Are Therapeutic Advancements Impacting the Demand for Surgery?

November 07, 2023 - According to the 2023 Trilliant Health report on trends shaping the health economy, the overall demand for surgical procedures has declined from 2017 to 2021.

Despite declining rates of surgical interventions, the national disease burden has not diminished. In fact, many chronic conditions have increased in prevalence. For example, between 2012 and 2021, obesity prevalence increased from 27.7% to 31.9%, with severe obesity rising from 6.4% to 9.2%.

Additionally, the rates of chronic disease in the United States have continuously increased. In 1995, approximately 118 million Americans had a chronic condition, which increased by nearly 40%, reaching 157 million in 2020. Beyond that, projections for 2030 anticipate that chronic disease will impact 171 million people in the United States.

Although the changes in surgical demand may be attributed to multiple factors, the report theorizes that innovations driving pharmacological or less invasive alternatives to surgical procedures could be responsible for the overall decline in surgical demand.

Changes in Surgical Demand

Although outpatient surgery rates have remained relatively stagnant, inpatient surgery demand declined by nearly 15%.

Based on the analysis from Trilliant Health, the demand for major surgical services is expected to decrease by 0.1% CAGR from 2023 to 2027. Despite this decline, a closer look at heart or vascular surgical demands and the digestive surgical market anticipates a 0.2% CAGR increase in demand in each category. Similarly, orthopedic surgical demand is growing at a rate of 0.1% CAGR.

Comparatively, OB/GYN, oncology, and neurological or spine surgical demand is expected to remain unchanged.

Therapeutic and Noninvasive Surgical Alternatives

In an interview with Penn Medicine, Robert Vonderheide, MD, PhD, director of the Abramson Cancer Center, hypothesized that the proliferation of new cancer therapeutics had contributed to the improved trends in cancer mortality.

Penn Medicine estimates that the cancer mortality rate in the US has dropped 33% since 1991, amounting to approximately 4 million diverted deaths.

“Much of that has to do with new therapies, which were all unknown drugs in a phase one clinical trial at some point. Every single drug you see advertised on TV — once upon a time, some patient somewhere was the first patient ever treated with it. This is why we do what we do,” said Vonderheide.

The Trilliant report highlights three significant examples of therapeutics or noninvasive alternatives to surgical procedures, including bariatric surgery, cardiac catheterization, and screening colonoscopy.

Bariatric Surgery

Across the US, approximately 250,000 bariatric surgical procedures are conducted yearly, amounting to a minimum annual provider revenue of $2.67 billion based on the average in-patient Medicare rate of $10,667.

However, recent advancements in obesity drugs could potentially replace the surgical standard of care for some patients. For example, patients taking GLP-1 agonists, such as Wegovy, for weight loss could significantly reduce surgical procedures.

Although it is unclear how that will affect overall healthcare spending, it will likely cut into provider revenues. The Trilliant Health report estimates that if GLP-1 agonists replace just 5% of bariatric surgery cases, it could lead to an annual revenue loss of $133.33 million. A 20% replacement scenario correlates with a $533.35 million reduction in provider revenues.

These medications have the potential to reduce the rates of bariatric surgery significantly; however, the adverse side effects associated with these medications may deter some patients. According to the Cleveland Clinic, GLP-1 agonists may cause a loss of appetite, nausea, vomiting, diarrhea, dizziness, tachycardia, headaches, indigestion, pancreatitis, medullary thyroid cancer, and acute kidney injury.

Comparatively, the University of Pittsburg notes that bariatric surgery may cause acid reflux, chronic nausea, vomiting, infection, bowel obstruction, low blood sugar, malnutrition, ulcers, and hernias. While the risks associated with bariatric surgery may deter some patients or providers, others may be more wary of the unknowns surrounding new weight loss medications.

Cardiac Catheterization

Another example is PCSK9/SGLT2 inhibitors, which may replace or minimize the rate of cardiac catheterization surgeries. Trilliant Health estimates that there are roughly one million cardiac catheterization surgeries annually in the US.

The minimum annual provider revenue is estimated at $40.74 billion based on an average inpatient Medicare rate of $40,737. If PCSK9/SGLT2 inhibitors replace 5% of cardiac catheterizations, the potential provider revenue loss is roughly $2.04 billion. A 20% replacement rate may correlate with $8.15 billion in provider revenue loss.

According to Harvard Health, PCSK9 inhibitors may cause flu-like symptoms, fatigue, back pain, muscle aches, and more. Additionally, an article in Frontiers in Cardiovascular Medicine notes that SGLT2 inhibitors may cause hypoglycemia, hypotension, fractures, urinary tract infections, and diabetic ketoacidosis.

Meanwhile, Stanford Healthcare notes that cardiac catheterization may cause bruising or bleeding at the catheter site, nausea, itching, blood clots, blood vessel damage, arrhythmia, chest pain, and stroke. 

Although pharmacological alternatives may have their own risks, providers should weigh medications against surgical interventions.

Screening Colonoscopy

Beyond replacing treatments, new diagnostic tools can be substituted for exploratory surgery. For example, screening colonoscopies with an average inpatient Medicare rate of $11,722 could be replaced by alternate screening tests, such as fecal occult blood tests, flexible sigmoidoscopy, or fecal DNA testing.

With an average of 15 million colonoscopies annually, the estimated minimum annual provider revenue is $175.83 billion. However, replacing 5–20% of screening colonoscopies may result in a $8.79–35.17 billion provider revenue loss.

With multiple available alternatives to colonoscopy for colorectal cancer screenings, providers and patients may opt for a less invasive option for patients who have low or average risk. However, most providers will recommend a colonoscopy for high-risk patients or a follow-up colonoscopy for patients with abnormal screenings.

Benefits of Surgical Alternatives

Pharmacological and therapeutic alternatives to surgical interventions have significantly impacted healthcare and treatment protocols. In addition to providing noninvasive or minimally invasive treatment options, therapeutic alternatives to surgical procedures can improve patient outcomes, expand treatment options, be more cost-effective, and improve accessibility and convenience.

• Less invasive treatment options: Noninvasive or minimally invasive treatment alternatives may allow patients and providers to minimize the risks, complications, and long recovery times of surgery.
• Expanded treatment options: Innovative developments in pharmacological alternatives to surgery may broaden the arsenal of treatment options that providers can choose from. These alternatives may benefit patients with surgical contraindications.
• Improved patient outcomes: Pharmacological interventions have improved patient outcomes by effectively managing and treating medical conditions.
• Cost-effectiveness: Pharmacological alternatives can often be more cost-effective than surgical interventions, which come with additional expenses such as operating room costs, anesthesia, hospital stays, and post-operative care.
• Accessibility and convenience: Unlike surgical procedures, pharmacological interventions may be more accessible and convenient for patients.

Risks of Surgical Alternatives

While pharmacological or therapeutic alternatives may offer benefits, there are also associated risks for some patients. Providers and healthcare professionals may consider the following risks of replacing surgery with medications:

• Limited efficacy: Pharmacological alternatives may not be as effective as surgical procedures. Additionally, pharmacogenomic differences in patient populations may impact how effective a drug is. Some patients may not achieve therapeutic relief with medications, while others may have incomplete improvement.
• Side effects: Although surgical procedures may come with their own risks, medication alternatives can have severe side effects that may impact patients differently depending on their medical history and genetic makeup.
• Long-term medication use: While surgical interventions may permanently address chronic conditions or offer relief for an extended period, most medications for these diseases require long-term or lifetime use.
• Treatment delay: Besides concerns about efficacy or long-term use, pharmacological tools may take a prolonged time to make a therapeutic difference, while surgical interventions can provide immediate or faster relief.
• Masking underlying conditions: Another risk of therapeutic alternatives is the chance that they may address the symptoms rather than the underlying conditions.

Overall, although therapeutic advancements may impact the rates of surgical interventions, some providers may continue to recommend surgery in place of medication due to the potential risk. While advances in medical technology and pharmacological alternatives have expanded treatment options, surgical procedures continue to play a vital role in healthcare and will likely remain essential. However, having a wide range of therapeutic options may improve overall treatment rates.