correct assessmentof the situation?
That's completely correct.
I mean, it is very hard.
It takes a lot of, time and effort
to maintain these standardsto a very, very high level.
And, you know, on one hand, you arguewe should be doing these things
(14:32):
regardless.
But on the other hand is that thethe capturing the data to prove
we're doing it, that
what’s really time intensive and resourceand financially incentive intensive.
So it really kind of makesyou think like how do we expand it.
Is it something that we just need to expand,
you know,
(14:56):
like awareness across the board?
But I would argue, you know,I think that's the easy answer,
but probably the least effective.
And I think what we really need to doand this is, again, very much speculation,
but is to rethink the waythat we create these programs, is
they don't match what the landscapeof health care looks like today.
Healthcare today is not delivered by single,
(15:18):
standalone hospitalsalmost anywhere, right?
They're increasingly expandinginto hospital networks and accreditation
standards like these, every hospitalhas to reproduce this across the network.
I think if what we really want to dois think about how to raise
the standard of care everywhere,we need to start thinking creatively about
how do we then align, you know,the accreditation and the metrics,
(15:40):
the things we ask everybody to do.
How do we use theseas actually opportunities
to push healthcare, healthcare networksand systems to be thinking in this way?
Like what opportunities are thereto eliminate redundancy but expand access?
And, and NAPRCreally has not achieved that yet.
So, with the few minutesI have left, I mean, I love talking,
(16:02):
to to my, my colleagues back at Michiganbecause the beauty is,
I anticipate sitting you're not sittingstill with these results.
I mean, I can only imagine there'sprobably
5 or 6 projects that you've already thinkingabout in the future.
Could you give us a couple hintsor teases about some of the work
that is planned ahead, in the networksthat you have there in the Midwest?
(16:24):
Yeah.
So, you know,this is comes to my interest.
You know, I, I'm really interestedand thinking about how you change
care usingall of these existing structures we have.
I think network is one really importantopportunity,
I think hospital networksare another really important opportunity.
And I could imagine that there'ssome innovative,
(16:47):
unique way to align some of these leverswe have, like NAPRC
With some of these structureswe have, like hospital networks,
and think about things like,you know, to be honest, tumor boards,
I mean,
ours has not met in personsince Covid, right?
Even thoughwe're all in the same physical building,
we all sign on to Zoom at the same timefrom our offices.
(17:08):
But it makes you really think it's
like if you've got smallerhospitals in your network,
are there opportunities that we could helppatients get radiation easier?
Chemotherapy easier.
You know, like,there's six months of treatment
before most rectal cancer surgery,and a lot of these patients
aren't even getting surgery anymore,but they still need a surgeon involved.
So I think there’s really coolinnovative ways we can be thinking about
(17:30):
how to improve care broadly, usingall of these structures we have in place.
So in terms of studies,
you know, one of the next thingsthat I'd really like to do
is be able to take a look at whether youhave an NAPRC hospital in your network,
and if that changes care.
You know, I mean, we've acknowledged
several of the limitations of this study.
And the more, you expand that
(17:50):
to a sort of increasingly, sort of,
contrived isn't the right word,but like, we're trying to create
sort of like conceptual spaceand using claims data,
you know, the limitationsonly continue to build.
But but that'swhat I've really been trying to,
what our group has really been tryingto think about is then, how do we start to
evaluate quality across networks, andhow do we use some of these lever points
(18:13):
to try to expand access,equitable access, to high-quality care?
And I think Amen to all of that.
I mean, I mean,I think that I don't want to take away,
a, the huge amount of workthat you guys have already done.
I mean, this paper is indeedthe first time
that we've conclusively proven that
(18:34):
being an NAPRC accredited hospital
and having a patient and having care atthat led to better outcomes.
I mean, that the,
you know, that that that was one of thetake home points of this paper.
And I think that what you alludedto before, the beauty of NAPRC
accreditation was that was reallyabout the multidisciplinary
program management and quality improvementthrough data audit
(18:56):
and you went away from arbitrary volumes,which is easy to say.
You know, it should be 50 cases or over 100 cases.
But you went beyond that, with this study.
And so kudos to you and kudos tothe American College of Surgeons for that.
That mind, that mind-shifting paradigm.
Yeah.
No, I mean, it's really amazingwhat they've done.
I think, you know, just one lastpoint is looking is, the hard part and I
(19:19):
and I is the author, I hate to say this,but I don't think we proved that.
I think we showed an association. Right?
And, and it's really
hard to extractlike what is the actual accreditation
and what is the fact that these hospitalswere able to achieve accreditation
and maybe also attest to the factthat, you know, there are some small
and moderate-sized hospitals out therethat have really kind of figured it out,
(19:42):
like they are doing something differentthat allows them to meet
what these standards are.
So I'm not trying to detract
from the standards at all,
but also say like, there's probablya lot more to learn here about what
these best practices areand how to actually implement them.
Well, I'm
smiling a little bitbecause I think many of us were are huge
fans of Avedis Donabedian over the yearsat the University of Michigan.
(20:05):
And it goes back to that time-testedthing, structure, process, outcomes.
And I believe that,
probably one of the thingsthat you guys will unearth
is there's something about the structure,the processes,
that lead to the betteroutcomes. You're right.
I give it it's, not proven.
Showed an associationwith better outcomes.
(20:26):
But more work ahead.
Dr Harbaugh, any final thoughtsto our amazing listeners that,
listening to this podcast?
No, I mean,thank you so much for this opportunity
to share the work.
And I'm really excitedto see all the things that ACS and NAPRC
does going forward.
Well, on behalf of our amazing audience,
thank you, Dr Harbaugh,and thank you to your coauthors
(20:48):
at the University of Michiganfor doing this incredible work.
Thank you for your ongoing work.
I hope that all of us can learn from
the work that you're doing aheadand improving outcomes and networks
and really transformingAmerican healthcare in the years ahead.
Really, really appreciate your time today.
On The Operative Word,the podcast for JACS.
Thank you so much. Thank you.
(21:12):
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian Erdahl
and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, loyal listeners,
welcome to another episodeof The Operative Word,
the podcast of the Journalof the American College of Surgeons, where
we connect with amazing authorswho published recent articles in JACS.
I'm honored to be joined todayby Dr Calista Harbaugh,
(00:50):
who is a colorectal surgeonat the University of Michigan.
Dr Harbaugh, welcome to the show.
Thank you so much. I'm happy to be here.
The first question to ask
is, do you have any relevant disclosuresfor this article?
I do not for this article.
So, full disclosure to our audience members,
as many of you know, I did my CT surgeryfellowship at the University of Michigan.
(01:12):
So, if I have a partial,you know, favoritism towards Dr Harbaugh,
I don't apologize for that. Go blue.
So with that,we'll go ahead and get started.
Dr Harbaugh,thank you for joining us today,
because we're going to be discussing thisamazing article that was
published in the August issue of JACS,which is titled “Association
of National Accreditation Programfor Rectal Cancer Accreditation
(01:35):
with Outcomes after Rectal CancerSurgery.”
And this abstract was presented
at the American College of Surgeons109th Annual Clinical Congress
that took place in Bostonin October of 2023.
Dr Harbaugh, as a start,
why do we go and do thisproject in the first place?
Yeah,
rectal cancer treatment has really changeddramatically over the last few decades,
(01:59):
and it's gotten increasingly complexfor any patient with rectal cancer.
Depending on where the tumor is at,how locally advanced it
is, there are treatment optionsthat may span anything from chemotherapy,
chemoradiation, immunotherapy,and with or without surgery.
So, with all of that complexity,we also see a lot of variation in care.
And there are some basic standardsthat every patient
(02:21):
should have in the treatmentworkup and treatment planning.
With all of that
variation in treatment,we also see the variation in outcomes.
And so to address that,the American College of Surgeons
established NAPRC in 2017
with the goal of improving rectal cancer
(02:41):
treatment broadly at all hospitals.
The NAPRC standards
focus really on the multidisciplinary care
of patients, with careful attention
to data capture and auditing,making sure every patient is presented
and all of the multidisciplinaryproviders are involved.
(03:02):
It focuses less on what the actual treatments are.
You know, there's a lot of questionearly on, because all of this
multidisciplinary programmanagement can be very resource intensive.
And there were some early questionsabout whether the NAPRC
A) would be accessible for most hospitalsand most patients,
and B) whether it would have any impact on outcomes.
(03:24):
So there were some early preimplementation studies
that tried to predict what would happenafter the NAPRC was implemented,
but really no studies so farthat have looked at what happened
after hospitals startedachieving accreditation.
So that was really our goal with
this was to look at A) who achievedaccreditation and B) what happened.
Well, and so extending on that.
So right who meaning the characteristicsof the hospitals that are doing NAPRC.
(03:49):
That was really the goal, not theindividual surgeon practices per se.
Correct.
We focused at the hospitallevel. Okay.
And I thought it was very novelbecause you're right.
there was a lot of attention, potentiallyeven a little bit of controversy
when NAPRC was rolled outbecause you went in the direction
of the multidisciplinary teamin the processes, but unlike other
(04:14):
accreditation programs, volumewasn't a consideration in the first place.
Correct? Yeah.
You know, there's so much to debateand a lot of controversy around the idea
of centers of excellence, which, I knowthis isn't a center of excellence per se,
but you could draw a lot of corollariesbetween that concept and accreditation.
And we know that at centers of excellencefor some other conditions,
(04:37):
really, didn't, they, they didn'thave the same effect as they wanted.
And, some argue that perhaps using volumeas standard is the problem,
is that that now isn't necessarily a proxyfor all of the different aspects of care
that go on.
So that was the unique thing about NAPRC,is it drilled down so heavily
on all of these multidisciplinary aspects
(04:59):
that's different than a lot of otherprograms and standards.
And so let's now go deep diving into this article.
So, you, the methodology,
first, the the selection of the database,you know,
you use the MedPAR or Medicare provideranalysis and Review database.
is that because it was so comprehensivein terms of the information
(05:22):
you get acknowledgingit's a Medicare patient population,
is that the reason why that database waschosen?
Yeah, it's one of the few opportunities to look at
a more population-level group recognizingeverybody's over the age of 65.
But there's not as much biasin terms of who was included
in that, in terms of demographicsand other aspects.
(05:42):
And most hospitalshave a Medicare population.
And so it gives us sort ofa unique ability to have insight broadly.
There's some limitations to that too, that we can discuss.
But this was as a first stepwhere we decided to start.
Absolutely.
And then and obviously, as you correctlypointed out, the primary exposure
variable for all the analysis was NAPRCaccreditation.
(06:04):
Yes/No.Did they have accreditation or not?
But I thought the interesting thingis, you started,
the analysis, from 2017 to 2020.
and I think that you put in therethe comment that recognizing
you started like a yearbefore it officially came out, thinking
that a lot of these hospitals probablywere doing the work of getting accredited,
(06:28):
from that aspect.
And so that was a surrogate,
that was a reasonwhy the time period was chosen.
Exactly.
So NAPRC startedaccepting applications in 2017.
It's about a 12 month processto achieve accreditation.
So, in order to achieve accreditationin 2018, they had to be adhering to
that standards for the year before.
So another really important limitation iswe did reach out and try to get exact
(06:50):
dates of when hospitals got accredited,but we were not able to get that.
We could only accesspublicly available information,
which tells you at the time pointthat I opened the website,
these are the hospitalsthat were accredited.
And so that was another reasonto include back to 2017,
because that limitation really appliesthroughout the entire study period.
And again, these accreditationsare not things that change very quickly.
(07:13):
Like these are things that hospitals
have to adhereto for a long period of time.
And then the outcomes,you know, the outcomes
that you looked at were, you know, welldocumented, measures of surgical safety,
including in-hospitalmortality, 30-day mortality complications.
we say serious
complications re-operations, readmissions
(07:35):
and 1-year mortality.
that looks likea pretty comprehensive list.
any thoughts after after you didthe study,
was there something elsethat you would have loved to have done?
If you can do this analysis over again?
Yeah.
I mean, I think the thing we all want to know is
what's the effect on cancerand our survival and our, you know,
1-year survival is a very,
(07:57):
broad outcome, especially when you'relooking at a cohort of older patients.
There's a lot of reasons
that people can have 1-year mortalityoutside of their tumor, their cancer itself.
And that's \what we don't have in these databases is,
we don't have access to adherenceto standards like staging.
We don't have accessto whether their cancer recurred.
so these were kind of the bestyou can get in a client's database.
(08:20):
You know, we asked whether we should usesome other databases,
like, you know, there’s SEER Medicarethat might give some more insight to that.
again, this was a good place to startbecause it gave us a comprehensive view.
There are definitely limitationsto things like SEER Medicare
that don't necessarily capture broadly.
Everybody across the US.
So, so this was a good place to start,but definitely not the end.
(08:42):
Beautiful.
Well, let's go ahead and, keep going.
So, obviously, you compared hospital-and patient-level characteristics
and then you ultimately ended updoing multivariable logistic regression,
really trying to figure outwhat were the drivers
of the outcome resultsthat you're looking at.
And I was fascinated by this.
(09:03):
So, you identified 20,202 patients
in the Medicare patient populationthat is between 65 and 99 years of age,
who underwent proctectomyfor rectal cancer
at one of the 1,984 hospitalsthat were identified.
I guess your hypothesis going in was,
(09:25):
your thought was that NAPRC,the hospitals should have better outcomes
and were most likelyto be at academic centers.
When you looked at the findings, were itwere any of the findings surprising,
for you when you did the analysis? Yeah.
I think the most surprising thingfor the first objective.
So just understanding
what types of hospitals achievedaccreditation is that actually a large
(09:46):
proportion of them were small to moderatesize hospitals, like less than 500 beds,
we hypothesized, you know,they were mostly teaching hospitals.
Actually, I should actually correct that,they were all teaching hospitals.
But in terms of thebed size, I thought that was surprising.
I thought mostly that the large hospitals
would be the ones that would be ableto achieve accreditation.
(10:07):
But that being said, even thoughthere were many small hospitals
that achieved accreditation, it's still Imean, we have to look at the numbers.
And only about 3% of all hospitalsachieved accreditation and 10%
of all patients received treatmentat a total accredited center.
Right.
You...that's amazing.As you correctly point out.
Yeah. So 10%.
So about a little over2000 patients underwent
(10:30):
protectomy for a rectal cancerat an NAPRC-accredited hospital.
And then,
this probably wasn't too surprising.
The patients who were treated
at the accreditedhospital were less likely to be Hispanic.
But there were no significant differencesin age, demographics, or comorbidities
between NAPRC hospital patientsand non-NAPRC hospitals.
(10:52):
Maybe that's a little surprising, right?
You would have thought that maybe
then NAPRC hospitalsshould be treating more sicker patients.
But that that wasn't the finding.
Yeah.
It's hard to know what to make of that.
And I think we definitely would have todelve in a little bit more to understand.
I mean, again, like half of the hospitalswere smaller, moderate sized. So,
(11:13):
you know, I definitely think
we got to dig in a little bit deeperto understand the nuance of that.
Yeah.
And then some of the other findings,
I guess the other onesI wasn't too surprised about.
I mean, more likely...NAPRChospital patients were more likely
to receive a minimally invasive approach.
They were more likely to get surgerieswith sphincter preservation.
(11:35):
But, I guess this one,this is kind of the,
the one that, it's always been a concernabout when you're developing centers
of excellence, patientswho were treated at any NAPRC hospitals
were more likely to travelfurther distances to get their care.
But in the modern age,
when information is availableat our fingertips,
(11:55):
is that necessarilya bad thing that maybe patients
need to travel a little bit furtherto get high quality care?
No,
I mean, that's an interestingone to think about is with a lot of,
a lot of cancer, we think a lot aboutwhether we should be centralizing care.
And I think that measure gets into thatconcept is in some
to some extent, patientsmay be centralizing themselves.
(12:20):
You know, itruns a little bit against NAPRC's mission.
It's not so much to identify centers of excellence,
but try to raise thestandard of care everywhere.
and, and so I do think we have to,
to think about measures like thata little bit,
because when we're thinking aboutnot just high-quality care, but equitable,
high-quality care,we need to think about who can travel.
(12:41):
So it definitely is a measurethat is A) not surprising.
And B) maybe in some sensewe should be moving towards.
But C) is that maybe also we shouldn't.
And maybe there's opportunitiesto think about
what kind of care we can delivercloser to home at a high-quality level,
and how to make NAPRC really achievethat stated mission.
(13:02):
And so, I mean, obviously,the most important
outcome of the paperwas you successfully proved,
the primary outcome, that is, NAPRChospital patients had significantly lower
risk of,risk-adjusted rates of in-hospital
mortality,lower 30-day mortality and complications,
lower 1-year mortalityas compared to non-accredited hospitals.
(13:26):
And so, you know, coming back to that, 3main points that you had of the
with the paper,
better outcomes at the
NAPRC hospitals,but unfortunately, only 1 in 10 patients
in this Medicare patient populationreceived their care at an NAPRC hospital.
And and the outcomes are clear,
(13:46):
I guess, really the question comes, whatwhere is the hesitation in this?
I mean, is a little bit of speculationon that, you know, because to me,
in one sense,that seems to be a no-brainer, right?
It's like maybe we should getall the hospitals NAPRC accredited.
But I think you alluded to this.
It's very labor intensive to get to be and, you know,
(14:09):
if financially incentive, intensiveto get to be an NAPRC hospital
is that a correct assessmentof the situation?
That's completely correct.
I mean, it is very hard.
It takes a lot of, time and effort
to maintain these standardsto a very, very high level.
And, you know, on one hand, you arguewe should be doing these things
(14:32):
regardless.
But on the other hand is that thethe capturing the data to prove
we're doing it, that
what’s really time intensive and resourceand financially incentive intensive.
So it really kind of makesyou think like how do we expand it.
Is it something that we just need to expand,
you know,
(14:56):
like awareness across the board?
But I would argue, you know,I think that's the easy answer,
but probably the least effective.
And I think what we really need to doand this is, again, very much speculation,
but is to rethink the waythat we create these programs, is
they don't match what the landscapeof health care looks like today.
Healthcare today is not delivered by single,
(15:18):
standalone hospitalsalmost anywhere, right?
They're increasingly expandinginto hospital networks and accreditation
standards like these, every hospitalhas to reproduce this across the network.
I think if what we really want to dois think about how to raise
the standard of care everywhere,we need to start thinking creatively about
how do we then align, you know,the accreditation and the metrics,
(15:40):
the things we ask everybody to do.
How do we use theseas actually opportunities
to push healthcare, healthcare networksand systems to be thinking in this way?
Like what opportunities are thereto eliminate redundancy but expand access?
And, and NAPRCreally has not achieved that yet.
So, with the few minutesI have left, I mean, I love talking,
(16:02):
to to my, my colleagues back at Michiganbecause the beauty is,
I anticipate sitting you're not sittingstill with these results.
I mean, I can only imagine there'sprobably
5 or 6 projects that you've already thinkingabout in the future.
Could you give us a couple hintsor teases about some of the work
that is planned ahead, in the networksthat you have there in the Midwest?
(16:24):
Yeah.
So, you know,this is comes to my interest.
You know, I, I'm really interestedand thinking about how you change
care usingall of these existing structures we have.
I think network is one really importantopportunity,
I think hospital networksare another really important opportunity.
And I could imagine that there'ssome innovative,
(16:47):
unique way to align some of these leverswe have, like NAPRC
With some of these structureswe have, like hospital networks,
and think about things like,you know, to be honest, tumor boards,
I mean,
ours has not met in personsince Covid, right?
Even thoughwe're all in the same physical building,
we all sign on to Zoom at the same timefrom our offices.
(17:08):
But it makes you really think it's
like if you've got smallerhospitals in your network,
are there opportunities that we could helppatients get radiation easier?
Chemotherapy easier.
You know, like,there's six months of treatment
before most rectal cancer surgery,and a lot of these patients
aren't even getting surgery anymore,but they still need a surgeon involved.
So I think there’s really coolinnovative ways we can be thinking about
(17:30):
how to improve care broadly, usingall of these structures we have in place.
So in terms of studies,
you know, one of the next thingsthat I'd really like to do
is be able to take a look at whether youhave an NAPRC hospital in your network,
and if that changes care.
You know, I mean, we've acknowledged
several of the limitations of this study.
And the more, you expand that
(17:50):
to a sort of increasingly, sort of,
contrived isn't the right word,but like, we're trying to create
sort of like conceptual spaceand using claims data,
you know, the limitationsonly continue to build.
But but that'swhat I've really been trying to,
what our group has really been tryingto think about is then, how do we start to
evaluate quality across networks, andhow do we use some of these lever points
(18:13):
to try to expand access,equitable access, to high-quality care?
And I think Amen to all of that.
I mean, I mean,I think that I don't want to take away,
a, the huge amount of workthat you guys have already done.
I mean, this paper is indeedthe first time
that we've conclusively proven that
(18:34):
being an NAPRC accredited hospital
and having a patient and having care atthat led to better outcomes.
I mean, that the,
you know, that that that was one of thetake home points of this paper.
And I think that what you alludedto before, the beauty of NAPRC
accreditation was that was reallyabout the multidisciplinary
program management and quality improvementthrough data audit
(18:56):
and you went away from arbitrary volumes,which is easy to say.
You know, it should be 50 cases or over 100 cases.
But you went beyond that, with this study.
And so kudos to you and kudos tothe American College of Surgeons for that.
That mind, that mind-shifting paradigm.
Yeah.
No, I mean, it's really amazingwhat they've done.
I think, you know, just one lastpoint is looking is, the hard part and I
(19:19):
and I is the author, I hate to say this,but I don't think we proved that.
I think we showed an association. Right?
And, and it's really
hard to extractlike what is the actual accreditation
and what is the fact that these hospitalswere able to achieve accreditation
and maybe also attest to the factthat, you know, there are some small
and moderate-sized hospitals out therethat have really kind of figured it out,
(19:42):
like they are doing something differentthat allows them to meet
what these standards are.
So I'm not trying to detract
from the standards at all,
but also say like, there's probablya lot more to learn here about what
these best practices areand how to actually implement them.
Well, I'm
smiling a little bitbecause I think many of us were are huge
fans of Avedis Donabedian over the yearsat the University of Michigan.
(20:05):
And it goes back to that time-testedthing, structure, process, outcomes.
And I believe that,
probably one of the thingsthat you guys will unearth
is there's something about the structure,the processes,
that lead to the betteroutcomes. You're right.
I give it it's, not proven.
Showed an associationwith better outcomes.
(20:26):
But more work ahead.
Dr Harbaugh, any final thoughtsto our amazing listeners that,
listening to this podcast?
No, I mean,thank you so much for this opportunity
to share the work.
And I'm really excitedto see all the things that ACS and NAPRC
does going forward.
Well, on behalf of our amazing audience,
thank you, Dr Harbaugh,and thank you to your coauthors
(20:48):
at the University of Michiganfor doing this incredible work.
Thank you for your ongoing work.
I hope that all of us can learn from
the work that you're doing aheadand improving outcomes and networks
and really transformingAmerican healthcare in the years ahead.
Really, really appreciate your time today.
On The Operative Word,the podcast for JACS.
Thank you so much. Thank you.
(21:12):
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
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