Outcomes from Elective Colorectal Surgery in England

1IBD in the UK How clinical information can improve future IBD care and outcomesMr Omar FaizConsultant Colorectal Surgeon & Senior LecturerSt Marks Hospital & Imperial College, LondonChair of ACPGBI Ileal Pouch Registry

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The origins of outcomes measurement

Florence NightingaleWilliam Farr....we do not want impressions, we want factsMade her name in the CrimeaSoldiers in England in peacetime were at double the mortality risk of civilian populationBy end of the century they were lower than civilian population 4The era of public reporting

State of New York adult cardiac bypass surgery

A 40% reduction in risk adjusted mortality was observed within 4 yearsfollowing public reporting

Outcome reporting has taken on a new meaningPublic reporting of outcome in cardiac surgeryReduction in mortalitySeems genuine as initial other causes for fall not substantiated5Data reporting is dynamicWhen performance is measured, performance improves. When performance is measured and reported, the rate of performance accelerates.Thomas S Monson6

The UK Inflammatory Bowel Disease Audit 1st Round in 2006 was the first UK-wide audit performed within gastroenterology. It demonstrated a marked variation in the resources and quality of care for IBD patients across the UK with particular deficits in some fundamental aspects of IBD care.The UK IBD audit seeks to improve the quality and safety of care for all IBD patients throughout the UK by auditing individual patient care and the provision and organisation of IBD service resources.As with the first, second and third rounds of the audit, reports of organisational audit data and clinical audit data have enabled participating sites to compare or benchmark their performance against national statistics. Following the data collection, analysis and reporting phases of all audit rounds, intervention strategies are used to improve the provision and quality of IBD care. Such strategies include the widespread dissemination of results, the availability of the national reports and the hosting of regional meetings to discuss findings and share learning.Data from all rounds is presented at key professional and patient meetings, previously including those of the British Society of Gastroenterology (BSG), Association of Coloproctology of Great Britain and Ireland (ACPGBI), British Dietetic Association (BDA), Royal College of Nursing Crohns and Colitis Specialist Interest Group and Crohns and Colitis UK.The specific aims of the UK IBD audit set out at the inception of the project were to:asssess processes and outcomes of care delivery (inpatient and outpatient) in IBDenable trusts to compare their performance against national standardsidentify resource and organisational factors that may account for observed variations in carefacilitate, develop and institute an intervention strategy to improve quality of carerepeat the audit to prove that change has occurredestablish measures for healthcare services to use to compare quality of IBD servicesdevelop a sustainability programme to maintain quality of care.

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OPTION 1 CENTRALISATION OF CAREThe volume outcome effect in surgery

Large effectOesophagusPancreasLungLess effectColonKidney Stomach810 years ago since this paper was publishedLed to centralisation on both sides of the atlanticNow we must do 20 cases per year8Volume analysis of outcome following restorative proctocolectomy.

British Journal of Surgery 2010

E Burns, A Bottle, P Aylin, S Clark, P Tekkis, A Darzi, RJ Nicholls, O Faiz

Do we have tangible evidence that decision making differs between surgeons?9Long term outcome in England

Burns E, et al. Br J Surg 2011N=5,771 pouchproceduresAnd this institutional skill (or experience) appears to be important when we look at pouch outcome on a national scale.In a study using HES data carried out at our own institution we looked at the role of pouch volume on outcome. You can see from this Kaplan Meier curve that high volume trusts demonstrated better outcome than low and medium volume institutions.In basic terms you might expect a very early widening to represent surgical septic complications whereas the later failures to represent pouch failures arising due to poorly selected patients such as those cases that turn out to have Crohns and the elderly. You can see that both early and late widening occur when the results in England are observed suggestive that both technical and selectionIssues account for this difference.

In a commentary that followed this article in the BJS the President of the ACP stated his desire to see the emergence of regional surgical IBD networks in the forthcoming years. 10Is it really all about volume?

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Dr Atul Gawande MDOPTION 2 QUALITY IMPROVEMENT

One contemporary thinker Atul Gawande has attemped to define and capture the essence of quality But healthcare is an extremely complex area. 1213

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OPTION 3. REPORTING OUTCOME

1590-day elective mortality CONCERNSOnly electiveOnly perioperativeMay reflect hospitals- Better than surgeon-Doesnt account for case-mix

"After all, in my view, if you can't describe what you're doing and define how well you're doing it, you have no right to be doing it at all

Bruce KeoghMedical Director of the National Health Service in EnglandAim of the Pouch Registry

To improve standards in ileal pouch surgery through a process of continuous national audit of activity and outcome in an observational registry

national benchmark.17Pouch activity

185 surgical teams

99 hospitals logged on the system

2383 cases submitted to the database (dating to 1977)

Since re-launching 90 and 100 RPCs submitted in 2010 & 2011 (HES data 361 and 327).

Now reached 3,000 cases!!!18Primary pouch surgery - diagnosis

Outcome pouch failure

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Summary

IBD StandardsIBD Audit & QIP- IBD Registry data- HES data- Pouch RegistryPerformance measurement underpins performance improvement- Need a clear picture of how good IBD management looks

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Ive upped my game. Now up yours!

Pat Paulsen american satirist 1927-1997Thank you26