Ben E. Byrne

Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery.

Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery.

The incidence and outcome of brain metastases after liver resection for colorectal cancer metastases

Aim  Brain metastases from colorectal cancer are rare, with an incidence of 0.6–4%. The risk and outcome of brain metastases after hepatic and pulmonary metastasectomy have not been previously described. This study aimed to determine the incidence, predictive factors, treatment and survival of patients developing colorectal brain metastases, who had previously undergone resection of hepatic metastases.

Outlier identification in colorectal surgery should separate elective and nonelective service components.

BACKGROUND: The identification of health care institutions with outlying outcomes is of great importance for reporting health care results and for quality improvement. Historically, elective surgical outcomes have received greater attention than nonelective results, although some studies have examined both. Differences in outlier identification between these patient groups have not been adequately explored. OBJECTIVE: The aim of this study was to compare the identification of institutional outliers for mortality after elective and nonelective colorectal resection in England. DESIGN: This was a cohort study using routine administrative data. Ninety-day mortality was determined by using statutory records of death. Adjusted Trust-level mortality rates were calculated by using multiple logistic regression. High and low mortality outliers were identified and compared across funnel plots for elective and nonelective surgery. SETTINGS: All English National Health Service Trusts providing colorectal surgery to an unrestricted patient population were studied. PATIENTS: Adults admitted for colorectal surgery between April 2006 and March 2012 were included. INTERVENTION(S): Segmental colonic or rectal resection was performed. MAIN OUTCOME MEASURES: The primary outcome measured was 90-day mortality. RESULTS: Included were 195,118 patients, treated at 147 Trusts. Ninety-day mortality rates after elective and nonelective surgery were 4% and 18%. No unit with high outlying mortality for elective surgery was a high outlier for nonelective mortality and vice versa. Trust level, observed-to-expected mortality for elective and nonelective surgery, was moderately correlated (Spearman &rgr; = 0.50, p< 0.001). LIMITATIONS: This study relied on administrative data and may be limited by potential flaws in the quality of coding of clinical information. CONCLUSIONS: Status as an institutional mortality outlier after elective and nonelective colorectal surgery was not closely related. Therefore, mortality rates should be reported for both patient cohorts separately. This would provide a broad picture of the state of colorectal services and help direct research and quality improvement activities.

Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012

AimLaparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown.MethodsAdults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002–2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined.ResultsLaparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20–0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12–0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002–2003 to 2011–2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9–15.2%).ConclusionsThere was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.

Do patients with gastrointestinal cancer want to decide where they have tests and surgery? A questionnaire study of provider choice

Backgrounds Choice of provider has been an important strategy among policy makers, intended, in part, to drive improvements in quality and efficiency of healthcare. This study examined the information requirements, and decision-making experiences and preferences of patients who have had surgery for gastrointestinal cancer, to assess the status of provider choice in current practice. Methods The single-item Control Preferences Scale was used to determine patients’ experiences and preferences when being referred for tests, and choosing where to have surgery. Participants used a Likert scale to rate the importance of 23 information items covering a variety of structures, processes and outcomes at the hospital level and the department level. Participants were recruited by post and online. Results 463 responses were analysed. Patients reported very low levels of involvement in provider choice, with their doctor deciding where they underwent tests or surgery in 77.0% and 81.8% of cases, respectively. Over two-thirds of participants would have preferred greater involvement in provider choice than they experienced. Of note, patient age and education were not associated with reported preferences. Information on how long patients with cancer wait for treatment, annual operative volume and postoperative mortality rate, as well as retained foreign bodies and infection rates were considered very important. Conclusions There was a substantial unmet desire for greater involvement in provider choice among study participants. Respondents attached particular importance to surgery-specific information. Efforts should be made to increase involvement of patients with gastrointestinal cancer in provider decisions, across primary and secondary care, to deliver more patient-centred care. The reported lack of patient involvement in provider choice suggests it is unlikely to be working as an effective lever to drive quality improvement at present.

Understanding how colorectal units achieve short length of stay: an interview survey among representative hospitals in England

BackgroundWide variation in the outcomes of colorectal surgery persists, despite a well-established evidence-base to inform clinical practice. This variation may be attributed to differences in quality of care, but we do not know what this means in practical terms of care delivery. This telephone interview study aimed to identify distinguishing characteristics in the organisation of care among colorectal units with the best length of stay results in England.MethodsTen English National Health Service hospitals were identified with the shortest length of stay after elective colonic surgery between January 2011 and December 2012. Semi-structured telephone interviews were conducted with a senior colorectal surgeon and ward nurse, who were not informed of their performance, at each site. Audio recordings were professionally transcribed and thematically analysed for similarities and differences in practice between units.ResultsAll ten short length of stay units approached agreed to participate, and 19 of 20 interviews were recorded. These units standardised clinical care based upon an Enhanced Recovery Program. Beyond this, they organised the clinical team to efficiently and reliably deliver this package of care, with the majority of day-to-day care delivered by consultants and nurses. Patients were closely monitored for postoperative deterioration, using a combination of early warning scores, nurses’ clinical judgement and regular senior medical review. Of note, operative volume and laparoscopy rates in these units were not statistically significantly different from the national average (p = 0.509 and p = 0.131, respectively). The postoperative analgesic strategy varied widely between units, from routine epidural use to local anaesthetic infiltration or patient-controlled analgesia.ConclusionsThe Enhanced Recovery Program may be seen as necessary but not sufficient to achieve the best length of stay results. In the study units, consultants and nurses led and delivered the majority of patient care on the ward. High quality teamwork helped detect and resolve clinical issues promptly, with nurses empowered to contact consultants directly if needed. Other units may learn from these teams by adopting protocol-based, consultant- or nurse-delivered care, and by improving coordination and communication between consultants and ward nurses.

FALLING EMERGENCY OPERATION RATES AND REDUCED MORTALITY AFTER COLON CANCER SURGERY IN ENGLAND: A COHORT STUDY

Introduction Recent years have seen many changes within colorectal surgery. Laparoscopic techniques, fast track management, and bowel cancer screening have become widespread. This study examined changes in surgical treatment and outcomes for colon cancer over time against background registration rates, with subgroup analysis by urgency and age. Method Annual data on colon cancer registrations and population size was obtained. Administrative data were used to identify adults undergoing colonic resection for cancer in England between April 1998 and March 2012. Cancer registrations, treatment and mortality rates were age-standardised. The proportion of registrations undergoing surgery was examined, and subgroups were analysed by urgency of admission and age group. Temporal trends were assessed using the Joinpoint Regression Program (National Cancer Institute, USA). Results The standardised rate of colon cancer registration rose from 27.1 to 29.1 per 100 000 population. The proportion of registrations undergoing surgery fell, from approximately 67% to 57% (Annual Percentage Change = −1.44, p < 0.05), due to a significant fall in non-elective operating; the elective treatment rate did not change. Postoperative 90-day mortality rates fell across all age groups for elective and non-elective surgery, from approximately 6.5% to 3% and 19% to 13%, respectively. Conclusion Colon cancer registrations increased over time. The surgical treatment rate per colon cancer fell, due to falling rates of non-elective surgery. Possible explanations include improved early detection of colon cancer, changes in case selection, and improvements in non-surgical treatments. Postoperative mortality fell significantly after elective and non-elective surgery for all age groups. Considered together, these findings suggest a global improvement in the quality of surgical care for colon cancer. Future studies should include non-surgical treatments with information on stage of cancer at presentation. Disclosure of interest None Declared.

LACK OF ENGAGEMENT IN SURGICAL QUALITY IMPROVEMENT RESEARCH IS ASSOCIATED WITH POORER QUALITY OF CARE

Introduction Existing research suggests consultants who engage in national specialty-specific audits have better outcomes than those who do not. This study used public data to assess for differences between units that did or did not participate in a recent interview study. Method Risk-adjusted length of stay after elective colonic surgery was determined for all English National Health Service hospitals between January 2011 and December 2012. Units with high or low outlying length of stay were selected for interview. Public data was collected for selected units, covering a range of structures, processes and outcomes, including: number of medical staff per bed; rate of incident reporting per 100 hospital admissions; healthcare acquired infection rates; and patient and staff surveys. Participant and non-participant groups were compared using the independent samples Mann-Whitney U test. Results Fewer long length of stay units participated in interviews (10/10 units with short versus 5/12 units with long length of stay, p = 0.005). Of 56 items compared between participants and non-participants, 9 were significantly different at p < 0.10. In each case, the difference suggested superior performance among participating hospitals, which had: lower rates of Clostridium difficile infections; lower rates of cancellation of elective operations; fewer staff reporting work-related stress; and higher patient survey ratings of doctors and nurses. Conclusion Failure to engage in quality improvement research may be a marker of poor performance. Future research should explore this lack of engagement, and identify strategies for overcoming barriers to participation. Organisations with poor performance may stand to benefit the most from quality improvement research. Disclosure of interest None Declared.

DO GASTROINTESTINAL CANCER PATIENTS WANT TO DECIDE WHERE THEY HAVE TESTS AND SURGERY? A QUESTIONNAIRE STUDY OF PROVIDER CHOICE AND INFORMATION NEEDS

Introduction Choice of provider has been an important strategy among policy makers over recent years, intended, in part, to drive improvements in quality and efficiency of health care. Provider choice has been relatively under-studied among patients with cancer, compared with benign disease. This study examines decision-making experiences, preferences and information needs among patients who have had surgery for gastrointestinal cancer. Method This questionnaire study used the single-item Control Preferences Scale to determine patients’ experiences and preferences when being referred for tests, and choosing where to have surgery. Participants used a Likert scale to rate the importance of 23 information items covering a variety of structures, process and outcomes at hospital- and department-level. Participants were recruited by post and online. Results 463 responses were included. Where indicated, 334 of 415 (80.5%) respondents had upper gastrointestinal cancer. Postal response rates were higher than online (47.2% vs 23.1%,p < 0.001). Patients reported very low levels of involvement in provider choice, with their doctor deciding where they underwent tests or surgery in 77.0% and 81.8% of cases, respectively. Over two-thirds of participants would have preferred greater involvement in provider choice. Information on how long cancer patients wait for treatment, annual operative volume and postoperative mortality rate, as well as retained foreign bodies and infection rates were considered very important. Conclusion There is a substantial unmet desire for greater involvement in provider choice among gastrointestinal cancer patients. Participants in this study attached particular importance to surgery-specific information. Improving involvement and information provision will require a coordinated approach in both primary and secondary care. Greater involvement in decision-making may increase satisfaction and contribute to a greater sense of control among these patients. Disclosure of interest None Declared.

Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery (Br J Surg 2013; 100: 1655-1663).

Sir This paper by Jorgensen and colleagues highlights the utility of existing data sets in exploring quality indicators in surgery. However, the conclusion that abdominoperineal resection (APR) rates do not represent a useful quality indicator for rectal cancer surgery requires closer scrutiny. APR rate was assessed as a quality indicator using correlation with outcomes for 34 hospitals and process measures for 18 units. Sample size will have limited the study’s power to detect important associations. For outcomes, all correlation coefficients were negative, interestingly associating higher APR rates with lower rates of adverse outcomes. Furthermore, coefficients as low as 0·3 may be considered quite high for associations with relatively insensitive quality indicators such as mortality rates. It is also worth highlighting that a lack of outliers on a funnel plot does not mean that the variation observed is unimportant. Funnel plots direct attention towards outliers, but it is also important to consider the variation of units between the control limits. Such considerations aside, the article contributes to the literature on quality indicators in healthcare. We argue that the concept of ‘good’ and ‘bad’ hospitals is being deconstructed. No organization achieves uniform performance across all areas. Even hospitals with systemic failings may be found to have areas of good practice1. This heterogeneity may extend to practice within a specialty. The demands of decision-making and operative technique in performing APR for low rectal cancer are very different from those for segmental colectomy in inflammatory bowel disease. Such complexity cannot be captured in a single number.