National bowel cancer audit – the highlights
08.00 Hall 1A Wednesday 3rd July
Nigel Scott (Clinical Lead NBOCA)
This year we place the National Bowel Cancer Audit back where it belongs – in the annual scientific meeting of ACPGBI. Clinical Audit is to improve patient management through systematic review of care against explicit criteria and so implement positive changes in treatment. This is a massive task for a clinical practice that now encompasses 30,000 diagnoses of colorectal cancer per year The National Bowel Cancer Audit encompasses a partnership between the NHS Information Centre responsible for collecting and “cleaning” the data uploaded by Trust cancer management teams, the analysts of the Clinical Effectiveness Unit based at RCS England and representatives of this Association. The Audit process has definite strengths and some weaknesses. Strengths included high case ascertainment (86%) as well as data linkage to HES and PEDW for follow up information (eg: stoma reversal); potential weaknesses include the limited ability to focus on non-surgical treatments, the lack of information about why patients do not have a surgical resection and an inability to explore the patient experience. Future development of the Audit will require building on our strengths and redesign to address the gaps.
But what we have in NBOCA is the ability to analyse important aspects and trends in colorectal cancer care. Thus we can state to the 60% of our patients that undergo a major resection – that the risk of dying even 90 days after surgery is at an all-time low. Of the 17,250 patients who had a major resection 2011/2012, 16,450 – or 95.5 per cent – were alive 90 days on from their operation – compared to 94.7 per cent in 2010/11 and 93.9 per cent in 2008/09. This represents a documented reduction in 90 day surgical mortality by nearly one third (6.1% to 4.5%) in only four years. A testimony to both patient selection and postoperative care, employed by multidisciplinary teams managing colorectal cancer. In addition laparoscopic colorectal cancer resection continues to push relentlessly forward – accounting for 40% resections in 2011/12, up from only 25% in 2008/09.
And the Audit moves forwards into the completely new territory of determining long term patient survival. For the first time we have the unprecedented finding that of 50,245 colorectal cancer patients submitted to the National Bowel Cancer Audit between April 2008 and March 2010 – 80% are still alive 2 years after major surgical resection. Not surprisingly if you are too frail and have too much disease to justify resection the chances of being alive 2 years later are only 45% – but again an outcome that we have only just established. No other country or health organisation can match, on anything like this scale, this real-time measurement of what happens after colorectal cancer resection.
Emergency admission with colorectal cancer continues at a stubborn 21-22% of all cases of colorectal cancer – 5,250 patients in 2011-2012. We know that this often frail, elderly group of patients with advanced disease face the double whammy of emergency services that are widely seen to be less than adequate. The result of this difficult combination of circumstances being that 1 in 7 of those selected for emergency resection do not survive beyond the first 90 days. Emergency colorectal cancer outcomes still represent one of the biggest care issue we face in the management of colorectal cancer; a message that bears repetition to NHS political and management leaders.
As for the rest – well read the Audit Report. It describes where we are at a national, network and Trust level. The outlier mechanism is now well understood and networks and Trusts outside the funnel plot are informed of their outlier status as a matter of routine. Often these outcomes are explained by the recipient organisation as being due to a “data issue” – but as the Audit progresses there will be the expectation that identified outliers demonstrate changes in management and pathways that benefit patient care.