SURGICAL PERSPECTIVE
Communicating Value: Use of a Novel Framework in the
Assessment of an Enhanced Recovery Initiative
Casey J. Allen, MD,  Nikhil G. Thaker, MD,y Laura Prakash, MD,  Brittany C. Kruse, DBH,z
Thomas W. Feeley, MD,§ Robert S. Kaplan, PhD,§ Ryan Huey, MD,zô Steven J. Frank, MD,zjj
Thomas A. Aloia, MD,  z Vijaya Gottumukkala, MD,z  and Matthew H. G. Katz, MD  Y
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Keywords: cost, goal-concordant care, harm, outcomes, price, quality, safety,
shared decision-making, value, value-based health care
(Ann Surg 2021;273:e7–e9)
T he 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
(Fig. 1A). Historically, it has been difficult to effectively visualize and
communicate all of the value framework’s outcomes and cost compo-
nents. 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
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
From the Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas; yDepartment of Radiation Oncol-
ogy, Arizona Oncology, Tucson, Arizona; zThe Institute for Cancer Care
Innovation, The University of Texas MD Anderson Cancer Center, Houston,
Texas; §Institute for Strategy and Competitiveness, Harvard Business School,
Boston, Massachusetts; ôDepartment of Medical Oncology, The University of
Texas MD Anderson Cancer Center, Houston, Texas; jjDepartment of Radia-
tion Oncology, The University of Texas MD Anderson Cancer Center, Hous-
ton, Texas; and Department of Anesthesia, The University of Texas MD
Anderson Cancer Center, Houston, Texas.
mhgkatz@mdanderson.org.
This project is a product of the work and thoughts of several leaders in value-based
healthcare transformation. It is not only the distillation of multiple theories but
could only have occurred with the input from these collaborators and data
analysts.
CJA is directly responsible for all aspects of this article. He participated in the
concept, collection, analysis and interpretation of data; drafting and revision of
the manuscript.
LP and BCK participated in the collection, analysis and interpretation of data;
drafting and revision of the manuscript.
NGT, TWF, RSK, and SJF participated as significant collaborators on concept,
design, analysis, interpretation, and revision of the manuscript. They were
critically important to the intellectual content.
RH, TA, and VG participated in the conception and design; analysis and interpre-
tation; review and revision of the manuscript. They were critically important to
the intellectual content.
MHGK had overall responsibility for the study; including conception and design;
analysis and interpretation; drafting and revision of the manuscript; obtaining
funding for this project; supervision.
The authors report no conflicts of interest.
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-00e7
DOI: 10.1097/SLA.0000000000004050
Annals of Surgery  Volume 273, Number 1, January 2021
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
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, emo-
tional, 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 path-
ways 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 imple-
mented 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
after implementation. The groups’ clinico-demographic profiles, includ-
ing 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 After pathway implementation, median
LOS decreased from 8 to 6 days (P < 0.001). The incidence of at least 1
postoperative AE (73%–63%, P ¼ 0.29) and the readmission rate
(14% vs 12%, P ¼ 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 ¼ 0.63).
QOL and Functional Recovery
QOL and functional recovery were assessed using the Func-
tion Assessment of Cancer Therapy-General, a 27-item questionnaire
that measures QOL in multiple domains. As this survey is not
routinely administered to patients, we obtained all available QOL
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 ¼ 0.98); scores were similar across all
subdomains including functional well-being (22  5 vs 22  4,
P ¼ 0.60).
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Allen et al Annals of Surgery  Volume 273, Number 1, January 2021

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.

e8 | www.annalsofsurgery.com ß 2020 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Surgery  Volume 273, Number 1, January 2021
Patient Experience
Patient experience was determined using the Hospital Con-
sumer Assessment of Healthcare Providers and Systems (HCAHPS),
a national, standardized, publicly reported survey of patients’ per-
spectives 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 imple-
mentation to those obtained within 5 months after implementation.
Because patient-level data are proprietary information, we report the
results as a percentage difference. HCAHPS scores increased by 24%
after 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 proprie-
tary information thus reported as a percentage difference. After
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 (ie, costs, complications, LOS) are plotted
inversely. The relative change in each metric is displayed against
an index value. Fig. 1B reflects the change in value that occurred after
implementation of the care pathways. This tool enables us to
visualize and communicate how the pathway implementation pro-
vides 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 1 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 under-
standable 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 2 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 compre-
hensive 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 assess-
ment 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,
ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Communicating Value
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 visuali-
zation 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, func-
tional 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 measure-
ment. 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 commu-
nicate value will facilitate shared decision-making among all stake-
holders involved in value-based health care.
REFERENCES
1. Porter ME, Lee TH. From volume to value in health care: the work begins.
JAMA. 2016;316:1047–1048.
2. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-
based Competition on Results. Boston, MA: Harvard Business School Press;
2006, 506.
3. Aloia TA. Should zero harm be our goal? Ann Surg. 2020;271:33–36.
4. Thaker NG, Ali TN, Porter ME, et al. Communicating value in health care using
radar charts: a case study of prostate cancer. J Oncol Pract. 2016;12:813–820.
5. Kaplan RS, Blackstone RP, Haas, DA, et al. Measuring and Communicating
Health Care Value with Charts. Harvard Business Review October 26, 2015.
Available at: https://hbr.org/2015/10/measuring-and-communicating-health-
care-value-with-charts. Accessed 5 December, 2020.
6. Katz MH, Wang H, Fleming JB, et al. Long-term survival after multidisci-
plinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol.
2009;16:836–847.
7. Denbo JW, Bruno M, Dewhurst W, et al. Risk-stratified clinical pathways
decrease the duration of hospitalization and costs of perioperative care after
pancreatectomy. Surgery. 2018;164:424–431.
8. Allen CJ, Yakoub D, Macedo FI, et al. Long-term quality of life and
gastrointestinal functional outcomes after pancreaticoduodenectomy. Ann
Surg. 2018;268:657–664.
9. O’Neill CB, Atoria CL, O’Reilly EM, et al. Costs and trends in pancreatic
cancer treatment. Cancer. 2012;118:5132–5139.
10. Schwarz L, Bruno M, Parker NH, et al. Active surveillance for adverse events
within 90 days: the standard for reporting surgical outcomes after pancrea-
tectomy. Ann Surg Oncol. 2015;22:3522–3529.
11. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assess-
ment-Instruments/HospitalQualityInits/HospitalHCAHPS. Accessed 5 December,
2020.
12. Schnipper LE, Davidson NE, Wollins DS, et al. Updating the American
Society of Clinical Oncology value framework: revisions and reflections in
response to comments received. J Clin Oncol. 2016;34:2925–2934.
13. Available at: https://www.nccn.org/evidenceblocks/. Accessed 3/2/20
14. Balch, A, and Lakdawalla, DN. The Case for Patient-centered Assessment of
Value. Available at https://www.healthaffairs.org/do/10.1377/hblog20170508.
059962/full/. Accessed 5 December, 2020.
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