Gives the background for ACPGBI's bowel cancer Clinical Outcomes Publication for 2018, including where the data has come from, its nature, collection and analysis and what it represents.
This report describing outcomes of individual consultant surgeons and trusts has been prepared by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and The National Bowel Cancer Audit (NBOCA). It is a response to an initiative of NHS England (Everyone Counts: Planning for Patients 2013/4) to create greater transparency and more choice for patients and commissioners. Ten clinical specialties were asked to report on outcomes for every consultant in that specialty.
This is the sixth time such an exercise has been undertaken for colorectal cancer surgery. The National Bowel Cancer Audit has reported surgical outcomes, but these have been reported for NHS Trusts and for regional Cancer Networks and never for individual surgeons. The reported outcomes relate only to surgeons practising in England.
The surgeon outcome measure assessed for this publication is the 90-day mortality rate following planned removal of a bowel cancer – that is the proportion of patients undergoing surgery who die from whatever cause within 90 days of their operation.
This year there are two new trust-level outcome measures proportion of colonic resections with >12 lymph nodes reported and reported negative circumferential rectal resection margin rates. This is in addition to previously published Trust measures: rate of major resection, case ascertainment, length of stay (over 5 days) and 30-day unplanned readmissions. The accuracy of the new outcomes is highly dependent on complete/near complete data submission. Readers are asked to consider this fact when interpreting the published data, especially for Trusts that have lower data completeness for negative circumferential rectal resection margin rate.
Major resection rate is the percentage of the colorectal cancer patients discussed by the multidisciplinary clinical committee who actually go on have their bowel cancer removed by surgery. Case ascertainment is the proportion of patients with bowel cancer entered into the Audit by a trust compared to the numbers predicted by other national data sources. Case ascertainment is a reflection of the ability of a unit to identify all the patients with bowel cancer in a particular area.
30 day unplanned readmission rate is the proportion of patients who are readmitted to hospital as an emergency within 30 days of their (emergency or elective) operation to remove their bowel cancer. Length of stay is the proportion of patients who stay in hospital for more than 5 days following their (emergency or elective) operation to remove their bowel cancer.
90-day mortality results are based on data submitted to the National Bowel Cancer Audit for patients whose bowel cancer was diagnosed between April 2012 and March 2017. The national average 90-day mortality after planned bowel cancer surgery is around 2.2% in this period. This means that about 1 out of every 45 patients undergoing planned surgery for bowel cancer did not survive beyond 90 days after the operation.
The other measures are for patients whose bowel cancer was diagnosed between April 2016 and March 2017. This report should be seen as the forerunner of what will become a powerful resource for patients, surgeons as well as for commissioners of bowel cancer services. Whilst the ACPGBI is committed to the project, it urges great caution when interpreting early releases of data for the reasons set out below.
The results were provided from the National Bowel Cancer Audit. This audit has been in place for a number of years and has collected data on patients with bowel cancer admitted to NHS hospitals in the UK. The audit collects information about the characteristics of the patients and their tumour, the treatments they receive and their follow-up. The number and overall proportion of patients who could be included in the audit and the completeness and quality of their data has increased year on year.
The audit was designed to look at cancer management and outcomes within NHS Trusts and regional Cancer Networks, not at the performance of individual surgeons, mainly because the treatment of colorectal cancer involves a large team of health care professionals working together, all of whom can influence the outcome for patients. For this reason, there can be difficulties in allocating each patient to an individual surgeon and to ensure that all of a particular surgeon’s cases are included in the analysis. The completeness and accuracy of the reports on the performance of individual surgeons has improved year on year following individual outcome publication.
The nature of the data
90-day mortality is a readily available but very crude measure of the performance of a surgeon. It does not give any information on important aspects of that surgeon’s care, such as success at completely removing the tumour, how well the surgeon interacts with the patient and the frequency of complications after surgery. The surgeon outcomes reported here are for a specific 5-year time period (patients diagnosed with bowel cancer between April 2012 and March 2017). This represents only a snap-shot of a surgeon’s overall activity. The surgeon’s 90-day mortality will vary over time as a result of the play of chance. During the reporting period, some surgeons may have had clusters of poor results which may then be followed by clusters of better results depending when the data are extracted. In other words, caution should be exercised when using these data to predict future surgical performance.
Type 2 objections/ National data opt-out
Patients in England who do not want their personal confidential information to be shared outside of NHS Digital, for purposes other than for their direct care, have been able to register a type 2 opt-out with their GP practice. The audit uses data from NHS Digital to calculate mortality and length of stay and so patients who registered a type 2 opt-out could not be included.
According to NHS Digital, across England as a whole the proportion of patients who have requested type 2 opt-out was 2.4% in March 2018, with variation by region. The proportion of audit patients who have opted out has increased over the last five years.
In May 2018 type 2 opt-out was replaced by the national data opt-out.
ACPGBI Executive Lead for Clinical Outcome Publication