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National Bowel Cancer Audit Programme Context Page

Royal College of Surgeons (RCS) Clinical Effectiveness Unit (CEU), NHS Digital, and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) run the National Bowel Cancer audit. It covers all patients with a diagnosis of bowel cancer admitted for the first time. It measures short and medium term survival and surgical outcomes such as mortality and length of stay.

Audit website: content.digital.nhs.uk/bowel

Metrics:

Case ascertainment

  • Rationale: the proportion of all eligible patients captured by the audit in the sampling period reflects the quality of participation of this hospital in this audit. The comparison is made against Hospital Episode Statistics data.
  • Guideline/mapping: there is no national guideline related to case ascertainment and the audit does not currently specify an aspirational threshold.
  • Graph/relative performance: there is no graphical display for this metric; the hospital’s performance should be compared against the national aggregate.
  • Quality improvement prompt question: consider the metrics below in the context of case ascertainment – particularly where ascertainment is low and should prompt questions about the quality of audit participation.

1. Crude post-operative length of stay (LOS) after major resection of more than 5 days proportion

  • Rationale: the widespread adoption of enhanced recovery programs means that discharge to home after 5 days has become an “ideal” in defining LOS after colorectal cancer resection; the length of time spent in hospital following surgery can be a marker of the quality of post-operative and rehabilitative care but may also reflect patient casemix (older, frailer patients with more complex care needs tend to have longer LOS).
  • Guideline/mapping: this metric maps approximately to the Guidelines for the Management of Colorectal Cancer, 3rd edition, ACPGBI, 2007, page 32. Mapping is approximate because an ideal LOS is not specified – rather, reduction of LOS is described as a realistic goal of enhanced recovery programmes. The audit itself does not specify an aspirational standard.
  • Graph/relative performance: there is no graphical display for this metric; the hospital’s performance can be compared against the national aggregate but caution is advised because the metric is not adjusted for casemix.
  • Quality improvement prompt question: hospitals with prolonged LOS proportion above the national aggregate should prompt questions about the quality of perioperative care, efficiency of post-operative rehabilitation and community-care links.

2. Risk-adjusted 90-day post-operative mortality rate

  • Rationale: death is the most serious outcome after colorectal cancer surgery and is known to vary across regions. A 90-day period is used because this captures outcomes of complicated cases (such as those with prolonged critical care support). This metric uses casemix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex casemix.
  • Guideline/mapping: there is no national guideline related to mortality after colorectal cancer surgery.
  • Graph/relative performance: risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 95% and 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means that the performance is different to the national average.
  • Quality improvement prompt question: ‘orange’ (caution) or ‘red’ (alarm) outlier status should prompt questions about actions which the Trust has taken to reduce their mortality rates following colorectal cancer surgery.

3. Risk-adjusted 2-year post-operative mortality rate

  • Rationale: as for metric 2; a 2-year period is used because published research suggests that complications sustained during the initial admission can affect patient outcomes for a considerable length of time after discharge; the metric is adjusted for casemix.
  • Guideline/mapping: there is no national guideline related to mortality after colorectal cancer surgery.
  • Graph/relative performance: risk-adjusted funnel-plot cross-section; as for metric 2.
  • Quality improvement prompt question: as for metric 2

4. Risk-adjusted 90-day unplanned readmission rate

  • Rationale: unplanned readmission after surgery is an unpleasant experience for patients and may reflect delayed presentation of post-operative complications, over-expedient discharge policies and/or deficiencies in community care capacity; the metric is adjusted for casemix.
  • Guideline/mapping: there is no national guideline related to unplanned readmission after colorectal cancer surgery.
  • Graph/relative performance: risk-adjusted funnel-plot cross-section; as for metric 2.
  • Quality improvement prompt question: ‘orange’ (caution) or ‘red’ (alarm) outlier status should prompt questions about the actions which the Trust has taken to reduce unplanned readmissions after colorectal cancer surgery.

5. Risk-adjusted 18-month ‘temporary’ stoma rate in rectal cancer patients undergoing major resection

Note, this therefore excludes surgeries performed with the intention of creating a permanent stoma e.g. APER.

  • Rationale: when it is anatomically feasible, rectal cancer surgery which does not result in a prolonged period of time with a ‘temporary’ stoma is a reasonable patient expectation; the metric is adjusted for casemix.
  • Guideline/mapping: there is no national guideline related to stoma reversal after rectal cancer surgery; 18 months is a threshold based on expert opinion.
  • Graph/relative performance: risk-adjusted funnel-plot cross-section; as for metric 2.
  • Quality improvement prompt question: ‘orange’ (caution) or ‘red’ (alarm) outlier status should prompt questions the actions which the Trust has taken to improve its rate of ‘temporary’ stoma reversal after rectal cancer surgery.
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