Colorectal cancer (CRC) affects nearly 153,000 adults in the US annually and is the second leading cause of cancer deaths in the country (Figure).¹,² This year, an estimated 53,000 patients will die due to CRC. The disease not only poses significant challenges for patients but also imposes a substantial financial burden on the US health care system, with the cost of CRC care reaching $24.3 billion in 2020, the second highest for any cancer type. 

Consequently, preventing CRC through properly administered colonoscopies and treating the disease effectively are critical, especially as the US population ages and more cases emerge. Practices must ensure they deliver high-quality screening and superior care from specialized physicians using advanced surgical technologies and care protocols for the best outcomes. However, without measuring outcomes and benchmarking against national standards, the belief that they are providing high standards of care remains speculative.

Collecting and analyzing patient data to drive improvement is a monumental task many practices do not tackle, as these processes require substantial effort and financial investment. However, those of us at Texas Colon & Rectal Specialists (TCRS), a division of Texas Oncology and part of The US Oncology Network, set out to do just that, and the results have been remarkable. 

Our Colorectal Surgery Quality Initiative is driving better patient outcomes, enhancing experiences, and reducing health care costs. A closer look at the program and how it was developed may provide insights for other CRC and specialty practices seeking to leverage their data to improve care.

Our interest in harnessing data began in the early 1990s when 6 physicians formed TCRS. We all emerged from training programs that focused on high-quality surgery. Findings from studies showed the quality of the surgery and the experience of the surgeon made a significant difference in the outcomes of patients with CRC. We knew patient care would be much better if more patients were treated by physicians specializing in CRC.

Although we believed our team provided high-quality care, we recognized that it was not enough to ask referring physicians to send their patients to us simply because we believed we provided good care. We needed data not only to project outwardly and demonstrate our quality but also to look inwardly to improve ourselves. This realization started us down a decades-long pathway to data collection that now plays a vital role in the care we provide every day.

Our group existed for many years before we formally engaged in data collection and analysis. Two factors finally motivated us to take action. First, the information that insurance companies and hospitals were presenting to us concerning our patients, such as length of stay and complication rates, was not accurate. Their adverse numbers simply did not reflect what we were experiencing. We wanted the introspection and knowledge of our patients so we would know more about our outcomes than any other entity. 

Second, we needed information to drive self-improvement. We wanted to do better. We started small, initially only examining a few factors, such as length of stay, adenoma detection rates (ADRs), and complications. Our team compiled monthly reports and drove improvement by sharing the information internally. This proved to be effective, and even today, a lot of our self-improvement comes from looking critically at how we compare with one another and how the high achievers are obtaining their results.

Approximately 9 years ago, we launched the formal, data-driven Colorectal Surgery Quality Initiative. The necessary data collection platform was developed, but we quickly outgrew it. A very effective second-generation system was implemented in 2017 that we still use today.

As we began our quest to collect data, we started by defining the components of care we wanted to track, as there are many factors to consider beyond survival. We tried to identify the various aspects of care delivery that are important and measurable and reflect the quality of care we want to deliver.

For instance, patients with CRC often start their cancer journey with a colonoscopy, and there are various factors we identified that help ensure the patient receives a high-quality examination.3 Were the preparations good? Did the physician spend appropriate time systematically examining the colon for polyps (withdrawal time)? Was the examination completed? Additionally, we identified the ADR of the physician as an important factor, as those with lower ADRs are more likely to miss spotting cancer. 

We also examined the kind of treatment that patients obtain from a surgical standpoint. Did they receive laparoscopic, open, or robotic approaches? What was the length of the hospital stay? Did they get back to productivity with minimal complications? Many other elements of postoperative clinical care were also collected.

As we began examining our data, it was apparent that if we wanted a more comprehensive, accurate picture of the patient’s condition, we needed to look at the whole encounter. This required us not only to rely on clinical data from the surgeons but also on input directly from patients regarding their ability to conduct their activities of daily living. We inquired about patient pain levels, mobility, self-care capabilities, and overall health. 

These quality markers offer a much more comprehensive and accurate assessment of the totality of care we provide. We eventually established our own performance standards, always keeping a keen eye on national benchmarks. If we do not meet a benchmark or beat it, we have improvements to make.

Collecting data without using them serves no purpose. It is important to act on them. There are several instances where our data drove significant improvements in our care. For example, surgeons within the group were using a variety of techniques. Many started their career doing open surgery and then transitioned to minimally invasive hand-assisted laparoscopic surgery combining laparoscopic and open techniques. Others were using robotic laparoscopic surgery, another minimally invasive procedure that uses a robot, enabling more precision than traditional laparoscopic surgery.

When we looked at our data for length of stay, comparing open with laparoscopic and then ultimately with robotic laparoscopic, one partner using robotics stood out above the rest. His patients were discharged a day earlier than those treated with other surgical techniques. It was eye-opening to see such a huge difference, and it motivated the slower adapters of robotics to better themselves by learning this new technique. We are all competitive by nature, and no one wants to fall behind their colleagues. Our own data motivated us to improve.

Approximately 75% of our elective surgeries are minimally invasive and primarily robotic compared with the US average of approximately 35%. Our data show we are averaging approximately 4 days for length of stay vs the national benchmark of approximately 8 days. Our patients also report less pain and a quicker recovery. Getting home sooner gives them a better recovery and saves health care dollars.

By looking at our ADR, a colonoscopy quality marker, our data revealed the longer the withdrawal time, the higher the ADR. Higher ADR, we believe, will prevent more cancer. We share these data with other Texas Oncology CRC surgeons, and now our group in San Antonio is testing a 9-minute withdrawal time minimum to see how that affects their ADR. Currently, no benchmark exists for CRC surgery that we have not surpassed. When we believe that margin—the difference between our performance and the benchmark—should be larger than what we are currently achieving, we analyze the data to identify factors that might be negatively affecting outcomes. 

For example, our readmission rate was already underneath the benchmark but still not where we wanted it, so we took a closer look at the data for our patients who were being readmitted. We quickly discovered the care the patient receives from diagnosis to discharge and beyond plays a critical role in readmission, not just what happens in the surgical suite.

For instance, our data showed us that some patients with ostomy have problems with fluid and electrolyte balances and need some postdischarge care. We reduced our readmission rate for this group of patients by developing a new protocol that includes a home health visit. By using our data, we were able to do something simple and inexpensive that had an impact on patients and saved significant health care funds by avoiding readmission. We have also enabled individuals to discuss postcare and realize the importance of it for these patients.

Due to the quality initiative being entirely selffunded, early champions of the program had to overcome initial resistance within the group. We came together, decided the information we wanted required investment of time and money, and set up a system for collection and analysis of our data. Setting up the system requires a substantial financial outlay, and there are ongoing costs for maintenance and data collection.

The elements we track come from various sources, including operative reports, discharge summaries, and laboratory charts. Data entry time averages approximately 2 colon resection surgeries per hour and 10 to 12 colonoscopies per hour. In addition to an administrator, an average of 2.5 full-time equivalent employees abstract data on approximately 3500 surgeries and 12,000 colonoscopies per year.

Although significant expenses are incurred, it is important not to view the program simply as a cost center. Although it is not a revenue-generating initiative, it is an investment in quality care and self-improvement. Contracting opportunities with payers and accountable care organizations are also enhanced, as the practice has data to prove it delivers high-value care. Additionally, the data drive improvements within our practice, resulting in millions of dollars of utilization savings for the health care system from fewer adverse effects, reduced hospital stays, and less frequent emergency department visits. Although these cost savings do not go to the practice, it is rewarding to know they affect the health care system in a positive way.

The success of the initiative also encourages other physicians and health care organizations to consider developing similar-quality programs. Breast surgeons and gynecologic oncologists within Texas Oncology are looking into how our program could work for their areas, and the American College of Surgeons and the American Society of Colon and Rectal Surgeons have expressed interest in learning more about our initiative.

Additionally, practices across The US Oncology Network have been in touch to learn more about what it takes to develop a program. We work with The US Oncology Network in selected geographies, using our program to look at the performance of individuals and groups who want to join the organization. By collecting samples of their data, we apply the same metrics to determine whether their performance meets The US Oncology Network standards.

The decades-long endeavor to develop our datadriven quality initiative has not been without its challenges. It takes commitment, hard work, and a substantial financial investment to substantiate claims of improvement. But those of us who have been on this path for a while can see the many benefits this program delivers: improved outcomes, a better patient experience, and significant savings to the health care system.

At the core of our program is the strong belief that data are necessary for improvement. Anything that can be measured can be improved, so it is critical for physicians to know their outcomes and why their performance is what it is.
We continue to cultivate our data and to use the information gleaned from it to improve our practice. 

Lifelong learning means little if not coupled with lifelong improvement, and that is our shared goal. We intend to continue to share our knowledge and our experiences with the medical community beyond our own group. Frankly, we never imagined our program would grow from examining a few data points to the inclusion of robust data from more than 40,000 colonoscopies and 22,000 surgeries.

What began as a humble introspection has evolved into what we believe is the largest data set from any single colorectal surgery practice. We plan to use this information to continuously improve our practice and to improve the outcomes of the patients entrusted to our care.

Colorectal cancer is a major public health problem. National Colorectal Cancer Roundtable. Accessed October 17, 2024. bit.ly/3ZmWAv1

Health and economic benefits of colorectal cancer interventions. CDC. October 16, 2024. Accessed October 17, 2024. bit.ly/4g1OTS6

Questions and answers about quality in colonoscopy. American College of Gastroenterology. Accessed October 20, 2024. bit.ly/49mF3rj.

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