Real-World Variation in Rectal Cancer Care: Benchmarking Quality Indicators Across 22 Hospitals

Rectal cancer surgery is a delicate and intricate procedure, often requiring a team of specialists to navigate a complex journey from diagnosis to recovery. The goal is always the same: to remove the cancer completely while preserving as much normal function as possible. Over the last few decades, doctors have developed detailed roadmaps, known as guidelines, to ensure every patient receives the best possible care. These roadmaps suggest specific steps, such as using certain imaging scans to plan the operation, avoiding unnecessary tubes or drains after surgery, and checking for specific side effects that can affect a patient's quality of life later on. In an ideal world, every hospital would follow these roadmaps exactly, ensuring that a patient's outcome depends on the disease itself rather than the hospital where they are treated. However, in many places, including parts of Europe, these guidelines are not enforced by a central authority. Instead, individual hospitals and surgeons decide how to apply them, leading to a patchwork of practices where the quality of care can vary significantly from one building to the next.

A team of researchers set out to map this landscape across twenty-two hospitals in Flanders, Belgium. They wanted to see how closely real-world medical care matched the established guidelines for treating rectal cancer. The researchers looked back at the records of 430 adults who had undergone elective surgery to remove rectal cancer between 2020 and 2024. This group included patients from three university hospitals and nineteen non-university hospitals, providing a broad view of the region's medical landscape. The team focused on specific, measurable actions that doctors should take, such as performing a colonoscopy before surgery, using oral antibiotics to prepare the bowel, or removing urinary catheters within two days of the operation. They calculated how often these recommended actions were actually performed and compared the results across the different hospitals.

The study revealed a story of two very different worlds within the same healthcare system. When it came to the initial diagnosis, the hospitals were remarkably consistent. Almost every patient received the recommended imaging scans, including a colonoscopy, a CT scan of the chest and abdomen, and an MRI of the pelvis. This high level of agreement suggests that the steps to identify and stage the cancer are well-understood and widely accepted. However, once the surgery began and the recovery phase started, the consistency vanished. The researchers found that adherence to recommended practices varied wildly from one hospital to another. For some critical steps, the difference between the best-performing hospital and the worst was stark.

The most striking gaps appeared in areas that are strongly recommended to improve recovery. For instance, the use of oral antibiotics before surgery, which helps reduce infection risks, was performed in only 13 percent of patients overall. In some hospitals, no patients received this treatment, while in others, nearly everyone did. Similarly, the practice of avoiding the placement of a pelvic drain—a tube used to collect fluid after surgery—was followed in only 13 percent of cases. The removal of urinary catheters within the first two days, a step known to help patients recover faster and move around sooner, happened in fewer than half of the patients. Even the assessment of a specific condition called low anterior resection syndrome, which involves checking for bowel control issues after surgery, was documented in only about a quarter of patients. These variations were not just small differences; they represented a fundamental disconnect between what the guidelines say should happen and what actually occurred in the operating rooms and recovery wards.

Despite these inconsistencies in how care was delivered, the short-term outcomes for the patients were generally within the range expected for this type of complex surgery. About 47 percent of patients experienced at least one complication during their hospital stay, such as a prolonged ileus, where the bowel temporarily stops working, or issues related to a stoma. The rate of serious complications, such as leaks at the surgical connection site or the need for a second surgery within 90 days, was significant but comparable to other large studies. The mortality rate, or the number of patients who died within 90 days, was 2.8 percent. These numbers suggest that while the hospitals are managing to treat the cancer, the lack of standardized care is likely leaving patients with unnecessary risks and a harder recovery than they need to endure.

The researchers concluded that the variation they observed was not due to the patients being different or the hospitals being unable to handle the cases. Instead, the differences pointed to how the hospitals were organized and how they implemented their daily routines. In a system where hospitals are free to choose their own methods, some have adopted the most effective practices while others have not. The study highlights that even in a wealthy, well-resourced healthcare system with clear guidelines, there is a significant gap between knowledge and action. The findings suggest that by focusing on these specific, high-impact areas—such as the use of oral antibiotics, the avoidance of unnecessary drains, and the timely removal of catheters—hospitals could significantly improve the quality of care without needing new technology or major structural changes. The path forward involves using these measurements to help hospitals learn from one another, ensuring that every patient receives the same high standard of care regardless of where they are treated.