Burns E 2013 PHD Thesis PDF

Investigating
the use of Hospital Episode
Statistics data to measure variation in
Performance and Quality in Colorectal Surgery
Miss Elaine Burns BSc.Edin Hons (Anatomical Sciences) MBCHB MRCS (Glasg)
DIVISION OF SURGERY, DEPARTMENT OF SURGERY AND CANCER,
IMPERIAL COLLEGE LONDON
Doctor of Philosophy (PhD) 2012
Supervisors: Mr Omar Faiz, Dr Paul Aylin, Professor the Lord Ara Darzi of Denham
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Investigating the use of Hospital Episode Statistics data to measure variation in Performance and Quality
in Colorectal Surgery

Table of Contents
Abstract ........................................................................................................................................... 12
Acknowledgements ..................................................................................................................... 14
Publications and presentations resulting from this thesis ............................................ 17
Statement of Contribution and Declaration of Originality ............................................. 23
Chapter 1- Introduction ............................................................................................................. 24
Hypothesis .................................................................................................................................. 29
Aim ................................................................................................................................................ 29
Chapter 2- What is surgical quality and how do we measure it? ................................. 30
Introduction ............................................................................................................................... 30
The demand for high-quality healthcare ......................................................................... 30
The definition of surgical quality ....................................................................................... 31
Reporting of surgical performance and quality ............................................................ 32
Measuring quality in surgery ............................................................................................... 36
Risk-adjustment and statistical considerations in quality measurement ............ 47
Measurement of quality in colorectal surgery ............................................................... 51
Chapter 3- Data sources for quality measurement. .......................................................... 59
Routinely collected datasets ................................................................................................ 59
Clinical databases .................................................................................................................... 62
National Surgical Quality Improvement Program ........................................................ 63
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Advantages and disadvantages of routinely collected data ...................................... 64
Systematic review of accuracy of routinely collected data ........................................ 69
Variation from HES data ........................................................................................................ 91
HES data and Colorectal surgery ......................................................................................... 96
Chapter 4- Materials and Methods ...................................................................................... 100
Hospital Episode Statistics (HES) .................................................................................... 100
HES Coding ............................................................................................................................... 101
Risk adjustment ..................................................................................................................... 103
Outcome measures ............................................................................................................... 108
Ethical considerations ......................................................................................................... 109
Statistical considerations ................................................................................................... 109
Volume ...................................................................................................................................... 110
Chapter 5- Variation in patient factors .............................................................................. 111
Introduction ............................................................................................................................ 111
Aim ............................................................................................................................................. 112
Methods .................................................................................................................................... 112
Results ...................................................................................................................................... 113
Summary .................................................................................................................................. 123
Chapter 6- Variation in Structural factors ........................................................................ 124
Introduction ............................................................................................................................ 124
Aim ............................................................................................................................................. 125
Methods .................................................................................................................................... 126
Results ...................................................................................................................................... 127
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Summary .................................................................................................................................. 142
Chapter 7- Variation in process factors ............................................................................. 144
Introduction ............................................................................................................................ 144
Aim ............................................................................................................................................. 147
Methods .................................................................................................................................... 147
Results ...................................................................................................................................... 149
Summary .................................................................................................................................. 160
Chapter 8- Variation in outcome factors ........................................................................... 161
Introduction ............................................................................................................................ 161
Aim ............................................................................................................................................. 162
Methods .................................................................................................................................... 163
Results ...................................................................................................................................... 172
Defining novel outcome measures from HES and assessing variation in these
measures 172
Variation in established colorectal outcome measures 197
The impact of process factors on outcome 209
Summary .................................................................................................................................. 210
Chapter 9- Reducing variation in outcome following colorectal surgery in
England- the role of volume in determining outcome .................................................. 212
Introduction ............................................................................................................................ 212
Aims ........................................................................................................................................... 221
Methods .................................................................................................................................... 221
Volume considerations 225
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Results ...................................................................................................................................... 233
Does a relationship exist between consultant team or Trust volume and outcome
following colorectal cancer surgery? 233
Is there a relationship between total resection workload (i.e. benign and malignant)
and outcome? 248
Is volume relationship mitigated in part by structural factors? 252
Is there a relationship between surgeon laparoscopic caseload and outcome?
252
Is there a relationship between caseload and outcome in subspecialist care?
260
Summary .................................................................................................................................. 265
Chapter 10- Discussion ........................................................................................................... 267
Main findings .......................................................................................................................... 267
Role of caseload in determining outcome .................................................................... 268
Quality improvement ........................................................................................................... 277
New outcome measures ...................................................................................................... 280
Laparoscopic versus open approaches .......................................................................... 287
Study limitations ................................................................................................................... 291
Conclusion ............................................................................................................................... 297
References ................................................................................................................................... 298
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List of figures
Figure 3.1: Schematic of inclusion following literature search. 74
Figure 5.1: Variation in admission type (elective and emergency) by Trust for all colorectal
resections (percentage of elective admission with 95% confidence interval error bars). 114
Figure 5.2: Variation in Trust diagnosis for all colorectal resections by Trust of all patients
undergoing a colorectal resection. 115
Figure 5.3 Variation in type of resection per Trust of all patients undergoing a colorectal resection.
116
Figure 5.4: Variation in Charlson scoring per Trust of all patients undergoing a colorectal
resection. 118
Figure 5.5: Variation in social deprivation by Trust of all patients undergoing a colorectal
resection 119
Figure 5.6: Variation in patient age by Trust of all patients undergoing a colorectal resection 120
Figure 6.1: Variation in total volume of colorectal resection over the study period (8 years) by 156
individual NHS Trust 130
Figure 6.2: Variation in elective colorectal cancer resection caseload per consultant team per year
over the study period. 133
Figure 6.3: Increase in mean consultant team elective colorectal cancer caseload over time with
95% confidence interval error bars. 135
Figure 6.4: The percentage of patients undergoing RPC in each provider volume category (LV, MV,
HV) from 1996 to 2008 140
Figure 6.5: The percentage of patients undergoing RPC in each surgeon volume category (LV, MV,
HV) from 2000 to 2008 141
Figure 7.1: Funnel plot of consultant team caseload and APE rates amongst patients with rectal
cancer 150
Figure 7.2: Funnel plot of NHS Trust caseload and APE rates amongst patients with rectal cancer
151
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Figure 7.3: Overall percentage APE use amongst rectal cancer patients over time 152
Figure 7.4: Uptake of laparoscopic approach for all elective resections and elective colorectal
cancer resections 154
Figure 7.5: Variation in minimal access surgery rate amongst patients undergoing an elective
colorectal resection across SHA in 2007 158
Figure 8.1: Funnel plot of adjusted reoperation rates for elective colorectal resectional procedures
for individual consultant teams by volume of elective surgery. 180
Figure 8.2: Funnel plot of adjusted reoperation rates for both emergency and elective colorectal
resectional procedures for individual NHS Trusts by volume. 181
Figure 8.3: Variation in incisional hernia rates following colorectal resection for each NHS Trust
with 95% confidence intervals 189
Figure 8.4: Variation in adhesion rates following colorectal resection for each NHS Trust with 95%
confidence intervals 190
Figure 8.5: Funnel plot of pouch failure rates by NHS Trust. 196
Figure 8.6: Variation in 30 day mortality following colorectal resection for each NHS Trust with
95% confidence intervals 200
Figure 8.7: Mean readmission rates following colorectal resection with 95% confidence intervals
per NHS Trust. 202
Figure 8.8: Variation in LOS amongst colorectal resection patients by NHS Trust with 95%
confidence intervals. 205
Figure 9.1: Funnel plot of adjusted 30-day mortality and Trust caseload. 240
Figure 9.2: Funnel plot of Trust postoperative return to theatre rates and caseload. 241
Figure 9.3: Funnel plot of consultant team caseload and 30-day postoperative mortality 242
Figure 9.4: Funnel plot of adjusted consultant team return to theatre rates and caseload. 243
Figure 9.5: Confidence intervals of odds ratios of 30 day mortality following rectal cancer
resection at incremental increases in rectal cancer surgical caseload to demonstrate critical
volume of surgery (increments of 5). 246
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volume of surgery (increments of 2.5). 247
Figure 9.7: Confidence intervals of odds ratios of 30 day mortality following cancer resection at
incremental increases in total surgical caseload to demonstrate critical volume of surgery
(increments of 10). 250
Figure 9.8: Confidence intervals of odds ratios of 30 day mortality following cancer resection at
incremental increases in total surgical caseload to demonstrate critical volume of surgery
(increments of 5). 251
Figure 9.9: Increase in number of consultant teams using the minimal access approach from 2002
to 2008 with dates of publication of randomised control trials and guidelines. 253
Figure 9.10: Kaplan Meier curve showing variation in failure rates according to institutional
volume groups 263
Figure 9.11: Funnel plot showing provider volume and failure rates following RPC 264
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List of Tables
Table 2.1: Advantages and disadvantages of quality metrics classified according to the Donabedian
approach. 38
Table 3.1: Advantages and disadvantages of HES data 65
Table 3.2: Assessment of quality of studies examining data accuracy of routinely collected data in
comparison to case note review 73
Table 3.3: Summary of included studies examining data accuracy of routinely collected data in
comparison to case note review 78
Table 3.4: Summary of included studies comparing routinely collected data with clinical registries
80
Table 5.1: Patient characteristics and type of surgery for all patients undergoing colorectal
resection. 117
Table 5.2: Characteristics of patients undergoing RPC between 1996 and 2008 122
resection. 128
Table 6.2: Patient characteristics and type of surgery for all patients undergoing colorectal cancer
resection. 132
Table 6.3: Patient characteristics in each institutional volume category operated on between 1996
and 2008 * 137
Table 6.4: Patient characteristics in each surgeon volume category of pouch patients operated on
between 2000 and 2008* 138
Table 7.1: Number of elective laparoscopic colorectal cancer resections by SHA in 2007. 156
Table 7.2: Multiple logistic regression of use of minimal access surgery in elective colorectal
cancer resection including those patients undergoing resection in 2007. 157
Table 7.3: Pouch laparoscopic use by volume category 160
Table 8.1: OPCS codes used to define reoperations following colorectal resection 165
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Table 8.2: Patient characteristics and type of surgery by approach for patients undergoing a
colorectal resection. 173
Table 8.3: Reoperation following colorectal resections for patients undergoing laparoscopic and
open procedures. 175
Table 8.4: Patient characteristics of those patients who necessitated a reoperation in the
postoperative period. 177
Table 8.5: Multiple regression analysis for reoperation and laparotomy amongst elective and
emergency patients. 178
Table 8.6: Descriptives of elective patients undergoing colorectal resection between 2002 and
2008 included for analysis of medium term adhesion and herniae rates. 184
Table 8.7: Rates of re-intervention for adhesions and incisional hernia repairs following
laparoscopic and open resection at one, two and three year post surgery. 186
Table 8.8: Multiple regression analysis of operative reintervention for incisional hernia and
adhesion 187
Table 8.9: Characteristics of restorative proctocolectomy patients who experienced failure
(372/5771) compared with those who did not 192
Table 8.10: Unifactorial and Multiple Cox regression analysis for pouch failure 194
Table 8.11: Variation in 30 day and 365 day mortality amongst elective and emergency colorectal
resection patients (unadjusted analysis). 198
Table 8.12: Variation in 30 day and 365 day mortality amongst elective and emergency colorectal
resection patients (multiple regression analysis). 199
Table 9.1:Previous research examining surgical provision and impact of caseload on outcome
using HES data. 218
Table 9.2: OPCS codes used to classify colorectal resection. 223
Table 9.3: Volume thresholds for elective colorectal resection. 227
Table 9.4: Volume categories and number of patients in each category for restorative
proctocolectomy. 229
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Table 9.5: Patient characteristics and type of surgery by approach for patients undergoing an
elective colorectal resection. 234
Table 9.6: Unadjusted outcome of elective colorectal cancer resection according to volume
categories. 237
Table 9.7: Multiple regression of 30-day postoperative mortality, 28-day unplanned readmission,
reoperation and length of stay for elective colorectal cancer resection. 238
Table 9.8: Patient characteristics of all patients undergoing an elective resection. 255
Table 9.9: Patient characteristic of cancer patients undergoing a laparoscopic elective colorectal
resection between 2002 and 2008 in each volume category. 256
Table 9.10: Outcome following elective laparoscopic colorectal cancer resection in each volume
category. 258
Table 9.11: Multiple logistic regression for reoperation, 30 day medical morbidity, 365 day
medical morbidity and LOS for patients undergoing an elective laparoscopic colorectal cancer
resection. 259
Table 9.12: Outcome of RPC according to institutional volume and surgeon volume 261
Table 9.13: Linear regression analysis for the logarithmic transformation of length of stay (LOS)
with institutional and surgeon volume considered separately for pouch surgery 262
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Abstract
This thesis provides a comprehensive overview of general and subspecialist colorectal
surgery in England. It examines variation in provision and outcome of colorectal surgery in
structure, process and outcome factors at the patient, consultant team and NHS Trust levels.
Finally, this thesis examines the potential role of increasing surgical caseload to reduce any
demonstrable variation and improve outcome. To address these questions, current issues in
surgical quality as well as the coding accuracy reported in the published literature have been
reviewed. Colorectal resection and the more specialised procedure of restorative
proctocolectomy were examined from the Hospital Episode Statistics dataset. Novel
outcome measures were derived using longitudinal analysis. Regression analysis was used to
understand the predictors of process factors and outcome measures.
I have defined new outcome measures and demonstrated considerable variation in these new
measures and in more traditional accepted measures in both general and subspecialist
colorectal surgery from routinely collected datasets. Routinely collected data offer an
exciting potential data source for measuring performance and quality. If data accuracy can be
assured, measures such as reoperation may be used alongside established measures of quality
in a meaningful way to benchmarking performance of surgical providers. The methods
described in this thesis can be applied to a broad range of surgical specialties.
Though volume may have a role in determining outcome and reducing variation in
subspecialist colorectal surgery, it is by no means the panacea to improve quality across all
providers in general colorectal care. The impact of volume on outcome in more general
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colorectal surgery is less clear. Though centralisation is likely to have benefits, further
evidence of the optimum way to implement such changes is needed rather than
indiscriminately increasing volume across all providers for general colorectal surgical care.
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Acknowledgements
This PhD was undertaken in the Department of Surgery and Cancer in St Marys Hospital
under the supervision of Mr Omar Faiz, Dr Paul Aylin and Professor Ara Darzi.
I am indebted to Omar Faiz for his excellent supervision throughout my PhD. As well as
finding a mentor, I have learnt many skills from him that will stand me in good stead
throughout the rest of my career.
Paul Aylin has been an amazing supervisor. He has always been supportive and a welcome
ear to listen to my PhD moans.
Id like to thank Professor Darzi for his support clinically and career wise, for giving me this
wonderful opportunity and for helping me achieve my career and research goals.
Without the statistical support and advice from Dr Alex Bottle, this PhD would not have been
possible. I am also grateful for the support of all members of the Dr Foster unit. Id like to
acknowledge Professor John Nicholls who has provided invaluable insights throughout this
research.
Id like to thanks the others who have helped me survive and enjoy research. Ravi
Mamidanna and Alex Almoudaris were fantastic collaborators in our burgeoning reseach
group. The current and previous residents of the Room 1029 have provided laughs, joy, tea
and wine at times of need. Thanks guys.
Finally but definitely not least, I like to acknowledge and sincerely thank my parents, Mary
and Martin, the rest of my family, my flatmate Caroline, and all my friends for keeping me
sane throughout this journey. They have been a constant source of distraction and happiness
and have gone way beyond the call of duty to support me in the last three years,
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Abbreviations
AAA Abdominal Aortic Aneursym
ACPGBI Association of Coloproctologists of Great Britain and Ireland
ACS American College of Surgeons
APE Abdominoperineal Excision
AUGIS The Association of Upper Gastrointestinal Surgeons of Great Britain
and Ireland
CRM Circumferential Resection Margin
EBHR Evidence-Based Hospital Referral
ERP Enhanced Recovery Programmes
HES Hospital Episode Statistics
IBD Inflammatory Bowel Disease
IPAA Ileal anal-pouch anastomosis
ICU Intensive Care Unit
IQR Interquartile Range
LOS Length of Stay
NBOCAP National Bowel Cancer Audit Project
NHS National Health Service
NICE National Institute for Health and Clinical Excellence
NSQIP National Surgical Quality Improvement Programme
PbR Payment by Results
PROMS Patient Reported Outcome Measures
RCT Randomised Control Trial
RPC Restorative proctocolectomy
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SEER Surveillance Epidemiology and End Results
SHA Strategic Health Authority
SD Standard Deviation
UK United Kingdom
US United States
VA Veterans Affairs
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Publications and presentations resulting from this thesis
Publications directly resulting from thesis (See Appendices)
Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O. Variation in reoperation after
colorectal surgery in England as an indicator of surgical performance: retrospective analysis
of Hospital Episode Statistics. BMJ. 2011 Aug 16;343:d4836
Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, Faiz OD.
Systematic review of discharge coding accuracy. J Public Health (Oxf). 2011 Jul 27.
Burns EM, Bottle A, Aylin P, Clark SK, Tekkis PP, Darzi A, Nicholls RJ, Faiz O. Volume
analysis of outcome following restorative proctocolectomy. Br J Surg. 2011 Mar;98(3):408-
17.
Burns EM, Mamidanna R, Currie A, Bottle A, Aylin P, Darzi A, Faiz OD. The role of
caseload in determining outcome following laparoscopic colorectal cancer resection. (Under
review Colorectal Dis 2012)
Burns EM, Currie A, Bottle A, Aylin P, Faiz O. An evaluation of incisional hernia and
adhesion-related outcomes following laparoscopic and open colorectal surgery in England.
Br J Surg. 2012 Nov 12. [Epub ahead of print]
Burns EM, Aylin P, Bottle A, Faiz O. Defining and measuring quality in surgery. (Under
review Postgraduate Medical Journal 2011)
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Burns EM, Bottle A, Almoudaris A, Mamidanna R, Aylin P, Darzi A, Nicholls RJ, Faiz OD.
The role of volume in elective colorectal surgery (under review BMJ 2012)
Associated with work from thesis
Burns EM, Naseem H, Bottle A, Lazzarino AI, Aylin P, Darzi A, Moorthy K, Faiz O.
Introduction of laparoscopic bariatric surgery in England: observational population cohort
study. BMJ. 2010 Aug 26;341:c4296
Almoudaris AM, Burns EM, Bottle A, Aylin P, Darzi A, Faiz O. A colorectal perspective
on voluntary submission of outcome data to clinical registries. Br J Surg. 2011 Jan;98(1):132-
9.
Burns EM, Faiz O. Evolution of the surgeon--volume, patient outcome relationship. Ann
Surg. 2010 May;251(5):991-2
Burns EM, Faiz O. Response to Khani et al., centralization of rectal cancer surgery
improves long-term survival. Colorectal Dis. 2010 Oct;12(10):1054.
Burns EM, Mayer EK, Faiz O. Surgeon volume does not predict outcomes in the setting of
technical credentialing: results from a randomized trial of colon cancer. Ann Surg. 2009
May;249(5):866;
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Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Aylin P. Hospital stay amongst patients
undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in
NHS hospitals. Colorectal Dis. 2011 Jul;13(7):816-22.
Faiz O, Brown T, Bottle A, Burns EM, Darzi AW, Aylin P. Impact of hospital institutional
volume on postoperative mortality after major emergency colorectal surgery in English
National Health Service Trusts, 2001 to 2005. Dis Colon Rectum. 2010 Apr;53(4):393-401.
Mamidanna R, Burns EM, Bottle A, Aylin P, Stonell C, Hanna GB, Faiz O. Reduced risk of
medical morbidity and mortality in patients selected for laparoscopic colorectal resection in
England: A population based study. Arch Surg 2011 Nov 21.
Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, Faiz O. Value of
Failure To Rescue as a marker of the standard of care following reoperation for
complications after colorectal resection. Br J Surg. 2011 Dec; 98 (12): 1775-83.
Presentations
Burns EM, Mamidanna R, Currie A, Bottle A , Darzi A, Faiz OD The role of caseload in
determining outcome following laparoscopic colorectal cancer resection. European Society of
Coloproctology Copenhagen 2011.
Burns EM, Currie A, Bottle A, Aylin P, Darzi A, Faiz O. Minimal Access colorectal surgery
is associated with fewer subsequent adhesion-related admissions and operations than the
conventional approach. European Society of Coloproctology Copenhagen 2011.
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Burns EM, Bottle A, Aylin P, Darzi A, Faiz O. Does surgeon or institution volume influence
abdominoperineal excision rate? European Society of Coloproctology Copenhagen 2011.
Burns EM, Bottle A, Aylin P, Darzi A, Faiz O. Does surgeon or institution volume influence
abdominoperineal excision rate? Tripartite Colorectal meeting Cairns 2011.
Burns EM, Bottle A, Aylin P, Darzi A, Faiz O. The role of surgeon volume in Colorectal
Cancer Surgery. Tripartite Colorectal meeting Cairns 2011.
Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz O. Variation in return to theatre
following colorectal surgery in England an indication of inequality of surgical
performance? Tripartite Colorectal meeting Cairns 2011.
Currie A, Burns EM, Darzi A, Faiz O, Ziprin P. Has shortened surgical training led to poorer
colorectal cancer outcomes? Tripartite Colorectal meeting Cairns 2011.
Burns EM, Bottle A, Aylin P, Darzi A, Faiz O. Return to theatre in Crohns Disease in the
biological era. European Society of Coloproctology Sorrento 2011.
Burns EM, Bottle A, Aylin P, Darzi AW, Faiz O. The impact of reoperation following
colorectal resection on postoperative mortality. European Society of Coloproctology Sorrento
2011.
Burns EM, Bottle A, Aylin P, Darzi A, Faiz OD. Does surgeon or institution volume
influence abdominoperineal excision rate? Association of Coloproctology of Great Britain
and Ireland Birmingham 2011.
Burns EM, Bottle A, Aylin P, Darzi A, Faiz OD. The impact of surgeon volume in colorectal
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cancer surgery. Association of Coloproctology of Great Britain and Ireland Birmingham
2011.
Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz OD. Variation in return to theatre
following colorectal surgery in England an indication of inequality of surgical
performance? Association of Coloproctology of Great Britain and Ireland Birmingham 2011.
Burns EM, Bottle A, Aylin P, Tekkis PP, Clark S, Darzi AW, Nicholls RJ, Faiz O. National
Outcomes Following Restorative Proctocolectomy In England. Association of Great Britain
and Ireland Liverpool 2010.
Burns E, Naseem H, Aylin P, Faiz O, Moorthy K. Trends in Laparoscopic Bariatric Surgery
and Comparisons of Outcomes with Open Surgery: a National study in England 2000-2008.
Association of Great Britain and Ireland Liverpool 2010.
Burns EM, Bottle A, Aylin P, Tekkis PP, Clark S, Darzi AW, Nicholls RJ, Faiz O.
Examining Differences In Postoperative Outcomes Between Hospitals with differing surgical
caseload following Restorative Proctocolectomy. Association of Great Britain and Ireland
Liverpool 2010.
Burns EM, Bottle A, Aylin P, Tekkis PP, Clark SK, Darzi AW, Nicholls RJ, Faiz O.
Examining differences in case selection between surgeons with differing surgical caseload in
pouch surgery. Association of Great Britain and Ireland Liverpool 2010.
Burns E, Bottle A, Aylin P, Faiz O, Moorthy K. The role of volume in Bariatric Surgery.
Association of Great Britain and Ireland Liverpool 2010.
Burns E, Bottle A, Aylin P, Faiz O, Moorthy K. National Outcomes following Bariatric
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Surgery in England. Association of Great Britain and Ireland Liverpool 2010.
Burns EM, Bottle A, Jing SS, Aylin P, Darzi AW, Faiz O. National Provision Of
Laparoscopic Pouch Surgery In England. Association of Coloproctology of Great Britain and
Ireland Bournemouth 2010.
National Outcomes Following Restorative Proctocolectomy In England. Association of
Coloproctology of Great Britain and Ireland Bournemouth 2010.
Examining differences in case selection between surgeons with differing surgical caseload in
pouch surgery. Association of Coloproctology of Great Britain and Ireland Bournemouth
2010.
Examining Differences In Postoperative Outcomes Between Hospitals with differing surgical
caseload in restorative proctocolectomy. Association of Coloproctology of Great Britain and
Ireland Bournemouth 2010.
Burns E, Bottle A, Aylin P, Kennedy R H, Hanna G, Faiz O. Disparity in use of laparoscopy
for colon cancer in England. Association of Great Britain and Ireland Glasgow 2009.
Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Darzi AW, Aylin P. Hospital stay amongst
patients undergoing major elective colorectal surgery: predicting prolonged stay and
readmissions in NHS hospitals. Association of Great Britain and Ireland Glasgow 2009.
22

Burns E, Aylin P, Kennedy R H, Hanna G, Faiz O. Disparity in use of laparoscopy for colon
cancer in England. Association of Coloproctology of Great Britain and Ireland Harrogate
2009.
Faiz O, Brown T, Bottle A, Burns EM, Darzi AW, Aylin P. The influence of hospital
provider volume on postoperative mortality and intestinal continuity rates after major
emergency colorectal surgery in England. Association of Coloproctology of Great Britain and
Ireland Harrogate 2009.
Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Darzi AW, Aylin P. Hospital stay amongst
patients undergoing major elective colorectal surgery: predicting prolonged stay and
readmissions in NHS hospitals. Association of Coloproctology of Great Britain and Ireland
Harrogate 2009.
Statement of Contribution and Declaration of originality
The work contained in this thesis is my own and was performed by myself. In the process of
carrying out this work, other individuals were involved. My supervisors, Mr O Faiz, Dr P
Aylin and Professor A Darzi provided direction and advice with conception, design and
editing of the studies included in this thesis. In addition, Dr A Bottle aided with data cutting
of the pouch database, statistical support and editing of the other chapters. Specifically in
Chapter 4, Dr E Rigby and Mr R Mamidanna acted as second and third reviewer for the
articles included in the systematic review of coding accuracy and helped with the drafting
and editing fo the final manuscript (See appendix). Mr A Almoudaris compiled the structural
data that were analysed by myself in Chapters 6 and 9. Though I carried out the analysis and
interpretation of the data, R Mamidanna derived the algorithm and provided the data for
defining medical morbidity in Chapter 8 and 9. All other work is appropriately referenced.
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Chapter 1- Introduction
Variation in the utilization of health care services that cannot be explained by variation in
patient illness or patient preferences.
Jack Wennberg (Dartmouth Atlas of Variation)
Over the last seventeen years, since the publication of the Calman Hine report, there has been
an increasing recognition that variation exists within the National Health Service (NHS)
(Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales,
1995). There has been a consequent impetus towards uniform practice across England and
Wales. The report, High quality care for all: NHS next stage review, went further in making
quality and standard setting central to the future of healthcare in the NHS in England (Darzi,
2008).
Variation in healthcare has been previously demonstrated in both the NHS and in other
healthcare systems such as in the United States (US). Patient factors such as ethnicity and
socioeconomic deprivation have been demonstrated to have a negative impact on both access
to services and outcome following treatment (Bagger et al., 2008, Smith et al., 2006).
Variation at an institutional level also exists. NHS Trusts vary in terms of the provision of
services and other structural factors such as caseload. These factors may or may not impact
on the healthcare provided and consequent outcome. In the NHS, Primary Care Trusts (PCT)
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commission services from Acute Trusts. PCTs differ in terms of which procedures that they
will or will not permit leading to the suggestion of a postcode lottery (Henderson, 2009) i.e.
where the services available for individual patients depend on their geographical location.
It is generally agreed that there is unacceptable regional variation in NHS services throughout
England (Darzi, 2008). This variation persists in surgical practice. Geographical disparities
have been examined using routinely collected hospital data in England. Dixon et al, found
marked variation in age and sex adjusted total hip and knee replacement rates (Dixon et al.,
2006). As a first step to improving quality in clinical care, this variation must be described
and demonstrated. Such descriptions can be used to direct quality initiatives. The NHS has
begun to publicly report this variation in the NHS Atlas of Variation (NHS Atlas). This Atlas
is similar to the Dartmouth Atlas in the US (Dartmouth Atlas of Variation). It describes
variation in a range of variables including bariatric surgery, spending on cancer and stroke
care.
Colorectal surgery
Colorectal surgery represents a significant portion of the elective and emergency general
surgical workload. In the financial year 2007/2008, there were over 35,000 admissions for
colorectal resections in England. It is a diverse speciality encompassing a wide range of
diseases including colorectal cancer, inflammatory bowel disease and diverticular disease.
Given the ageing population, the workload of this speciality is likely to increase over time.
One study predicted a 42% increase in the number of colonic resections between 2000 and
2020 in the US (Liu et al., 2004).

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Colorectal surgery is associated with marked morbidity (Alves et al., 2005) and, in the
emergency setting a significant risk of mortality (Faiz et al., 2010a). Considerable variation
between institutional and individual colorectal surgical practice and outcome has been
demonstrated previously (Morris et al., 2008, McArdle and Hole, 1991). Such variability is
increasingly unacceptable to clinicians, healthcare managers, commissioners and patients.
Describing this variation in performance is an important step to allow quality assessment and
subsequent improvement.
In the United Kingdom (UK), nationwide administrative data that include all patients
admitted to National Health Service (NHS) hospitals are collected. The current availability
and comprehensive coverage of these datasets makes them an attractive potential source for
measuring performance. Reducing variation to improve outcome is desirable. Several quality
improvement measures have been suggested to improve outcome. These include centralising
services, increasing individual provider caseload, clinician revalidation or surgeon
credentialing to ensure adequate technical proficiency. Surgeon credentialing involves
assessing surgeons as competent in performing a particular operation or set of interventions.
Revalidation represents a regulatory process incorporating regular audit and assessment to
ensure clinicians meet nationally agreed standards (General Medical Council, 2010). This
process may reduce variation within the health service and improve outcome. For
revalidation to be effective, reliable performance measures are necessary. In the US, in
addition to outcome measures such as mortality, length of stay and readmission, other
measures have been used to examine variation in colorectal surgery such as return to theatre
and complication rates (Billingsley et al., 2007, Billingsley et al., 2008, Morris et al., 2007a).
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As yet colorectal reoperation rates have not been examined at a national level using UK
based data.
Previous studies have demonstrated variation in colorectal surgical practice in England.
Using Hospital Episode Statistics (HES) data, Tilney and colleagues found considerable
inter-centre variation in Abdominoperineal Excision (APE) rates (Tilney et al., 2008). Using
HES data linked to cancer registry data, Morris and co workers suggested that surgeon-to-
surgeon variation in the use of APE persisted despite case mix adjustment (Morris et al.,
2008). As well as differences at an institutional level both these studies found increased rates
of APE use amongst those patients from more socially deprived areas. Tilney and colleagues
in a study using a clinical database also found a relationship between lower socioeconomic
status and increased rates of APE use (Tilney et al., 2009).
Alongside colorectal excisional surgery, it is necessary to describe variation following more
specialist surgery. Restorative proctocolectomy (RPC) or ileal pouch anal anastomosis
surgery (IPAA) is widely accepted as the operation of choice for patients with Ulcerative
Colitis (UC) or Familial Adenomatous Polyposis (FAP) who require colectomy. It is one of
the most challenging operations in colorectal surgery and requires a high level of both
technical skill and clinical acumen in choosing the appropriate patients to undergo the
procedure. There have been many large series from single institutions describing outcome
following RPC in the UK and US (Fazio et al., 1995, Tulchinsky et al., 2003, Chapman et al.,
2005). Published audits of outcome at a national level are, however, limited. One previous
study examined outcome following RPC using the UK National Ileal pouch registry (Tekkis
27

et al., 2010). This audit took place over thirty years with ten contributing centres in the UK.
Examination of variation in outcome or the role of surgeon or institutional caseload in
determining outcome was beyond the remit of this study. Kennedy and colleagues examined
the role of caseload in determining volume using administrative data in a single region in
Canada (Kennedy et al., 2006). This study found increased reoperation and failure rates
amongst lower volume institutions. The results of this study may not be applicable to the UK
setting. Furthermore this study did not examine the role of individual surgeons caseload in
determining outcomes.
This thesis seeks to assess whether it is feasible, given accurate data, to measure performance
and quality in surgery from HES data. As part of assessing the HES databases use to
measure performance and quality, we review current issues in surgical quality and existing
measures of quality. This thesis will examine variation in structure, process and outcome
measures at the NHS Trust, and consultant team levels. This thesis, however, goes further in
seeking to ascertain whether this variation can be negated through increasing institutional or
surgeon caseload.
28
Hypothesis
There is variation in colorectal surgical performance and quality that can be measured using a
national routinely collected dataset.
Aim
1. Define current issues in surgical quality and performance with particular reference to
colorectal surgery
2. Examine current variation in colorectal surgery and contributing factors to this
variation from routinely collected datasets
3. Derive new possible measures of colorectal surgical performance from routinely
collected datasets
4. Explore use of administrative datasets to benchmark performance and quality in
colorectal surgery
5. Assess the role of caseload in reducing any apparent variation.
29

Chapter 2- What is surgical quality and how do we measure it?
Introduction
Healthcare accounts for a significant proportion of government and individual spending. In
the US, in 2008, total healthcare expenditure was $2.4 trillion -17% of the Gross Domestic
Product (2009d). In the UK in 2009 healthcare was responsible for 102.6 billion of public
spending (www.ukspending.co.uk, 2009). Policy-makers, healthcare funders and patients
demand high quality medical care to justify current spending levels in a period of financial
austerity. Central to efficiency in healthcare is a fundamental need to demonstrate quality of
service provision. Although it is useful to speak about improving quality in broad terms,
what does quality in healthcare actually mean?
This chapter seeks to define surgical quality, discuss the reasons for measuring quality, and
describe existing quality metrics.
The demand for high-quality healthcare
In the report, Crossing the Quality Chasm: A New Health System for the 21st Century, the
Committee on Quality of Healthcare from the Institute of Medicine in America recognised
that there was a significant gap between current healthcare performance and the quality that
is possible (Committee on Quality Health Care in America, 2001). This document advocated
redesign of the American healthcare system in order to achieve superior quality (Committee
on Quality Health Care in America, 2001). In England, the 2008 government report, High
quality care for all: NHS next stage review outlined the vision for the future of the NHS.
30

This document, along with the NHS Constitution, (NHS Constitution, 2009) and the recently
formed National Quality Board, underline the health services commitment to delivering a
high quality service for all patients (National Quality Board). Other countries similarly
overtly promote high quality healthcare. Australia, for example, has a well established
Commission on Safety and Quality in Healthcare. This commission has wide-ranging remit to
drive quality improvement, disseminate knowledge and publicly report performance against
national standards (Australian Commission on Safety and Quality in Healthcare, 2009).
The definition of surgical quality
The definition of quality in surgical care is debated. It should reflect all aspects of care; not
just outcome including mortality and morbidity but also patient centred factors such as
patient experience and postoperative quality of life. The National Institute of Medicine in the
US defines quality as the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge (Institute of Medicine, 1990). This definition recognises the need for
care to meet current standards and the requirement for healthcare professionals to deliver up
to date treatment. The above description of quality does not however define desired health
outcomes.
Surgical quality is deeply intertwined, but not synonymous, with both performance and
safety. Performance is the way in which a person or organisation functions whereas quality
is a measure of excellence. Safe practice must be followed to deliver quality care. High
quality service provision requires excellent clinical performance. Improving safety is a focus
31

for many quality initiatives. As such, quality initiatives may begin with improving surgical
safety. The World Health Organisation (WHO) recognised the need for global action to
improve safety in surgery with the Safe Surgery Saves Lives initiative. The latter resulted in a
simple checklist that could be used globally in many types of surgery to attempt to reduce
adverse events. Initial pilot studies demonstrated that this checklist resulted in a 47%
reduction in mortality after its introduction (Haynes et al., 2009). It also illustrated that such a
simple intervention can be applied internationally irrespective of differences in healthcare
systems.
Reporting of surgical performance and quality
Since Florence Nightingale, attempts have been made to measure performance and make
comparisons between institutions. Nightingale together with William Farr first openly
published hospital mortality rates in 1857 (Spiegelhalter, 1999). They used these statistics to
galvanise public opinion to improve quality in poorly performing institutions. Similarly,
Ernest Codman encouraged the public reporting of surgical outcome in the early 1900s
(Neuhauser, 2002). Both Nightingale and Codman were however subject to criticism for their
methods - most notably because their data did not account for variation in case-mix.
Even today controversy exists regarding the use of publicly reported outcome measures
(Mohammed et al., 2009). One frequently cited concern is that surgeons may be less willing
to operate on high-risk patients if outcomes are openly reported (Schneider and Epstein,
1996). The Cardiac Surgery Reporting System has been collecting and publishing risk-
adjusted cardiac surgery mortality data for New York State since 1989 (Chassin et al., 1996).
32

Initial analyses suggested that, three years following the introduction of the public reporting
scheme, mortality after cardiac surgery decreased by 41% (Hannan et al., 1994). Some
authors, however, questioned whether this decrease in mortality reflected true improvements
in quality. Omoigui suggested that the apparent improvements may have occurred as a result
of changes in surgical case-mix (Omoigui et al., 1996). This study examined the referral
pattern of patients from New York to the Cleveland clinic in Ohio from 1989 to 1993. The
482 patients referred from New York were sicker than the other referral cohorts in the clinic
and had higher risk scores than those patients who remained in New York. Relative to the
Ohio referral group, those referred from New York State had an increased risk of mortality
[odds ratio of 1.7 (Confidence Interval 1.1-2.7), p=0.030]. Chassin and co-workers refuted
the data in the Omoigui study by arguing that the time period used by Omiogui and
colleagues was premature given that the first publicly reported outcomes were issued in late
1989 (Chassin et al., 1996). In addition, the referral numbers to the Cleveland clinic were
small in comparison to the total number of procedures performed in the comparable period in
New York. Ghali and colleagues argued that the dramatic improvement in mortality seen in
New York was not necessarily due to the reporting of outcome data (Ghali et al., 1997). Ghali
found a similar reduction in mortality despite the absence of statewide reporting in
Massachusetts. It is unknown whether this reflects a baseline improvement in mortality due
to medical advances or whether the positive effects from New York State diffused to other
regions. The concern that public reporting of outcome measures can lead to a change in
surgical case mix was further contested in a recent study reviewing surgical practice
following the publication of cardiac surgery mortality data in the UK (Bridgewater et al.,
2007). This study observed an increase in the number and proportion of high-risk patients
undergoing cardiac surgery after the introduction of public reporting of cardiac surgical
33

outcome. Despite concerns regarding the potential hazards of public reporting of outcome
data, this type of programme is likely to take on a wider role especially in the UK given
patients right to choose their treatment location (NHS Constitution, 2009). Hibbard and co-
investigators studied the effects on hospital performance of public reporting of quality of care
data versus reports for internal consumption and finally no feedback. Hibbard found that
public reporting and to a lesser extent internal feedback led to not only increased quality
improvement activity but also to improvements in performance in poorer performing
hospitals (Hibbard et al., 2005). The use of public reporting of outcome measures for quality
improvement purposes, however, remains questionable. A recent systematic review found
that although public reporting leads to quality improvement activity at a hospital level, it is
unclear whether this increase in activity translates into genuine improvements in quality
(Fung et al., 2008).
An alternative to public reporting is the production of reports for internal monitoring. The
National Surgical Quality Improvement Programme (NSQIP) provides an example of an
intervention that uses risk-adjusted quality metrics to drive quality improvement
(ACS/NSQIP 2009). This programme started amongst the Veterans Affairs (VA) hospitals,
following a legal mandate in 1985 for the VA to report their risk-adjusted outcomes
benchmarked against national figures (Davis et al., 2007). The VA was in a unique position
to create risk-adjusted models and began to inform sophisticated outcome measure reporting
through their own progressive information technology systems and centralised organisation.
Using this monitoring system the VA created NSQIP to encourage surgical quality
monitoring across all VA hospitals. With support of the American College of Surgeons
(ACS), this system is now disseminating to private hospitals as a means of reporting
34

outcomes. The ACS/NSQIP system uses a combination of semi-annual reports, ad hoc
reports and online reporting to feedback to individual hospitals. The reports are designed for
internal review rather than for public reporting, and are used as a basis to identify areas where
quality improvement initiatives can be implemented to improve outcomes and track the
results from such initiatives. Internal reporting of outcome data for quality measurement and
improvement is used in the UK based initiative, Dr Foster Intelligence. This is an online tool
that is used for timely analysis of outcome data through case mix adjusted cumulative sum
charts at a provider level to allow early identification of potentially poor performance and
prompt remedial action to improve the quality of care (Bottle and Aylin, 2008).
Irrespective of whether external or internal reporting is favoured, performance measurement
in surgery demands identification of appropriate and measurable outcomes that can be
accurately risk-adjusted and used to distinguish between good and substandard performance.
The risk-adjustment model should only adjust for those factors that are outside the control of
the system being measured. In the case of repair of fracture neck of femur, when assessing
surgical technique in isolation, adjustment should be made for the preoperative clinical state
of the patient as this is beyond the control of a surgeons technical skills. In contrast, for a
hospital level assessment, adjustment should be made for the state of the patient at admission,
but not for the degree of medical stabilisation prior to surgery or preoperative care as this will
impact on their survival, and is within the control of the system.
Mortality, although useful and relevant in elective cardiac and some abdominal surgery, is an
insensitive quality measure for most other elective procedures. As such, it is necessary to
define what constitutes appropriate quality measures for various surgical specialities.
35

Outcome measures are not necessarily the best way of defining surgical quality. Iezzoni
described outcome as the sum of patient factors, effectiveness of care and also random
variation between individual patients and providers (Iezonni, 2003). It follows that
institutional or surgeon-specific performance may be determined by random variation if
complete reliance on outcome measurement alone is used to define and benchmark quality in
surgery.
Measuring quality in surgery
The Agency for Healthcare Research and Quality defines a quality measure as a mechanism
that enables the user to quantify the quality of a selected aspect of care by comparing it to a
criterion (Center for Health Policy Studies, 1995). A useful quality metric is reproducible,
easily measured over time, objective, reliable and relevant to clinicians, health service
providers and patients (Bergman et al., 2006). These metrics must reflect the complexity of
the underlying processes and be resistant to the gaming effect where an organisation
manipulates a particular metric rather than improving the overall quality (Smith, 1995).
When used for comparison between surgeons or providers, a metric should be adjusted to
reflect variation in case mix, and be shown to be a valid proxy of overall quality.
Furthermore, the National Quality Forum in the US, in outlining their proposed criteria for
quality metrics, suggested that metrics should address a high impact area of healthcare, be
evidence based, relevant, feasible, reliable and credible. The measure should be usable by
the intended audience and be useful to distinguish between good and poor quality. In
addition, the National Quality Forum underlines the importance of risk-adjusting metrics
where possible. Using the Donabedian approach, (Donabedian, 1980) quality metrics may be
36

subdivided according to whether they represent structural, process or outcome measures
(Table 2.1).
37

Table 2.1: Advantages and disadvantages of quality metrics classified according to the
Donabedian approach.
Factor Example Advantages Disadvantages

Structural Surgical caseload Easily measured May not reflect changes in
outcomes
Can be improved through Over simplistic
system changes
Process Number of lymph Reflect agreed standards of Need to be directly related to
nodes harvested in care improved outcomes to be
oncological colorectal useful
resections
Reduce inequality in care Restrict the provision of
when used effectively individualised patient care
Usually not available from
routine data
Outcome Postoperative mortality Easily understood by Usually infrequent events
healthcare professionals and
patients
Can be collected through Can be crude measures of
existing data sources quality
Can be risk-adjusted to reflect
case-mix
38

Structural factors
Structural factors reflect characteristics that relate to the surgeon or the organisation.
Examples of structural factors include the number of subspecialist surgeons at an institution,
the nursing-to-patient ratios, the number of surgical beds, (Brook et al., 1996) and the
operative volume carried out at a given institution. Structural measures are potentially
attractive quality metrics as they are easily measured. The impact of operative volume, or
caseload, of a given procedure on performance has been subject to significant scrutiny
(Dimick et al., 2005). Indeed, a relationship between poor operative outcome and both low
surgeon or low institution volume has been demonstrated for a range of surgical procedures,
(Luft et al., 1979, Begg et al., 1998) including pancreatic resection, (Sosa et al., 1998,
Bentrem and Brennan, 2005) coronary artery bypass grafting, (Hannan et al., 2003, Wu et al.,
2004) orthopaedic, (Katz, 2001) and vascular surgery (Killeen et al., 2007, Holt et al., 2007a,
Holt et al., 2007b). The Leapfrog Group, an American alliance aimed at using employer
purchasing power to improve surgical quality and outcomes, has used the volume-outcome
relationship to determine payment and referral policy. (Leapfrog Group, 2007) For seven
elective procedures the alliance promotes Evidence-Based Hospital Referral (EBHR) that is
largely centred on hospital caseload. Surgical volume as a proxy measure of quality is also
being used in the English healthcare system to justify centralisation of upper gastrointestinal
cancer services with the aim of improving quality. Regional oesophagogastric cancer centres
in England should presently serve a population base of greater than 1 million people and
perform a minimum of 100 oesophageal and gastric cancer resections per year (Department
of Health, 2001). Volume as a quality metric is also being applied to colorectal surgery in the
UK. It is currently recommended that a colorectal surgeon should carry out a minimum of
twenty colorectal cancer operations per year (NICE, 2004). However, some surgeons argue
39

that the volume-outcome relationship may represent an oversimplification. It is possible that
volume identifies and remedies the problem associated with poor performers carrying out low
surgical volumes. However, this comes at the expense of surgeons who demonstrate good
performance but with low surgical caseload. A recent study, based on data from Clinical
Outcomes of Surgical Therapy randomised control trial, highlighted the possible role of
credentialing (i.e. establishing the proficiency of surgeons at a given technique) in
determining quality (Larson et al., 2008). This may account for good outcomes amongst
some low-volume surgeons. Discriminating between the relative independent impact of
credentialing and volume in determining quality within surgery requires further research
given the growing emphasis being placed upon caseload in service planning in many
countries. In addition to surgical caseload, outcomes following complex surgery have been
found to improve with better staffing in intensive care units and optimum nurse-to-patient
ratios (Dimick et al., 2001).
Process measures
Structural measures yield little information regarding the actual care received by individual
patients. In contrast, process measures seek to reflect the interactions that lead to effective
care. Process metrics frequently measure adherence to treatment standards or guidelines. As
quality metrics, these measures are attractive as they can be standardised and provide
information about the areas in which quality improvement may be focused. Surgical-specific
process measures are currently being sought both in the US and UK (ACS/NSQIP 2009, Care
Quality Indicators, 2009). The American Society of Clinical Oncology have derived a range
of surgical quality process measures for breast and colorectal cancer (Desch et al., 2008).
These metrics include provision of Tamoxifen or Aromatase Inhibitor in breast cancer, lymph
40

node harvest for colonic and rectal cancer resection and the timing of radiotherapy and
chemotherapy for breast and colorectal cancer. They aim to reflect the quality of operative
treatment as well as adjuvant care.
Process measures should, however, be directly linked to outcome to confirm their use as a
valid quality marker. This however can prove difficult (Evans et al., 2001). Pitches and
colleagues in a systematic review concluded that there was little relationship between process
measures and mortality. This conclusion was controversial as 51% (26/51) studies included in
their review did demonstrate such a relationship (Pitches et al., 2007). Exclusion of outlying
institutions from individual studies negated any relationship. Recently, there has also been a
growing appreciation of the variable use of some clinical processes in the perioperative
period such as early nutrition, (Fearon et al., 2005) epidural analgesia, (Gendall et al., 2007)
as well as goal-directed fluid administration (Noblett et al., 2006). Protocols, such as
enhanced recovery programmes (ERP), which incorporate a number of processes that are
each independently associated with high-quality care, have been shown to be clinically
effective at accelerating recovery in patients undergoing colorectal surgery (King et al., 2006,
Wind et al., 2006). More importantly, implementation of evidence-based care through ERPs
may also facilitate standardization of high-quality postoperative care and thus improve
outcome.
A single process measure is unlikely to capture all the main aspects of quality and may only
capture a fraction of the variation in outcome. This requires the combined use of several
measures, which can be problematic. One option is to use the proportion of patients for whom
all the evidence-based processes have been followed. However, providers adhering well to
41

one process may adhere very poorly to another, even in the same group of patients (Peterson
et al., 2006). Combining measures into one, for example by the use of a composite measure
(like a star rating system), requires a set of weights for this combination, and the choice of
composite measure has been shown to affect the relative performance (rankings) of hospitals
(Jacobs et al., 2005). An often-quoted advantage for process measures is that they do not
require case mix adjustment because the protocol to which they relate should be followed in
all patients. While this is true in theory, in practice the sicker and disadvantaged patients have
been suggested to have such protocols followed less often than other patients (Peterson et al.,
2006). Other than poorer standards of care, possible reasons for this could include greater
levels of contra-indications and patient refusal.
In addition to clinical processes, effective teamwork is associated with superior outcomes in
many different industries, including healthcare. Team working has certainly been associated
with better outcomes in intensive care units, (Shortell, 1991) and primary care (Bower et al.,
2003). Furthermore, it is central both to the delivery of healthcare and to its improvement.
Group information processes such as multi-disciplinary ward rounds have also been found to
be associated with lower mortality and morbidity rates, (Gurses and Xiao, 2006, Plantinga et
al., 2004) as well as a reduced incidence of prescription errors (Leape et al., 1999). In
addition, in the surgical context, Young and colleagues found that low-morbidity hospitals
had higher levels of team communication and coordination (Young et al., 1998). These
examples all suggest that teamwork is a critical mediator for the delivery of both safe and
high quality surgical care.
42

Outcome
Outcome measures are frequently used as quality metrics as they can be collected from
existing data sources. They seek to reflect the endpoint of the cumulative processes of a
patients care. Furthermore they may be objective (e.g. mortality) or subjective (e.g. patient
reported outcomes). When outcome measures represent either rarely occurring events (such
as postoperative mortality, surgical site infection rates (Fry, 2008), reoperation rates (Morris
et al., 2007a), or leak rates following elective gastrointestinal surgery), these can represent
blunt instruments with which to measure quality. Moreover, use of inaccurate data,
inadequate case-mix adjustment or even chance variation between patient outcomes may lead
to difficulty in interpretation of performance ranking. In turn, this may invalidate, or render
erroneous, subsequent service or policy decision-making.
Given that measures such as mortality and anastomotic leaks are infrequent events in most
surgical populations, consideration should be given to the sample sizes required to judge
whether outcome differences reflect true variation in performance or whether they reflect
patient factors or chance alone. Singh and co-workers calculated the necessary population
sizes required to detect underperformance using mortality as the outcome measure in radical
cystectomy (Singh et al., 2003). They found that, given an acceptable mortality rate of 3.5%,
a cohort of 211 patients would be necessary to demonstrate that a surgeon with an 8%
mortality rate was underperforming rather than this high mortality being due to chance or
case mix. Depending on the specialty, this may represent several years worth of patients.
Given the large number of patients required to detect significant variation in performance, it
may be necessary to combine performance indicators to derive a meaningful composite
measure that reflects quality. Superiority of empirically derived composite measures over
43

individual surgical quality indicators has recently been shown in the context of explaining
variation in mortality after aortic valve replacement surgery (Staiger et al., 2009).
Postoperative mortality represents one of the most commonly used surgical outcome
measures of quality. It has been used to examine performance in vascular surgery, (Holt et
al., 2008b) urology (Chalasani et al., 2009), and, following the Bristol inquiry, it has been
used to monitor cardiothoracic surgery outcomes in the UK (Keogh and R, 2003, Keogh et
al., 2004). Postoperative mortality represents an outcome measure that is easily collected,
can be validated and risk adjusted (Keogh et al., 2004). Although it is an important measure
of outcome, it is however a crude quality measure that, as mentioned previously, is relevant
only to a small number of high risk procedures where this outcome occurs routinely (Califf
and Peterson, 2009). As previously stated, public reporting of mortality data has raised the
concern that surgeons will either reject high risk patients or refer them elsewhere. In addition,
for mortality rates to be genuinely useful as a comparative measure they must be corrected
for case-mix differences and thus far risk adjustment has proved to be imperfect (also see
later section below) (Landon et al., 2003). Knowing that your unit has a high mortality rate is
not the same as knowing why that rate is high and how to reduce it.
Postoperative mortality is an example of an objective outcome metric. It does not however
reflect the patient experience, subsequent life expectancy or offer a subjective measure of
satisfaction. Patient Reported Outcome Measures (PROMs) are instruments that measure
patients illness experience. In the UK, it has been mandatory from April 2009 to collect
general and disease-specific PROMs before and following certain elective procedures
including inguinal hernia repair, varicose vein surgery, unilateral knee replacements and
44

unilateral hip replacements (Department of Health, 2009). Work is planned to assess the
degree of risk adjustment required for these measures.
Specific measures assess the impact of a single disease or system on a patients wellbeing.
Disease-specific questionnaires include the Oxford knee score for patients undergoing total
knee replacements, (Dawson et al., 1998) and European organisation for research and
treatment of cancer (EORTC QLQ CR38) questionnaire, which is the most commonly used
disease-specific measure in colorectal cancer patients (Gujral et al., 2008). Generic measures
such as EuroQol 5D and SF-36 evaluate the overall quality of life irrespective of underlying
pathology. PROMs highlight the importance of considering quality from the patients
perspective. It may be argued that, as the healthcare user, the patients view of the impact of
a treatment is the most significant measure of quality.
The relationship between structures, processes and surgical outcomes is complex. NSQIP has
made an attempt to understand the latter relationship (ACS/NSQIP, 2009). Risk-adjusted
outcome data that were routinely collected from the VA hospital sites were analysed against
observations made during site visits (Daley et al., 1997), as well as responses on a survey of
structure and care processes from the same sites (Schifftner et al., 2007). The results were
mixed. The researchers found that risk-adjusted morbidity bore close correlation with
observations of the quality of care observed during the site visits. However, the survey
responses did not demonstrate this association between outcomes and processes of care.
Regardless of the slightly conflicting findings of these studies, what is important is that the
NSQIP has made an attempt to explain how variability in the structure of surgical teams and
the use of care processes may explain some of the variability in outcomes identified across
45

surgical units. Furthermore, perhaps their findings from the site visits suggest that the ideal
approach to measuring quality involves quantifying a combination of structural and process
measures as well as outcomes. Lilford and colleagues argue that while outcome measures are
useful, for internal consumption, to monitor trends within an organisation, process measures
may be more fair to make comparisons across organisations (Lilford et al., 2004). The
collective appraisal of all these factors might permit a more global appraisal of surgical
service quality and allow fair comparisons to be made across institutions.
In addition to choosing the appropriate quality measures to examine, the timing and
population to which to apply these measures needs to be ascertained. Due to ease of
collection, outcome measures are often defined as in hospital complications. Post-discharge
complications require dedicated resources to collect. Bilimoria and colleagues found that
inclusion of post-discharge complications did change the outlier status of some institutions
(Bilimoria et al., 2010a). The additional expense of collecting such variables is likely to
preclude inclusion of out of hospital events in performance monitoring unless linkage to other
datasets such as general practice databases is performed. Surgical practice can be broadly
divided into emergency and elective admissions. For some conditions, such as colorectal
cancer some emergency admissions will represent a failure to diagnose a condition at an early
enough stage. Many existing outcome measures focus on elective practice. Emergency
admissions tend to have poorer outcome and involve a different care pathway than elective
admission. Institutions may perform well in elective surgery but poorly in emergency surgery
(Ingraham et al., 2011).
46

Risk-adjustment and statistical considerations in quality measurement
Variation in measured performance is not solely due to variation in the quality of care. For
performance measures to be meaningful and reliable, adequate risk adjustment is essential
(Shuhaiber, 2002, Krumholz et al., 2006). Ptok and colleagues demonstrated, using German
data, that risk adjustment largely negated apparent marked differences in unadjusted
mortality rates between two providers emphasising the need to account for patient factors in
any comparisons (Ptok et al., 2011). The literature is awash with scoring systems that attempt
to account for patient-related variation. One of the simplest systems is the American Society
of Anaesthesiologists Classification (ASA). This is a tool to assess the physical status of a
patient prior to undergoing surgery (Davenport et al., 2006). This system has the benefit of
being easily applied but is subjective with low inter-observer reliability (Mak et al., 2002).
The NSQIP risk-adjustment system is the most commonly used robust scoring system in the
US. It contains 60 clinical variables and was developed and validated from procedures
performed in VA hospitals (Khuri et al., 1997, Khuri et al., 1998). Use of ASA alone for risk
adjustment has been compared with the use of all the NSQIP variables for adjustment
(Davenport et al., 2006). Although ASA was a strong predictor of morbidity or mortality,
using the all the NSQIP variables to risk adjust improved prediction. In addition, the authors
cautioned against the use of ASA given its subjective nature. The NSQIP methodology is
widely used in the US NSQIP quality improvement programme (2009a). It, however, requires
input of a large number of variables making it complex and less user friendly. The
Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity
(POSSUM) is a British scoring system that contains only 12 physiological and 6 operative
variables and is used to predict mortality in surgical patients (Copeland et al., 1991). This
system has been validated for patients undergoing vascular and colorectal surgery (Midwinter
47

et al., 1999, Sagar et al., 1994, Al-Homoud et al., 2004). POSSUM has been used previously
to risk-adjust mortality and morbidity when benchmarking surgeon performance (Sagar et al.,
1996). POSSUM is useful both because of its reduced number of variables and it takes into
account the impact of surgical as well as patient factors. The Portsmouth POSSUM (P-
POSSUM) and Colorectal-POSSUM (Cr-POSSUM) are adaptations of this system (Prytherch
et al., 1998, Tekkis et al., 2004).
Despite the apparent validity of many existing risk adjustment methods, surgeons remain
reluctant to have their performance measured following risk adjustment using these systems.
In a questionnaire of American surgeons in hospitals involved in the roll-out of the NSQIP
programme to the private sector, Neuman and co-workers determined that only 46% of
surgeons believed that surgeon-specific outcomes should be reported (Neuman et al., 2009).
Furthermore, only 24% of respondents felt that the NSQIP risk-adjustment system should be
used to determine pay for performance.
The statistical methods used to differentiate performance between providers or healthcare
professionals have been the subjects of much debate. To assist policy and decision-making,
these methods must serve two purposes. Firstly, statistical methods must enable appropriate
discrimination between good and poor performers for a particular quality metric. In addition,
they should enable sequential monitoring to rapidly identify temporal changes in quality. The
use of league tables, funnel plots and control charts for these purposes are described below.
Bilimoria and colleagues used the NSQIP database to compare several methods of identifying
outliers at the hospital level in general and colorectal surgery (Bilimoria et al., 2010b).
Included outcome measures were 30 day mortality and complications. They compared
48

identification of outliers using a standard logistic regression with a confidence intervals set at
90%, 95% and 99% with hierarchical analysis and rankings based on quintiles or quartiles.
Each method yielded a difference number of outliers for mortality and morbidity.
Hierarchical and single level logistic regression analyses offered similar numbers of outliers.
This study did not assess techniques such as funnel plots or control charts.
League tables and caterpillar plots have been used to describe performance data within
healthcare. Caterpillar plots have however been criticised as they can be difficult to interpret,
do not take into account the issues of multiple testing and cannot be used for sequential
testing (Mohammed and Deeks, 2008). Furthermore, by their nature, these plots do invite the
user to rank institutions. This may be hazardous if not appropriately adjusted for case-mix
differences. Moreover, a minimum volume of cases appropriate to the performance outcome
being measured is required for meaningful analysis. Specifically, poor performance at low
volume levels can occur by chance and this method fails to permit its distinction from
genuinely substandard care. Funnel plots were originally described as a means of identifying
publication bias in meta-analyses (Egger et al., 1997), but Speigelhalter first suggested using
funnel plots to examine performance between institutions (Spiegelhalter, 2002). Mayer and
colleagues have recently published a comprehensive review on the use of funnel plots in
surgery (Mayer et al., 2009b). Funnel plots have been used to compare outcomes in patients
undergoing interventions including cardiac, (Stark et al., 2001) and upper gastro-intestinal
surgery (Tekkis et al., 2003a). They represent a graphical presentation of outcome data
adjusted for caseload. Aberrant institutions, or outliers, represent those that demonstrate
variation outside the common cause variation i.e. special cause variation, thereby
prompting further investigation (Marshall et al., 2004). Their principal disadvantage,
49

however, is their inability to efficiently represent sequential changes in performance over
time. Control charts (and recently cumulative funnel plots (Kunadian et al., 2008)) have been
used in recent years to overcome this problem. They were first devised by Shewhart to
improve quality in the industrial setting (Shewhart, 1939). Along with a curve expressing the
average, limits denoting the upper and lower control ceilings are illustrated. Several different
control charts are in use in healthcare, (Thor et al., 2007) including charts based on a
cumulative sum (CUSUM) technique (Aylin et al., 2003). These charts can detect sustained
minor differences between the observed performance and the benchmark and trigger an alarm
when the set control limit or threshold is breached. A systematic review of the statistical
process control approach in healthcare found that control charts were useful in many settings
including surgery, primary care as well as in the monitoring of chronic disease in individual
patients (Thor et al., 2007). These charts have been used retrospectively to detect aberrant or
unexpected performance such as that seen following the Bristol cardiac paediatric surgery
case, (Mohammed et al., 2001) and in the Shipman case (Mohammed et al., 2001, Aylin et
al., 2003). In the latter, Aylin and co-investigators, used the CUSUM chart to examine
primary care data to investigate General Practitioners with significantly high patient mortality
(Aylin et al., 2003). Using this chart, they concluded that Dr Shipman would have been
identified as demonstrating special cause variation, potentially prompting earlier
investigation of his practice. Similarly, a recent article by Coory and colleagues examined 30-
day in-hospital mortality rates following admission for acute myocardial infarction using
administrative data (Coory et al., 2008). This study aimed to compare funnel plots with
sequential monitoring using control charts. Although when using the funnel plots no outliers
were identified above the three standard deviation threshold, on the control charts 5 of the 18
hospitals were flagged as having a relative risk increase of 75% or greater. The authors
50

suggested that control charts allowed earlier identification of potential problems permitting
more timely investigation of units. As with all statistical methods, however, control charts do
have certain disadvantages. Firstly, the threshold settings for the control limits require careful
consideration. If the alarm is triggered frequently, then the chart is likely to be discredited
(Lim, 2003). Secondly, as these charts were designed for the high-volume industrial setting,
they do require a certain case load to permit their use as an effective performance monitoring
technique (Lim, 2003). Finally, due to imperfect risk-adjustment methods, the triggering
alarm may not represent true poor performance but rather variation due to alternative factors.
Measurement of quality in colorectal surgery
Several quality measures have been suggested in colorectal surgery (Almoudaris et al.,
2010a). These may also be divided into structure, process and outcome measures according to
the Donabedian approach. An exhaustive list of possible measures is not within the remit of
this chapter. However, the important or frequently used measures are summarized below.
Structure
Role of caseload
Similar to other areas of surgery, volume has been suggested as a quality measure and a
means of improving quality in colorectal surgery. There is an abundance of literature
suggesting a relationship between surgeon and hospital caseload and complex surgical
procedures such as oesophagectomy (Bilimoria et al., 2008a), abdominal aortic aneurysm
repair (Holt et al., 2007a) and cardiothoracic procedures (Hannan et al., 2003). The volume
outcome relationship in colorectal surgery is less clear. Research has focused on the
51

relationship of caseload with a variety of outcome measures following mostly cancer surgery
with few studies looking at the volume outcome relationship in other diseases such as
inflammatory bowel disease and diverticular disease. A myriad of volume thresholds have
been suggested using a plethora of different methodologies. In the US, a high volume
hospital has been defined as anything from 25 colorectal procedures per year to over 125
procedures per year (Rabeneck et al., 2004, Bilimoria et al., 2008a). Given the lack of
consensus as to what constitutes a high volume surgeon or hospital, it is difficult to draw
meaningful conclusions from the literature. For colonic surgery, some studies have found a
relationship between hospital volume and mortality (Ko et al., 2002, Hannan et al., 2002,
Birkmeyer et al., 2002, Callahan et al., 2003, Ho et al., 2006, Schrag et al., 2000, Schrag et
al., 2003) while others have failed to find such a relationship (Morris and Platell, 2007,
Billingsley et al., 2007).
The Association of Coloproctology of Great Britain and Ireland (ACPGBI) have proposed a
minimum volume per surgeon of 20 colorectal cancer cases per year (2007). This is based on
an audit of colorectal cancer outcome amongst surgeons in the northern region of England
(Borowski et al., 2007). In this study high volume surgeons were considered as those who
performed more than 18.5 elective and emergency colorectal cancer resection per year. High
volume surgeon caseload correlated with higher rate of restorative surgery and reduced
perioperative mortality. Few other studies corroborated Borowski and colleagues initial study
thresholds. Though the same study group, three years later, categorised a high volume
surgeon as those that performed greater than 40 procedures per year. At these volume
thresholds, operative and long term survival was better amongst higher volume surgeons
(Borowski et al., 2010). Both McGrath and colleagues in an Australian study and Hermanek
52

and colleagues in a German study, using greater than seventeen resections per year and
fifteen per year respectively to define the high volume threshold, failed to find an association
between colorectal surgeon caseload and outcome (McGrath et al., 2005, Hermanek and
Hohenberger, 1996). In the volume literature a variety of approaches have been taken for
volume. Some of these have been statistical and some have used a priori thresholds to define
volume groups. Of the statistically defined methods, most studies have divided the patients
or providers into equal groups. Studies have divided providers into three (tertiles) (Harmon
et al., 1999, Miller et al., 2004, Simunovic et al., 2000, Harling et al., 2005, Meyerhardt et al.,
2003), four (quartiles) (Borowski et al., 2010, Borowski et al., 2007, Kee, 1999, Rogers et al.,
2006) or five (quintiles) (Bilimoria et al., 2008a) groups. Some studies though have treated
volume as a continuous measure (Ho et al., 2006, Ko et al., 2002, Panageas et al., 2003,
Schrag et al., 2000).
In modern day colorectal practice, some questions regarding the role of caseload remain
unanswered.
1. Is there a relationship between hospital and surgeon volume and quality of care or
have we negated this by specialised care?
2. If such a relationship exists, which is the critical factor, the surgeon or the hospital
volume?
3. Furthermore, if such a relationship exists, what is the optimal provider volume for
best care?
4. If hospital volume is important, are there hospital characteristics such as radiology
services that are significant in this volume effect?
53

5. Is overall resection volume important or just cancer volume? Can an Inflammatory
Bowel Disease (IBD) surgeon perform and offer quality perioperative care for cancer
resections
We seek to begin to answer these questions in subsequent chapters.
Processes
Lymph node yield
Lymph node yield has been proposed as a marker of surgical quality. Guidelines suggest that
at least 12 regional lymph nodes are removed and pathologically examined for resected colon
cancer. Identification of at least 12 lymph nodes has been strongly correlated with colorectal
surgical training and surgeon case volume (Dillman et al., 2009, Miller et al., 2004).
However, in the US less than 40% of institutions achieved identification of more than 12
lymph nodes in at least 75% of their cancer resections (Bilimoria et al., 2008d). Furthermore,
Wong and colleagues failed to find an association between hospital lymph node yield and
patient survival and other process measures such as use of adjuvant chemotherapy (Wong et
al., 2007). A systematic review, however, suggested that lymph node yield correlated with
survival for stage II and stage III disease (Chang et al., 2007). In addition, lymph node yield
may be a useful measure of institutional quality as it reflects both the surgeons technical skill
and the pathologists ability to identify lymph nodes in the resected specimen. Its use for
assessing individual surgeons may consequently be limited.
Use of laparoscopy in colorectal resections
NICE guidelines in 2006 suggested that laparoscopic colorectal cancer resection should be
offered to suitable patients where the surgeon has the necessary skill to perform such a
54

resection (NICE, 2006). One study suggested that laparoscopy improved the quality of rectal
resections in rectal cancer (Gouvas et al., 2009). Variation in use of laparoscopy may reflect
patient characteristics but also surgeon and institutional factors such as age of surgeon,
innovation or size of institution. Use of laparoscopy should be tailored to individual patients
but wide variation between providers will reflect more than differences in case mix.
Abdominoperineal excision (APE) rate
Considerable variability in surgical techniques employed between individual surgeons has
been observed (McArdle and Hole, 1991). APE involves resection of the rectum along with
the anal sphincters necessitating a permanent colostomy. Anterior resection with or without a
covering ileostomy has been suggested to be oncologically superior to APE (How et al.,
2011). Tilney and co-workers suggested use of abdominoperineal excision (APE) versus
restorative anterior resection for rectal cancer as a surrogate marker for surgical quality in
elective rectal surgery (Tilney et al., 2008). A recent systematic review found that anterior
resection was associated with reduced tumour perforation and circumferential resection
margin (CRM) involvement as well as improved survival and local recurrence rates (How et
al., 2011). Morris and co-workers, examined variation in APE rates across the English NHS
using administrative data linked to cancer registry data (Morris et al., 2008). This study found
significant variation in the use of APE in rectal cancer across the health service in England
re-emphasising the potential of APE rates as a quality measure. It is important to state that
not all rectal cancers are amenable to excision by anterior resection nor have substantial
differences in postoperative quality of life been noted between anterior resection and APE
(Cornish et al., 2007). The Association of Coloproctology of Great Britain and Ireland
(ACPGBI) have recommended that the number of resectable rectal cancers treated by APE
55

should be less than 30% of rectal cancer resections (ACPGBI, 2007). Process measures like
APE rates and the quality of surgical excision by histological examination of the plane of
surgical dissection can be used to measure aspects of surgical quality in rectal cancer
treatment (Quirke, 2003).
Participation in National Audit
Participation in National Audit is central to good clinical practice and governance in all
specialties including colorectal surgery (NBOCAP, 2004). Registries exist for colorectal
cancer and restorative proctocolectomy. These registries aim to improve quality through
national audit. Indeed, Almoudaris and colleagues found that those organisations that did not
submit to the National Bowel Cancer Audit Project (NBOCAP) had higher mortality rates
than those that did submit (Almoudaris et al., 2011). The reasons for this discrepancy are
unclear. The infrastructure necessary to allow submission may reflect a better organized
institution with improved care processes and therefore better outcome.
Outcome
Mortality
Mortality is a quality measure that has been historically relied upon and one of the most
widely recognised measures of surgical quality (Morris et al., 2011b). In the elective setting,
postoperative mortality following colorectal surgery occurs infrequently making it an
insensitive alert to poor performance and requiring many cases to meaningfully identify
outliers. A long audit period is required for it to be statistically stable. Commonly used
definitions such as all cause mortality and 30 day in hospital mortality do not discriminate
between all deaths and those that are potentially preventable. Finally, many failures in care
56

do not always lead to death. The effect of public reporting of mortality data in colorectal
surgery is unknown.
Length of stay and readmission
One of the main determinants of the cost of an admission is the length of in hospital stay
(LOS). Optimum length of stay is desirable from the provider and patients viewpoints.
Programmes have been designed to reduce length of stay such as ERP (Wind et al., 2006).
Considerable variation in LOS across institutions has been demonstrated following colorectal
surgery in England and in the US (Cohen et al., 2009, Faiz et al., 2011b). Fry and colleagues
suggested that prolonged length of stay correlates well with adverse events and is a good
quality measure (Fry et al., 2009). Though prolonged LOS has been proposed as a useful
quality measure that can be used to drive quality improvement, caution should be applied
when assessing individual surgeons with this metric. LOS is not always within the surgeons
control and may reflect other factors such as availability of rehabilitation services and
coordination of discharge planning.
Readmission has become increasingly important with the suggestion that providers will not
receive reimbursement for emergency readmissions after surgery. This will be especially
significant in the context of the ERP where shorter LOS may be offset by increased
readmissions. Distal bowel resection, benign diagnosis, young age, and social deprivation
were predictors of readmission following colorectal cancer resection (Faiz et al., 2011b).
57

Reoperation
Postoperative reoperation has been suggested as a useful quality marker in the United States
for general surgery (Birkmeyer et al., 2001), more recently for colorectal surgery (Morris et
al., 2007a, Merkow et al., 2009) and in the UK for vascular surgery (Holt et al., 2009a).
Reoperations following colorectal surgery are undertaken mostly for surgical morbidity such
as postoperative bleeding or anastomotic leaks. Reoperation is associated with poor clinical
outcome including higher risk of early death and local recurrence as well as poorer overall
survival (Mirnezami et al., 2011). A small single centre study found that approximately 50%
of reoperations could be a result of technical failure (Isbister, 1998). In a review of quality
indicators using the Delphi technique a multidisciplinary team suggested that anastomotic
leak following surgery should be an outcome measure used to assess surgeon quality
(Gagliardi et al., 2005). This review prioritized 30 day mortality as an outcome measure but
did not prioritize readmission, LOS or unplanned return to theatre. From administrative data
it is likely that a substantial portion of reoperations represent anastomotic leaks. A measure
such as reoperation, when taken alongside other accepted measures such as mortality,
potentially offers a sensitive and relevant marker of surgical quality.
Quality in surgery and specifically in colorectal surgery is a broad subject. Defining and
measuring surgical quality is aimed towards improving quality of care experienced by
patients. This thesis seeks to derive new possible measures from routinely collected data to
allow measurement of quality and performance benchmarking if data accuracy can be
assured.
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Chapter 3- Data sources for quality measurement.
Irrespective of the structural, process or outcome metrics employed to appraise quality, data
sources are necessary from which to derive these measures. These sources need to be reliable
for the specified use and relevant to the purpose or group to which the metrics are being
directed. In broad terms current external data sources, i.e. beyond individual surgeon or
departmental audit, include routinely collected administrative data sets and clinical registry
data.
Routinely collected datasets
Routinely collected datasets are primarily collected for administrative reasons. In the US,
they are used for insurance and billing purposes. In the UK, administrative datasets are used
for hospital reimbursement through the Payment by Results system and for healthcare
management purposes as well as being increasingly used to audit hospital performance by
agencies such as the Care Quality Commission (Care Quality Commission, 2009).
In the UK, there are four separate routinely collected datasets for England, Scotland, Wales
and Northern Ireland. The Hospital Episode Statistics (HES) is the dataset for England. The
Information Services Division Scotland (ISD) database is the routinely collected database in
Scotland. The HES dataset comprises data for every hospital admission that takes place in
England. These data can be used to examine regional procedure rates and outcome measures
59

such as inpatient mortality and length of hospital stay but, through linkage to other national
datasets, can also be used to measure other outcome such as out of hospital mortality. These
outcome measures have been used to compare inter-centre variability (Jarman et al., 1999).
HES data have been collected since 1987 from all inpatient admissions in NHS trusts in
England. The database contains clinical information about primary and secondary diagnoses,
procedures and patient level information such as age group, gender, postcode and ethnicity.
The database contains information on waiting list time, date and mode of admission. The
main unit of the dataset is the Finished Consultant Episode (FCE). The FCE is defined as the
period of admitted patient care under a consultant or allied healthcare professional within an
NHS trust (www.hesonline.nhs.uk). Each episode has an assigned primary diagnosis and up
to 20 secondary diagnoses which are currently coded using International Classification of
Disease (10th revision) (ICD-10) with procedures categorised with up to 24 procedure fields,
coded using the Office of Population Censuses and Surveys Classification of Surgical
Operations and Procedures (4th revision) (OPCS-4).
HES data have been linked to other national datasets such as the Office of National Statistics
and the Cancer Registry for additional clinical and outcome information such as out of
hospital mortality and tumour staging (HES/ONS methodology, 2002, Morris et al., 2008).
HES have been previously used to examine outcome measures such as mortality, unplanned
readmission and length of stay. Complications such as reoperation have been published and
used to benchmark hospital performance using American administrative data (Birkmeyer et
60

al., 2001, Morris et al., 2007a). Such a measure has not been previously reported using a UK
administrative dataset for colorectal surgery. Recently, Holt and colleagues examined re-
interventions on the index admission following abdominal aortic aneurysm repairs (Holt et
al., 2009a).
In the US, there is no single nationwide dataset. Administrative databases are, however,
maintained by state and federal governments as well as private health insurers. Three
examples of such databases maintained in the US are described below. Medicare, a federal
initiative, has since 1965 provided health insurance for those over 65 years of age and people
with disabilities and end stage renal failure (Iezonni, 2003). In 2000, Medicare served 39
million people - 14% of the US population (DeParle, 2000). Separate from Medicare, the
Department of Veterans Affairs (VA) provides patient care for veterans and their dependants.
As stated previously the VA have dedicated substantial efforts to improving information
capture for performance monitoring through NSQIP (ACS/NSQIP, 2009). Medicaid
represents another major US healthcare provider that is a combined state and federal
program, (Iezonni, 2003) which provides cover to those with disabilities as well as long-term
care for older people. In 1998 Medicaid provided coverage for more than 15% of the US
population (DeParle, 2000).
Unlike American datasets, HES data cover all of England and therefore afford a national
overview of practice and outcome. Routinely collected datasets in the US employ ICD-9-CM
diagnosis coding whereas in the UK ICD-10 is used. The codes used to denote procedures
61

also differ. These differences can lead to difficulties in translating clinical indicators from
the US to UK (Bottle and Aylin, 2009, Raleigh et al., 2008).
Clinical databases
To examine inter-institutional variation in surgical provision and outcome, large databases
are required. These databases may be clinical or routinely collected datasets. The largest UK
colorectal clinical dataset is the National Bowel Cancer Audit Project (NBOCAP) database.
This dataset was originally set up under the auspices of the Association of Coloproctology of
Great Britain and Ireland (ACPGBI). This audit project is administered by ACPGBI and the
National Clinical Audit Support Programme. It has previously been used to examine
variation in surgical practice for colorectal cancer, to describe outcome following colorectal
resections for cancer and derive predictive models of mortality (Tilney et al., 2009, Tan et al.,
2007, Tekkis et al., 2003b). Furthermore annual reports are produced describing national
process measures such as APE rates, circumferential margin clearance rates, permanent
stoma rates and use of laparoscopy as well as outcome measures such as postoperative
mortality. However, not all NHS Trusts submit data to this audit and data completeness
remains problematic (NBOCAP, 2009). Case ascertainment was estimated at 69% in the
latest report (NBOCAP, 2009).
Clinical databases contain data relevant to a specific clinical condition or procedure. Data are
usually collected through voluntary submission from clinicians or institutions and cover a
wide range of clinical information concerning patient demographics, treatment and outcome.
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Often these databases are set up under the auspices of specialist societies with an interest in a
particular condition or procedure. A clinician or allied healthcare professional usually
submits the data. This attempts to ensure the accuracy of the data and also gives clinicians a
sense of ownership of the data. Furthermore, outcome data can be tailored to the specific
disease or condition for example quality of life data or data on postoperative function.
Submission to these datasets is not mandatory (Almoudaris et al., 2011). Bias may be present
or perceived as those who have feel that they deliver optimum care maybe more likely to
submit data. This makes comparisons between clinicians or institutions using these datasets
problematic. Moreover, as these datasets are often under the direction of specialist societies
rather than direct government control, there is a question of how to investigate those
clinicians or institutions that appear to be outliers.
National Surgical Quality Improvement Program
The National Surgical Quality Improvement Program (NSQIP) is endorsed by the American
College of Surgeons and is a large scale audit project involving all Veteran affiliated
hospitals. This program is also being rolled out across many private hospitals (2009a). The
aim of this audit is to use benchmarked internal data feedback to facilitate quality
improvement. Each hospital submits data collected by a trained research nurse. This audit
uses a sampling technique rather than collecting data about all patients admitted to
participating hospitals. Much work has been performed to refine the risk adjustment of the
data to facilitate bench marking between institutions (Khuri et al., 1998, Khuri et al., 1997).
NSQIP has been extensively used for population based studies in a broad range of surgical
specialties (Abedi et al., 2009, Lancaster and Hutter, 2008, Campbell et al., 2008, Bilimoria
63

et al., 2008b, Bilimoria et al., 2008c). In the US, NSQIP data are considered the gold standard
(Fink, 2009). However data collection is expensive, time consuming and selective requiring
additional trained staff (Kaafarani and Rosen, 2009).
The cost of maintaining HES data has been estimated at 1 per record with clinical registry
data costing up to 60 per record (Raftery et al, 2005). Given the low cost and universal
nature of routinely collected data, they offer an attractive potential source of benchmarking
performance and quality in healthcare.
Advantages and disadvantages of routinely collected data
Table 3.1 summarises the advantages and disadvantages of using HES data. Despite the
advantages of size, low cost (per record) and ease of collection, routinely collected datasets
do have weaknesses. In keeping with their administrative origins they collect limited clinical
information and the data input is by non-clinicians. The routinely collected databases do not
currently collect subjective measures of performance that might afford patient-centred
performance benchmarking. In England, the independent healthcare regulator, the Healthcare
Commission, which has recently been reorganised into the Care Quality Commission, carries
out yearly patient surveys designed to systematically gather patients opinions regarding the
care that they have received (Care Quality Commission, 2009). These surveys cover a broad
range of enquiry into a patients experience. The Care Quality Commission uses the results of
this survey as part of a global assessment of performance when rating healthcare providers.
To date these have been not been linked to the HES dataset.
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Table 3.1: Advantages and disadvantages of HES data
Advantages of HES data Disadvantages of HES data

Inexpensive Non clinicians coding data may reduce accuracy
Non clinicians coding data may ensure objectivity of coding
National Data quality concerns
Inclusive of all practitioners, diseases and
Lack of clinically relevant information
conditions
Many years of data Limited outcome and process measures
Linked episodes for longitudinal analysis
Potential linkage to other data sources
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The accuracy of coding is variable. Campbell and co-workers, in a systematic review of UK
administrative data published in 2001, found a median accuracy for coding of 91% for
diagnostic codes and 69.5% for procedure codes (Campbell et al., 2001). There have been
system changes since this review. Some authors suggest that the quality of HES data is not
yet sufficiently robust to use for public reporting of routine activity and outcome monitoring.
However, predictive models derived from HES data have been shown to be as accurate as
those derived from vascular, cardiac and colorectal clinical registry data for predicting
mortality for three common procedures (Aylin et al., 2007a). Aylin and colleagues compared
risk prediction models derived from HES for isolated coronary artery bypass graft (CABG),
abdominal aortic aneurysm repair (AAA repair) and colorectal cancer resection to those
published from the national cardiac surgery database, the national vascular database and the
colorectal cancer database. Good agreement, measured by Receiver Operating Characteristic
score, was found between the models derived from HES and those derived from clinical
registries (CABG HES 0.77 Clinical registry 0.78, ruptured AAA repair HES 0.66 Clinical
registry 0.65, unruptured AAA repair HES 0.74 Clinical registry 0.70 and colorectal cancer
resection HES 0.80 Clinical registry 0.78) (Aylin et al., 2007a). At a national level HES has
been shown to be more comprehensive, and at least as accurate, as the Association of
Coloproctology of Great Britain and Ireland (ACPGBI) colorectal cancer database and the
National Vascular database (Garout et al., 2008, Aylin et al., 2007b). Garout and colleagues
compared case volume and postoperative mortality for patients undergoing colorectal cancer
resection with the ACPGBI database.(Garout et al., 2008) HES reported 12% more
procedures than ACPGBI in 2001-2002 in Trusts than submitted to the database. ACPGBI
reported 5.8% mortality with 5.6% reported on HES. It must be stressed that the definitions
of mortality differed between HES and the ACPGBI database. 30 day in hospital mortality
66

was available on HES whereas in and out of hospital mortality was reported on the ACPGBI
database. Aylin and colleagues similarly compared volume and mortality for patients
undergoing a range of vascular procedures including AAA repair, carotid endarterectomy and
infrainguinal bypass (Aylin et al., 2007b). For those Trusts that submitted data to both
databases, 8461 more cases were reported on HES (HES 16923 and Vascular database 8462).
When only the consultant teams that were known to submit data to the registry were included
in the analysis, HES still had 2141 more cases than the vascular registry. Amongst these
patients, there were no differences in mortality between the two datasets. Westaby and
colleagues compared congenital heart surgery as reported on HES with that reported on the
central cardiac audit database (CCAD) (Westaby et al., 2007). The authors reported that the
HES database included less cases and underestimated mortality when compared to CCAD.
However, similar to the study by Garout and colleagues (Garout et al., 2008), the definition
of mortality differed between the two databases with the CCAD recording in and out of
hospital mortality whereas just in hospital mortality is available on HES. Furthermore,
Westaby looked at a wider range of procedures and the coding differed between studies
leading to the discrepancies in the included procedures and hence numbers.
There have been changes in the use of routinely collected data with the introduction of
Payment By Results (PbR scheme). This is an initiative directing healthcare funding based
on information drawn from coding data. An individual Trusts payment is based on the
activity carried out at the hospitals within the Trust. Tariffs are adjusted for case mix. Each
episode of patient care gets coded into a tariff, the Healthcare Resource Group (HRG). It is
this HRG that determines hospital payment. A clinical audit programme was carried out for
the first time in all acute NHS trusts in 2007-08, including over 50,000 episodes equating to
67

73 million under the PbR scheme (Audit Commission, 2008). Results of the audit showed
that errors in coding were having a significant impact on payment accuracy. Average error in
Healthcare Resource Group (HRG) coding was 9.4% with a range of 0.3% to 52% across
trusts reflecting a gross error of 3.5 million or 5% of the sample size. Although the net
financial impact was close to zero, there were a number of cases where the net local financial
impact was significant. The NHS operating framework for 2008-09 calls on organisations to
focus on clinical coding in the drive for world class patient care (Department of Health,
2007). The focus on accurate coding alongside the link to financial reimbursement may have
improved coding accuracy.
Prior to the reliance on routinely collected hospital data for identification of substandard
performance at either an institutional or surgeon level, validation of the data source, as well
as of the metric that is being used to denote the quality of a given care pathway, is a pre-
requisite. It is difficult to quantify coding accuracy and in particular amongst surgical
patients. The Audit Commision report assesses a sample of case notes across all Trusts. The
focus is not exclusively on surgical patients. In order to attempt to answer this question in the
modern day setting with current information technology system, the focus on data accuracy
and following the introduction of the PbR scheme, a systematic review of data accuracy
recorded in the existing literature was performed. The primary objective of this study is to
identify and review studies investigating the accuracy of hospital episode data. Secondary
objectives are to investigate factors influencing variation in coding errors.
The accuracy of routinely collected data can be assessed against various standards. In this
review the gold standard is assumed to be where coding is compared to that derived from
68

independent assessment of the case notes. This requires reliable data within the case notes.
In some studies, where indicated, coding is compared to other sources such as clinical
registry data. Each system is subject to possible inaccuracy as the data quality depends on
those inputting the data. In addition, registries may not use OPCS or ICD 10 to code data
further introducing inherent differences. Therefore, in this review, studies that use clinical
registry data are considered separately from case note review studies.
Systematic review of accuracy of routinely collected data
Methods
The measurement tool for assessment of multiple systematic reviews (AMSTAR), which
consists of 11 items for assessing methodological quality of systematic reviews was
employed (Shea et al., 2007).
Literature Search
We searched PubMed, EMBASE, The Cochrane Database and Ovid. Studies assessing the
accuracy of hospital coding data from Great Britain were identified. Studies published from
1989 to present were included.
Search terms included
1. Scottish Morbidity Record, OCD, SMR, OPCS, ICD (MeSH), HES, HAA
2. Classification, nomenclature (includes vocabulary controlled)(MeSH), Medical
records (MesH), Medical records, computerised (MeSH), Medical Record Linkage
(MeSH), Registries (MeSH), Forms and record control, clinical coding.
3. Accuracy (Ti/Ab), Quality (Ti/Ab)
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4. Limit year 1989 to present
5. Great Britain
6. 5 and 6
7. 1 and 3
8. 2 and 3
9. 1 and 2 and 3
10. 6 and (7 or 8 or 9)
Using the search term PEDW did not yield any further relevant articles.
References of the articles identified were also hand searched for further relevant articles. In
addition, expert knowledge of potential further sources such as the Audit Commission was
used to ensure as comprehensive a review of available sources as possible.
Review selection criteria
Studies from the electronic searches were reviewed independently by myself and another
researcher. Discrepancies between selected papers were assessed by another researcher for
inclusion and agreed through consensus. All papers assessing accuracy of hospital coding
data were included and no restrictions were made on the type of study.
Inclusion criteria
Included studies had to:
1. Compare routinely collected hospital coding data with independent review of hospital
notes or discharge summaries
2. Examine ICD and/or OPCS codes
3. Measure data quality against published standards and rules
70

4. Be based in Great Britain
5. Be published in the English language
6. Be published after 1989
7. Have identifiable accuracy rates
Quality assessment
Papers were assessed using a pre-defined checklist of quality criteria derived from Crombie
(Crombie, 1996) and utilised by Campbell et al (Campbell et al., 2001) in a previous review
of discharge coding accuracy. Quality criteria were as follows:
1. Random sampling of episodes. This was coded as yes if random sampling was
explicitly stated or all episodes from a defined time period were obtained; no if
sampling was mentioned, but not random and unclear when the sampling strategy
was not outlined.
2. At least 90% of episodes sampled were available for analysis. This was coded as
yes if the percentage was greater than 90%; no if the percentage was less than 90%
and unclear when the percentage was not recorded or able to be calculated from the
data.
3. Trained coders were utilised. This was coded as yes when coders training or
experience was specifically mentioned; no when coders were stated as clinicians or
untrained and unclear when the training of coders was not mentioned.
4. Inter- and intra-coder reliability rates were reported. This was coded as yes when
rates were recorded; no when no record of reliability rates was made and unclear
when reliability was discussed but not explicitly stated.
71

5. Awareness of codes at time of discharge. This was coded as no - unaware when
coders were blinded to the original coding of a procedure or diagnosis; yes - aware
when coders were aware of the original diagnoses when recoding case notes or
discharge summaries or unclear when awareness of coders to previous coding was
not noted.
Reported accuracy rates refer to the primary diagnosis and main procedure code. Accuracy is
defined as the percentage agreement between coding allocated through independent
assessment of hospital notes or discharge summaries and that recorded on the routinely
collected dataset. The overall diagnosis and procedures accuracies were calculated where
applicable. In those studies that assessed the accuracy of both the procedure and diagnosis, if
stated in the paper the overall accuracy was used to contribute to calculation of the median
overall accuracy of the studies. If not stated in the paper, the diagnostic and procedure
accuracies were considered separately. Some studies report three or four level accuracy. The
accuracy level reported is that described by the authors of the individual studies as stated in
Table 3.2. The clinicians diagnosis at discharge was taken to be the standard against which
the accuracy was measured.
72
Investigating*the*use*of*Hospital*Episode*Statistics*data*to*measure*variation*in*Performance*and*Quality*in*Colorectal*Surgery*
*
Table 3.2: Assessment of quality of studies examining data accuracy of routinely collected data in comparison to case note review
Data source 90% Coder
Random Trained Coder Definition of
First Author Reference Year sampled Awareness
sampling coders reliability Accuracy
available of codes
Sellar C (Sellar et al., 1990) 1990 Registry and Case note No Yes Unclear No Yes, aware Unclear
Smith SH (Smith et al., 1991) 1991 Case note review Yes Yes No No Unclear Unclear
Yeoh C (Yeoh and Davies, 1993) 1993 Case note review Yes No Unclear Yes No, unaware Unclear
Panayiotou B (Panayiotou, 1993) 1993 Case note review Unclear Yes Yes No Yes, aware Three digit
Cleary R (Cleary et al., 1994) 1994 Case note review Unclear Unclear Yes Yes Unclear Four digit
Drennan Y (Drennan, 1994) 1994 Case note review Yes Yes Yes No No, unaware Unclear
Gibson N (Gibson and Bridgman, 1998) 1998 Case note review Yes No Unclear No Unclear Four digit
Dixon J (Dixon et al., 1998) 1998 Case note review Yes Yes Yes Yes Unclear Four digit
Kirkman M.A (Kirkman et al., 2009) 2009 Discharge summary Yes Unclear Unclear No Unclear Four digit
Reddy-Kolanu GR (Reddy-Kolanu and Hogg, 2009) 2009 Case note review Yes Yes Yes No Unclear Unclear
Nouraei SA (Nouraei et al., 2009) 2009 Case note review Yes Yes Yes Unclear Unclear Four digit
Mitra I (Mitra et al., 2009) 2009 Case note review Yes Unclear Yes No Unclear Four digit
Beckley (Beckley et al., 2009) 2010 Case note review Yes Unclear Yes No Unclear Unclear
Audit Commission (Audit Commission, 2010) 2010 Case note review Yes Unclear Yes Unclear Unclear Four digit
Murchison J (Murchison et al., 1991) 1991 Case note review No Yes Unclear No Unclear Unclear
Park RH (Park et al., 1992) 1992 Case note review No Yes No No Unclear Unclear
McGonigal G (McGonigal et al., 1992) 1992 Case note review No Yes No No Yes, aware Four digit
Pears J (Pears et al., 1992) 1992 Case note review Unclear No Unclear Unclear No, unaware Four digit
Samy AK (Samy et al., 1994) 1994 Case note review Yes Unclear Unclear Unclear Unclear Unclear
Dornan S (Dornan et al., 1995) 1995 Case note review Yes Yes Yes No Yes, aware Unclear
Harley K (Harley and Jones, 1996) 1996 Case note review Yes Yes Yes No Unclear Three digit
Case note review and
Davenport RJ (Davenport et al., 1996) 1996 No Yes Unclear No Yes, aware Unclear
Local registry
Kohli HS (Kohli and Knill-Jones, 1992) 2009 Case note review Yes Yes Unclear No Yes, aware Four digit
Hasan M (Hasan et al., 1995) 1995 Case note review Yes Yes Yes No Unclear Four digit
Colville RJ (Colville et al., 2000) 2000 Operation note review Yes Yes No No No, unaware Four digit
73
Investigating*the*use*of*Hospital*Episode*Statistics*data*to*measure*variation*in*Performance*and*Quality*
in*Colorectal*Surgery*
*
Results
69 potential studies were identified by the searches. Of these, 37 studies were excluded.
Figure 3.1 shows the reason for exclusion of these studies.
74

Figure 3.1: Schematic of inclusion following literature search.
7
750 initial
results
681 excluded on review of title

and abstract
69 papers
37 papers excluded when full papers
reviewed
- 7 letters
- 13 non HES data
- 12 did not include accuracy
- 1 study was not UK based
- 2 reviews
- 2 outpatient data
32 papers
25 case note 7 clinical registry
review
75
S

Of the 32 included studies, 25 studies compared the data accuracy of routinely collected data
with case or operation notes (Colville et al., 2000, Davenport et al., 1996, Dixon et al., 1998,
Dornan et al., 1995, Gibson and Bridgman, 1998, Harley and Jones, 1996, Hasan et al., 1995,
Kirkman et al., 2009, Kohli and Knill-Jones, 1992, McGonigal et al., 1992, Mitra et al., 2009,
Murchison et al., 1991, Nouraei et al., 2009, Panayiotou, 1993, Park et al., 1992, Pears et al.,
1992, Reddy-Kolanu and Hogg, 2009, Samy et al., 1994, Sellar et al., 1990, Smith et al.,
1991, Yeoh and Davies, 1993, Cleary et al., 1994, Audit Commission, 2010, Beckley et al.,
2009) and seven studies contrasted routinely collected data with clinical registry data (Jen et
al., 2008, Mukherjee et al., 1991, Raza et al., 1999, Milburn et al., 2007, Garout et al., 2008,
Aylin et al., 2007b, Westaby et al., 2007).
Tables 3.3 and 3.4 summarise the details of the included studies that examined the data
accuracy using case note review and registry data respectively. Of the papers that compared
routinely collected data accuracy with case note review, 14 papers (56%) used English
datasets (Cleary et al., 1994, Kirkman et al., 2009, Gibson and Bridgman, 1998, Yeoh and
Davies, 1993, Panayiotou, 1993, Sellar et al., 1990, Reddy-Kolanu and Hogg, 2009, Smith et
al., 1991, Dixon et al., 1998, Nouraei et al., 2009, Mitra et al., 2009, Audit Commission,
2010, Beckley et al., 2009), nine (37.5%) examined Scottish data (Murchison et al., 1991,
Park et al., 1992, Kohli and Knill-Jones, 1992, McGonigal et al., 1992, Dornan et al., 1995,
Samy et al., 1994, Pears et al., 1992, Harley and Jones, 1996, Davenport et al., 1996) and two
studies used Welsh data (Colville et al., 2000, Hasan et al., 1995). 20 of these papers
assessed the accuracy of diagnostic coding (Cleary et al., 1994, Colville et al., 2000,
Davenport et al., 1996, Dixon et al., 1998, Dornan et al., 1995, Gibson and Bridgman, 1998,
Hasan et al., 1995, Kirkman et al., 2009, Kohli and Knill-Jones, 1992, McGonigal et al.,
76

1992, Murchison et al., 1991, Nouraei et al., 2009, Panayiotou, 1993, Park et al., 1992, Pears
et al., 1992, Samy et al., 1994, Sellar et al., 1990, Yeoh and Davies, 1993) and nine papers
assessed the accuracy of procedure coding (Colville et al., 2000, Dixon et al., 1998, Harley
and Jones, 1996, Mitra et al., 2009, Nouraei et al., 2009, Reddy-Kolanu and Hogg, 2009,
Smith et al., 1991, Drennan, 1994). The majority of studies that assessed diagnostic coding
accuracy used ICD9 (11 studies) exclusively. However, four studies examined ICD10 and
three studies with long study periods used a combination of ICD9 and ICD8. A version of
the OPCS4 coding system was used in seven of the nine studies that examined procedure
coding. The remaining two studies assessed the use of the OPCS3 or an unspecified version
of the OPCS coding system.
77
Investigating the use of Hospital Episode Statistics data to measure variation in Performance and Quality in Colorectal Surgery

Table 3.3: Summary of included studies examining data accuracy of routinely collected data in comparison to case note review
Number of
Country First Author Reference Year Diagnosis/Procedure included Study dates Coding system Setting Data accuracy
cases sampled
England Sellar C (Sellar et al., 1990) 1990 Deliberate self poisoning 1980-1985 ICD8, ICD9 488 Single hospital Diagnosis 95.7%
England Smith SH (Smith et al., 1991) 1991 Joint replacements 1988 OPCS3 139 3 hospitals Procedure 85.0%
(Yeoh and Davies, 37 1990, Diagnosis 54.1% 1990
England Yeoh C 1993 Paediatric diagnoses 1990, 1991 ICD Single acute hospital
1993) 117 1991 Diagnosis 84.6% 1991
England Panayiotou B (Panayiotou, 1993) 1993 Cerebrovascular disease Unspecified ICD9 117 Single acute hospital Diagnosis 76.0%
All general medicine and
England Cleary R (Cleary et al., 1994) 1994 1990-1991 ICD 501 2 acute hospitals Diagnosis 51.0%
general surgery diagnoses
Urology, Cardiothoracics, OPCS4.2 Diagnosis 68.0%
England Drennan Y (Drennan, 1994) 1994 1990-1991 2044 4 acute hospitals
Cardiology, General Surgery ICD9 Procedure 83.0%
(Gibson and
England Gibson N 1998 General Surgery diagnosis 1995 ICD10 298 Single acute hospital Diagnosis 71.0%
Bridgman, 1998)
Diagnosis 1252 Diagnosis 50.5%
England Dixon J (Dixon et al., 1998) 1998 All 1991-1993 OPCS4, ICD9 2 hospitals
Procedure 416 Procedure 65.9%
ICH 978 Diagnosis ICH 95.9%
England Kirkman M.A (Kirkman et al., 2009) 2009 Haemorrhagic stroke 2002-2007 ICD10 4 acute hospitals
SAH 1169 Diagnosis SAH 96.1%
(Reddy-Kolanu and Hospital day surgery
England Reddy-Kolanu GR 2009 ENT procedures 2008 OPCS4 79 Procedure 69.6%
Hogg, 2009) unit
Diagnosis 96.2%
England Nouraei SA (Nouraei et al., 2009) 2009 Otolaryngology procedures 2007-2008 OPCS4, ICD9 1250 Single acute hospital
Procedure 85.1%
Head and Neck Surgery
England Mitra I (Mitra et al., 2009) 2009 2006 OPCS 34 Single acute hospital Procedure 52.6%
procedures
England Beckley (Beckley et al., 2009) 2009 Urological procedures 2007 ICD10, OPCS4 500 Single acute hospital Procedure 83.4%
Overall 87.0%
(Audit Commission,
England Audit Commission 2010 All diagnoses 2009-2010 ICD10, OPCS4 unknown Multiple hospitals Diagnosis 87.0%
2010)
Procedure 90.0%
ENT- Ears Nose and Throat
SAH- Subarachnoid Haemorrhage
ICH- Intracerebral Haemorrhage
ICD- International Classification of Disease
OPCS- Office of Population, Censuses and Surveys (OPCS) classification of interventions and procedures

Table 3.3: Summary of included studies examining data accuracy of routinely collected data in comparison to case note review contd
Number of
Country First Author Reference Year Diagnosis/Procedure included Study dates Coding system Setting Data accuracy
cases sampled
All NHS Overall 93.7%
Scotland Murchison J (Murchison et al., 1991) 1991 Inflammatory Bowel Disease 1968-1983 ICD8, ICD9 255 hospitals in Crohns 95.5%
Scotland Ulcerative Colitis 91.0%
Scotland Park RH (Park et al., 1992) 1992 Wilson's disease 1974-1989 ICD8, ICD9 40 All Scotland Diagnosis 87.50%
Gastrointestinal Diagnosis, Co- Multiple
Scotland Kohli HS (Kohli and Knill-Jones, 1992) 1992 1987 ICD9 778 Diagnosis 73.6%
existing Arthritis hospitals
Scotland McGonigal G (McGonigal et al., 1992) 1992 Dementia 1974-1988 ICD 196 Single hospital Diagnosis 93%
Paediatric and general medical 52 paediatric Paediatric diagnosis 67.0%
Scotland Pears J (Pears et al., 1992) 1992 Unspecified ICD9 Single hospital
diagnoses 100 medical Medical diagnosis 54.0%
Abdominal Aortic Aneurysm
Scotland Samy AK (Samy et al., 1994) 1994 1979-1991 ICD9 500 Unclear Diagnosis 97.80%
diagnosis
Upper Gastrointestinal
Scotland Dornan S (Dornan et al., 1995) 1995 1989-1991 ICD9 3447 Single hospital Diagnosis 58.40%
diagnoses
Multiple Diagnosis 89.2%,
Scotland Harley K (Harley and Jones, 1996) 1996 All diagnoses 1992, 1994 ICD9, OPCS4 17959
hospitals Procedure 88.2%
Scotland Davenport RJ (Davenport et al., 1996) 1996 Stroke Unclear ICD9 566 Single hospital Diagnosis 94.2%
Wales Hasan M (Hasan et al., 1995) 1995 Cerebrovascular disease 1993 ICD9 166 Single hospital Diagnosis 74.0%
Overall 78.0%
Wales Colville RJ (Colville et al., 2000) 2000 Plastic surgery procedures 1998 OPCS4 50 Single hospital Diagnosis 62.0%
Procedure 98.0%
ENT- Ears Nose and Throat
SAH- Subarachnoid Haemorrhage
ICH- Intracerebral Haemorrhage
79

Table 3.4: Summary of included studies comparing routinely collected data with clinical registries
Country First Author Reference Year Diagnosis/Procedure Study Coding Comparison registry Measure used Setting % Data recorded on
considered dates system HES versus Registry
England Jen MH (Jen et al., 2008) 2008 Clostridium Difficile, 2004- ICD10 HPA mandatory Numbers Multiple Clostridium
Orthopaedic Surgical Site 2005 reporting registry included on hospitals DifficileHPA 93121
infection (SSI) each database HES 36757
SSI HPA 1191
HES 1045
England Mukherjee AK (Mukherjee et al., 1991 Ovarian Neoplasm 1979- ICD9 Ovarian Tumour Case inclusion Multiple Ovarian Tumour
1991) 1983 Registry and Regional hospitals Registry 685
Cancer Registry HAA 611
England Garout M (Garout et al., 2008) 2008 Colorectal Cancer 2001- OPCS4 National Clinical Patient volume Multiple ACPGBI registry 6, 617
2002 Registry and outcome hospitals cases
HES 7, 516 cases
Comparable mortality
rates
England Aylin P (Aylin et al., 2007b) 2007 Vascular procedures 2001- OPCS4 National Clinical Patient volume Multiple NVD 8,462 cases
2003 Registry and outcome hospitals HES 16,923 cases
Comparable mortality
England Westaby S (Westaby et al., 2007 Cardiac paediatric 2000- OPCS4 National Clinical Case inclusion Multiple CCAD 1745 HES 2182
2007)* procedures 2002 Registry hospitals Mortality- HES 4.2% vs
CCAD 6.4%
Scottish Raza Z (Raza et al., 1999) 1999 Vascular procedures 1994 ICD9, Local vascular Operative Single Local vascular database
OPCS4 database accuracy hospital 840 cases
ISD 793 cases
Scottish Milburn JA (Milburn et al., 2007) 2007 General, paediatric and 2003- ICD10, Local database Accuracy of Multiple Clinically acceptable
vascular surgery 2004 OPCS4 diagnosis and hospitals match Diagnosis 86.9%,
procedure Procedure 84.0%
coding
HPA- Health Protection Agency
ACPGBI- Association of Coloproctology of Great Britain and Ireland
NVD- National Vascular Database
HES- Hospital Episode Statistics
CCAD Central Cardiac Audit Database ISD- Information and Statistics Division
* Definition of 30 mortality and breadth of included procedures varied between HES and CCAD
80

Papers comparing routinely collected data with case note review
- Study quality
The studies varied according to the size of included admissions from 34-17,959 admissions
with a median of 298 admissions (Table 3.3). Table 3.2 summarises the quality assessment
for each of these studies. 17 studies stated that their samples were random. 16 studies
assessed greater than 90% of the case notes selected for sampling. Only ten studies stated
that trained coders were used and only three studies assessed inter-coder reliability. Six
studies stated that the coders performing case note review were blinded to the original codes.
Table 3.2 states the level of accuracy where stated assumed for each study.
- Accuracy
The overall median accuracy was 83.2% (IQR 67.3%-92.1%). The median diagnostic
accuracy was 80.3% (IQR 63.3%-94.1%) with a median procedure accuracy of 84.2% (IQR
68.7%-88.7%).
Payment by results (PbR) was introduced in 2004. When we compared those studies that
included data prior to the introduction of PBR and those afterwards, there were no differences
in the overall accuracy of codes [Overall accuracy pre-PbR 77.0% (IQR 66.2%-89.0%)
versus post-PbR 86.1% (IQR 73.1%-96.1%),p=0.207] or the accuracy of procedure codes
(p=0.602) but the accuracy of the primary diagnosis improved from 73.8% (IQR 59.3%-
92.1%) to 96.0% (IQR 89.3%-96.25) (p=0.020). There were no differences in overall
accuracy between those datasets that examined accuracy across multiple hospitals and those
that looked at single sites (p=0.252). When studies examining Scottish data were compared
81

with those assessing English data, there were no differences in overall, procedure or
diagnosis accuracy (p=0.292, p=0.245 and p=0.742 respectively).
Those studies that used random sampling for case selection had lower median accuracy
[Median random accuracy 83.1.0% (IQR 68.0%-88.2%) vs Median non random 93.7% (IQR
90.3%-95.0%), p=0.033].
Papers comparing routinely collected data with clinical registry data
Seven studies compared routinely collected data with clinical registry (Jen et al., 2008,
Mukherjee et al., 1991, Raza et al., 1999, Milburn et al., 2007, Garout et al., 2008, Aylin et
al., 2007b, Westaby et al., 2007). Five of these studies compared HES data with national
registry data (Aylin et al., 2007b, Garout et al., 2008, Jen et al., 2008, Mukherjee et al., 1991,
Westaby et al., 2007). Three of these studies compared number of procedures and mortality
against surgical society clinical registries (Aylin et al., 2007b, Garout et al., 2008, Westaby et
al., 2007).
A further study examined rates of Clostridium Difficile reported on HES database against
those reported to the Health Protection Agency (HPA) (Jen et al., 2008). Reporting cases of
Clostridium Difficile to the HPA is mandatory. Murkherjee and colleagues compared rates of
ovarian neoplasms against a local registry and histopathology dataset (Mukherjee et al.,
1991). Two further Scottish studies compared ISD data against local databases or registries
(Milburn et al., 2007, Raza et al., 1999). Table 3.4 summarises these studies and shows the
number of procedures recorded on the registries versus those recoded on administrative
datasets.
82

The HES dataset recorded twice as many procedures as compared with the National Vascular
disease (NVD) registry (HES n=16923 and NVD n=8462) with slightly higher death rates
recorded on HES (HES 18% and NVD 15%) (Aylin et al., 2007b). Garout and colleagues
found a higher number of colorectal procedures reported on HES than on the Association of
Coloproctology of Great Britain and Ireland (ACPGBI) colorectal cancer database (HES
n=7516 and ACPGBI n=6617) with comparable overall mortality at a national level [HES
418 (5.6%) vs ACPGBI 383 (5.8%), p=0.416] (Garout et al., 2008). Westaby and colleagues,
however, found a higher number of reported infant cardiothoracic procedures on the Central
Cardiac Audit Database (CCAD) than on HES (HES n=1745 and CCAD n=2182).(Westaby
et al., 2007) The reported mortality was lower on HES than on the CCAD [HES n=74 (4.2%)
vs CCAD n=139 (6.4%)]. However, the two datasets differed in the types of procedures
included in the analysis with all procedures included in the CCAD and a limited number
included in the HES data analysis. In addition the definition of 30 day mortality differed
between datasets, with HES recording only those deaths in hospital and the CCAD including
all deaths in and out of hospital. Thus, the comparison was inhibited by the different coding
systems and difficulty in defining the same procedures and outcomes.
Discussion
Main findings of the study
Data accuracy has been a concern for clinicians, managers and central government for several
years (Audit Commission, 2002). Steps have been taken to improve quality with the Care
Quality Commission mandating yearly audits of individual Trust data quality (Care Quality
Commission, 2009). This study examines the accuracy of administrative data in the United
83

Kingdom in the published literature from 1989 to the present day. Overall accuracy was 83%
with accuracy for procedure coding (84.2%) found to be higher than that of primary diagnosis
coding (80.3%). Accuracy of diagnostic coding has been shown to have improved
substantially in recent years.
Implications of data accuracy
Questions should be asked as to whether an accuracy of 83%, or 87% when the most recent
data from the Audit commission are considered (Audit Commission, 2010), is reasonable to
allow the data to be used for research, service planning, financial reimbursement, or
performance and quality assessment. Currently there is no consensus as to what is an
acceptable level of data accuracy. The ultimate goal would be a data accuracy of 100%. The
greatest data accuracy recorded was 98% in the study of abdominal aortic aneurysms (Samy
et al., 1994). This may be a more realistic target. The involvement of clinicians in coding has
been proposed to achieve this improvement in accuracy (Williams JG, 2002). Yeoh and
Davis initially examined changes in accuracy after clinicians became responsible for coding.
They found over a one-year period the accuracy increased from 54% to 85% (Yeoh and
Davies, 1993). Though, given such a low initial coding accuracy, it may be argued that there
were serious flaws in coding in earlier years, questioning the applicability of this research to
other trusts. Nouraei and colleagues observed that use of a clinician coding multi-
disciplinary team (MDT) in Ear Nose Throat (ENT) surgery resulted in a change to 24.1% of
records and an increase in departmental revenue of 443,371 (4.8 times the cost of
maintaining such an MDT) (Nouraei et al., 2009). This suggests that clinician involvement
may be a cost effective means of improving data quality and improving hospital
84

reimbursement. Greater education is needed amongst clinicians about clinical coding and its
uses.
The majority of studies included in this review defined inaccurate coding as inaccurate four
digit coding (Table 3.2). Both OPCS and ICD10 mostly use four digit codes to signify
procedures and diagnoses respectively. The first letter refers to the chapter in which the code
is contained and the subsequent two or three numbers refer to a related group of diseases or
procedures and then specific disease or procedure within that group. For example, ICD10
code K35.0 refers to Acute appendicits with generalised peritonitis. The K chapter is any
disease of the digestive system and K35 group is all acute appendicitis. It may be that for
some purposes the chapter and group of diseases (e.g. K35) or three digit code may be
sufficient. Cleary and colleagues reported an accuracy of 51% at the four digit level but 90%
at the three digit level suggesting that many inaccuracies occur with four digit coding (Cleary
et al., 1994). For some uses, three letter accuracy may be sufficient and therefore the coding
accuracy will be higher than that described in this study.
The accuracy reported in this study is lower than that reported by Campbell and colleagues in
their original systematic review (Campbell et al., 2001). In this review the accuracy of coding
was variable but with a median of 90%. The current study contains a larger number of more
recent studies. It is difficult to assess how applicable these figures are to general accuracy
rates in the NHS or whether they reflect a degree of publication bias. Clinical studies that
demonstrate good data accuracy may not be published with the aim of assessing data
accuracy but focus on examining a particular clinical condition. Such articles may not be
included in this analysis. Similarly, some articles that demonstrate poor data accuracy may
have originally been conceived to look at a particular condition thereby skewing our results
85

towards a lower overall accuracy rate. The latest audit of data quality from the Audit
Commission concluded that the accuracy of data coding was improving each year suggesting
that there may be a discrepancy between data accuracy figures published in the literature and
the real life data accuracy figures (Audit Commission, 2010).
If we accept that the overall accuracy (87%) that was reported by the Audit Commission,
what are the possible uses of administrative data within the NHS? Epidemiological and
outcome based research are areas for which HES has been used (Bottle and Aylin, 2009, Faiz
et al., 2008a, Faiz et al., 2008b, Faiz et al., 2010a, Mayer et al., 2010, Faiz et al., 2011b). It is
difficult to quantify the potential impact of this level of accuracy on research. An assumption
is made in this research that there are no systematic inaccuracies that may bias the studies. A
study that examines for example the impact of an explanatory variable on outcome assumes
that the level of inaccuracy will be the same across that explanatory variable. The impact of
this will be impossible to measure without a large NHS wide survey of all Trust accuracies
across specialties. Such a study would be expensive to undertake for merely academic
purposes but may be possible through data collected by the Audit Commission National
Audit. It is important that the current focus on improving data quality continues despite the
proposed disbandment of the Audit Commission following the recent Government Spending
review.
Administrative data are used to determine individual Trust reimbursement. Several studies
and the Audit Commission report examined the effect of data inaccuracy on reimbursement
(Audit Commission, 2010, Nouraei et al., 2009, Beckley et al., 2009). Potential savings for
the individual Trusts are considerable. One study estimated that inaccurate coding could lead
86

to losses of up to 10% of a departments profits (Beckley et al., 2009). Indeed, it is in the
interests of Trusts to maximise their financial returns. By optimising coding practices, these
gains can be made. Though it is important that the data are still as accurate as possible as
there may be a temptation to use codes associated with the greatest financial return. Such
gaming may be avoided. In conjunction with outcome based research, administrative data
offer an attractive source for quality measurement and performance benchmarking. Poor
quality data collection may reflect more widespread system failures within Trusts or
departments. Those Trusts with more inaccurate data maybe judged to be worse by these
data than they actually are. In performance measurement, outlier status using administrative
data can serve as a prompt for further investigation rather than a definitive assertion of poor
performance. Caution should therefore be exercised regarding the reliability of identification
of outliers from routinely collected data.
The introduction of PbR led to an improvement in data accuracy though there is likely to be
econtinuing variation in accuracy rates. Factors such as efficiency of support systems in a
hospital, differences in case mix or prevalent diseases between units, organisational culture or
management structure may further underlie this variation. However, further work is required
to assess the impact of these factors.
This review seeks to assess data accuracy in Great Britain but increasingly routinely collected
and registry data are being used to draw international comparisons of performance (Coleman
et al., 2011). It is essential that when using both administrative and clinical registry
databases that country to country variations in these datasets are well understood, for
example databases may not be comprehensive or may be only inclusive of patients treated at
87

centres of excellence with an interest in data collection. Attempts should be made in each
country to address the issues of data accuracy outlined in this study in order to ensure that the
data maybe meaningfully used to explore national and provider differences.
Clinical registry versus administrative databases
Clinical registries are purpose built databases for prospective data collection. In contrast to
the inclusive mandatory administrative datasets, clinical registries are mostly voluntary.
Given this voluntary nature, they will not include all patients with a given condition nor will
all the datafields be complete for each patient (NBOCAP, 2009). These databases contain
tailored data fields that allow collection of disease specific clinically relevant data. As to be
expected, two studies found HES and registry data to be largely comparable for mortality
with larger patient volumes recorded on HES (Aylin et al., 2007b, Garout et al., 2008). Four
studies, however, found fewer cases recorded on the administrative database than in the
clinical registries (Westaby et al., 2007, Jen et al., 2008, Mukherjee et al., 1991, Raza et al.,
1999). The reasons for this discrepancy are uncertain. It may represent poor coding on the
HES dataset. However, there was considerable variation in the coding and classifications
used in the two datasets. For example, the definition of mortality and included procedures
differed between the the HES and CCAD datasets in the study by Westaby and colleagues
(Westaby et al., 2007). Such comparisons therefore are unlikely to be comparing like with
like. Though registries contain useful clinically meaningful data, they are more expensive to
set up and maintain and require enthusiastic clinicians to support data submission. Costs of
maintaining HES data have been estimated at 1 per record with clinical registry data costing
up to 60 per record (Raftery et al., 2005). Though useful in discrete conditions or for
specific treatments, they do not have the breadth of national administrative datasets. They
may also not fully reflect the range of procedures performed even within a given specialty as
88

clinicians may favour the entry of interesting or complex cases over more straignforward
cases.
Limitations of this study
The accuracy of routinely collected data is infrequently published. This review includes
studies from an extended time period. The historical nature of the data limits the
applicability of the accuracy to the current time. Though our review was as broad as
possible, some studies that have not referenced accuracy in the title or abstract or that have
not been referenced in other articles will not have been included in the study. The accuracy
of coding may be just one aspect of a paper and therefore not included in the title or abstract.
Such papers will not have been included in this study. It is difficult to quantify the impact of
such bias on the results of this study.
The studies included in this systematic review are heterogeneous. They vary in methods used
to assess accuracy, the diagnoses and procedures included and the personnel involved in
assessing the data quality. As a result of this heterogeneity, meta-analysis was not possible.
Indeed due to the small number of papers, limited statistical analysis was possible. Few
studies looked at accuracy in recent years following the introduction of PbR and concerted
efforts to improve data quality such as the National Audit Office reports and the focus by the
Care Quality Commission. There was a wide range of data accuracies reported in the
literature. This may reflect considerable variation in practice across the NHS. It may also
reflect the differences in methodologies used in the included studies. Inter-coder reliability
was rarely stated in these studies. Only 68% of the studies used random sampling and only
48% of the studies stated that trained coders were used. Methods of identifying case records
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for review varied across studies. Some studies used local databases (Milburn et al., 2007,
Sellar et al., 1990) or all admissions in a defined period with or without a specific diagnosis
or under a certain physician (Yeoh and Davies, 1993, Nouraei et al., 2009, Dixon et al., 1998,
Harley and Jones, 1996, Reddy-Kolanu and Hogg, 2009, Colville et al., 2000, Hasan et al.,
1995, Kirkman et al., 2009, Kohli and Knill-Jones, 1992, Samy et al., 1994, Cleary et al.,
1994, Murchison et al., 1991, Panayiotou, 1993, Audit Commission, 2010, Pears et al., 1992,
Drennan, 1994, Beckley et al., 2009) to identify the base denominator of included patients.
Finally there may be publication bias in the literature. Studies with accuracy rates at the
extremes of the spectrum may be preferentially reported. Though given the wide range of
accuracies reported preference for the low or high end of the spectrum is likely to be limited.
The overall accuracy reported in this study may not be applicable to individual NHS Trusts as
there will be Trust to Trust differences in accuracy rates. Some Trusts will have more
reliable data than others. This may have significant implications regarding performance
benchmarking. In addition, some diagnoses or procedures maybe better coded than others so
there is likely to be differences in accuracy between conditions.
Accuracy rates of administrative data coding have improved in recent years in the NHS.
This may relate to the introduction of pro rata financial reimbursement for financial activity.
This review suggests that data accuracy is high enough to facilitate its use in most
circumstances. Wide variation in reported accuracy may reflect variation in individual trusts
coding suggesting that care should be exercised when using these data for clinician and
institution benchmarking. Identification of apparent unacceptable institution or individual
performance using administrative data may serve as a prompt for further investigation and
should be interpreted with caution.
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Variation from HES data
Variation in the provision or outcome in England has been demonstrated previously in other
disciplines.
Clinician variation
Bloor and colleagues used HES data to explore variation in consultant activity and the link
between consultant activity and type of contract (Bloor et al., 2004). Consultant surgeons
with discretionary salary points and those with maximum part-time contracts had higher
activity than other consultant surgeons.
Management variation
Preference for particular procedures differs geographically in the HES dataset. In 1996,
Mulholland and colleagues described threefold difference in the rate of vaginal to abdominal
hysterectomy by regional health authority (Mulholland et al., 1996).
Bragg and colleagues used maternity data collected on HES to assess the existing variation in
caesarean section rates across England (Bragg et al., 2010). This study suggested that there
was considerable variation in both the patient characteristics across units and also the
adjusted section rates suggesting that there is considerable variation at the patient level and
the unit level. More variation existed amongst emergency patients.
Other authors have found significant geographical variation in the provision of elective
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surgery. Two studies suggested that there is considerable regional variation in the provision
of hip and knee joint replacements (Dixon et al., 2006, Judge et al., 2009). Keenan and
colleagues showed marked geographical variation in cataract and glaucoma surgery rates by
local authority with rates of cataract surgery varying from 172 to 548 procedures per 100000
population (Keenan et al., 2007) (Keenan et al., 2009b). This variation was also associated
with social deprivation indices.
Khan and colleagues found that despite an overall exponential increase in plastic surgery,
there was a 4.6 fold difference in plastic surgery rates across health authorities (Khan et al.,
2010). Some of this variation may be explained by case mix and variation in coding but the
possibility of real differences in healthcare access must be explored.
Geographical variation has also been described in lower limb amputation rates with
unadjusted rates varying between 3.9 per 100,000 and 7.2 per 100,000 of the population in
different SHAs (Moxey et al., 2010). 30 day in hospital mortality following major amputation
also differed by SHA between 20.2 and 14.0%.
Variation over time
In addition, HES data have been used to explore trends in disease activity and admissions
over time in epilepsy (Bruce et al., 2004), circumcision rates (Cathcart et al., 2006),
ophthalmic and retinal surgery (Clarke and Fraser, 2006, El-Amir et al., 2009, Fraser and
Wormald, 2008, Keenan et al., 2007, Keenan et al., 2009a, Keenan et al., 2009b), oral
surgery (Dhariwal et al., 2002, Moles and Ashley, 2009), obesity surgery (Ells et al., 2007,
Burns et al, 2010), road collisions (Gill et al., 2006), infectious diseases (Hayward et al.,
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2008, Trotter et al., 2008), urology (Hussain et al., 2008), hepatobiliary disease (Kang et al.,
2003a, Thomson et al., 2008, Tinto et al., 2002), appendicitis (Kang et al., 2003b), vascular
surgery (Kanwar et al., 2010, McCaslin et al., 2007, Moxey et al., 2010), plastic
surgery(Khan et al., 2010), orthopaedics (McColl et al., 1998, Wu et al., 2011), drug
reactions (Patel et al., 2007), gynaecology (Reid, 2007) and deliberate self harm (Wilkinson
et al., 2002).
Variation in outcome
Callery and colleagues used HES data to assess variation in paediatric readmission rates in
North West English NHS Trusts. Even amongst the small number of included hospitals, there
was demonstrable variation in readmission rates (Callery et al., 2010).
Holt and colleagues showed considerable variation in mortality following elective AAA
repair. Thirty hospitals had a significantly greater mortality than elsewhere and three of these
hospitals had over twice the mortality of the rest of England (Holt et al., 2008b).
Patient differences- variation and social deprivation
HES data have been used to explore the association between social deprivation and surgical
provision and outcome in several specialties including orthopaedics (Cookson et al., 2007,
Judge et al., 2010) and oncology (Raine et al., 2010).
Cookson and colleagues explored the impact of social deprivation and provision of total hip
replacements (Cookson et al., 2007). During the ten year study period, social deprivation
appeared to play a diminishing role in determining access to total hip replacement. Judge and
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colleagues corroborated this finding and suggested that social deprivation was associated
with access to both total hip and total knee replacements (Judge et al., 2010).
Raine and colleagues analysed admissions with rectal, breast and lung cancer in patients over
50 years of age from 1999 to 2006 (Raine et al., 2010). Elective procedures and anterior
resection for rectal cancer and breast conserving surgery for breast were deemed preferential
to other procedures in this study. Patients form areas of greater social deprivation underwent
lower levels of preferred procedures. Given that variation in stage of disease at presentation
impacts on choice of surgical procedure, the absence of staging data in this dataset is a
significant flaw.
Gilbert and colleagues demonstrated that patients from more socially deprived areas admitted
with a fall were less likely to return to their home than more affluent patients (Gilbert et al.,
2010).
Gender
Filipovic and colleagues explored gender differences in the provision of and outcome
following AAA repair for ruptured AAA (Filipovic et al., 2007). Women underwent fewer
repairs and had a higher mortality than men.
Management of disease
David and colleagues examined current management in gallbladder disease across England
(David et al., 2008). They concluded that the provision of early laparoscopic cholecystectomy
in 2003-2004 was suboptimal with a higher rate of open procedures and a low rate of
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cholecystectomy on the initial admission.
Furthermore, HES data have been used to examine clinical outcome from comparative
procedures such as laparoscopic and open surgery (Faiz et al., 2008b, Faiz et al., 2008c,
Burns et al., 2010) open versus endovascular aneurysm repair (Holt et al., 2010) and to
demonstrate the safety of certain procedures (West and Card, 2010).
Health policy
Farrar and colleagues used HES data to explore the impact of PbR on hospital practice
(Farrar et al., 2009). Day case rates increased and there was a trend towards increased
hospital activity following the introduction of PbR.
Propper and colleagues examined the possible impact of patient choice on distances travelled
from a patients home to hospital (Propper et al., 2007). Patients from more affluent areas
travelled greater distances to hospitals. Propper suggested that more affluent patients may
benefit from patient choice more as they are more willing to travel to remote hospitals.
Holt and colleagues examined the feasibility of reconfiguring vascular services to centralize
hospitals. They postulated that services could be concentrated in 48 centres from the current
242 institutions offering vascular services. They proposed that there would be a significant
reduction in elective mortality without increasing patient travel significantly. This model was
unable to account for resultant changes in emergency services but was the first study to
provide an evidence base to predict impact of such a widespread change in practice (Holt et
al., 2008a).
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HES data have also been used to examine the impact of public health initiatives such as the
introduction of the smoking ban in public places on the population. It is difficult to find a
causal link but this study did find a decrease in admissions for myocardial infarction after the
introduction of the smoking ban (Sims et al., 2010).
These studies suggest that HES data can be used to not only look at variation in disease but to
assess the impact of health policy interventions and also attempt to predict the effect of future
policies.
HES data and Colorectal surgery
Provision
Specifically in colorectal surgery, HES data have been used to examine provision and
outcome of certain procedures. Day case colorectal surgery has been shown to be
underutilised and Faiz and colleagues have suggested that increases in day case rates can
significantly improve hospital efficiency (Faiz et al., 2008a).
Hartmanns procedure was originally described in 1921 by Henri Hartmann for resection of
an obstructing colonic tumour (Hartmann, 1923). The procedure involves resection of an
affected segment of sigmoid colon, leaving a rectal stump and necessitates stoma formation.
This stoma may be reversed at a subsequent procedure. A systematic review has suggested
that primary resection and anastomosis in nonelective diverticular disease may be associated
with a lower mortality than the Hartmanns procedure (Constantinides et al., 2006a). Primary
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anastomosis is also more frequently used by colorectal specialist in the emergency setting
(Constantinides et al., 2006b). David and colleagues examined use of Hartmanns procedure
and subsequent reversal in England (David et al., 2009). They found that only 23.3% of
patients who had a Hartmanns procedure underwent a reversal during the study period.
Using similar methodology, David and colleagues also explored reversal of stoma rates
following anterior resection with covering ileostomy and found that 75% of patients had a
reversal of ileostomy (David et al., 2010). This study may overestimate the number of
patients who were reversed following surgery, as some patients may not have been actively
coded with an additional stoma formation code.
HES data have also been used to explore possible causes of fluctuations in disease.
Sonnenberg found that fluctuations in admissions for viral and bacterial intestinal infection
mirrored admissions for Crohns disease (Sonnenberg, 2008). He suggested a possible causal
link between intestinal infections and exacerbations of Crohns disease. This highlights an
area for further research but cannot definitely establish such a link due to other possible
confounders not present on the HES dataset.
Colorectal outcome
HES data have been used to examine mortality, following colorectal resection, in the
emergency setting (Faiz et al., 2010c) and among the elderly population (Faiz et al., 2011a).
In the emergency setting, postoperative mortality at thirty days was high (13.3% following
colorectal cancer resection and 15.4% following diverticular resection). Furthermore, one
year mortality rose to 34.7% and 22.6% for cancer and diverticular resections respectively
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(Faiz et al., 2010c). There is significant mortality rates in elderly patients following elective
colonic surgery with those patients over 85 years of age having approximately 2.5 times the
risk of death than those aged 75-79 years of age (Faiz et al., 2011a). Morris and colleagues
identified significant NHS Trust variation in 30 day mortality rates using cancer registry
linked HES data (Morris et al., 2011b). In a previous study using a similar dataset, Morris
and colleagues examined variation in APE rates for rectal cancer (Morris et al., 2008). It has
been suggested that APE rates should be below 30% of a surgeons rectal cancer caseload
(ACPGBI, 2007).
Readmission and LOS following elective colorectal surgery was investigated by Faiz and
colleagues (Faiz et al., 2011b). Colonic resection resulted in a shorter LOS than for rectal
resection with stomas increasing the duration of inpatient stay. Furthermore there was a
decrease in LOS of two days from 1996 to 2006. LOS and readmission varied by disease
type, age, social deprivation. Use of laparoscopy led to a shorter LOS.
Kang and colleagues described early trends in diverticular admission between 1989 and 2000
(Kang et al., 2003c). Jeyarajah and colleagues examined later trends in admission for
diverticular disease and predictors of outcome (Jeyarajah et al., 2009). They found an
increasing number of admissions for diverticular disease from 1996 to 2006. The majority of
admissions were nonelective. Admissions increased in the elderly populations. An
emergency admission, increasing age and co-morbidity were associated with poorer outcome.
Faiz and colleagues used HES data to compare outcome following laparoscopic and open
elective colorectal resections with selection for laparoscopy being associated with lower
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perioperative and one year mortality and a reduced length of stay (Faiz et al., 2009).
Policy implications
The impact of introducing guidelines has been explored using HES data. The use of
laparoscopic colorectal resection increased despite initial NICE guidelines preferring open
surgery (Green et al., 2009). The effect of subsequent guidelines recommending
laparoscopic colorectal resection is unclear from this study (2006).
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Chapter 4- Materials and Methods
Hospital Episode Statistics (HES)
The HES database is an administrative dataset of routinely collected data that collates patient
level information from all English NHS Trusts. It includes all NHS and private patients
admitted to NHS hospitals. Its core component is the Finished Consultant Episode (FCE).
This reflects a period of uninterrupted inpatient care under a single consultant team or allied
health care professional. Episodes may be linked together to form a single admission or
spell. If a patient is transferred to a different Trust during this time then these admissions are
linked into a single superspell.
Each admission contains a primary diagnosis and up to 20 secondary diagnoses, categorised
according to the International Classification of Disease (10th revision) (ICD-10), (WHO) and
up to 24 procedure fields coded using the Office of Population Censuses and Surveys
Classification of Surgical Operations and Procedures (4th Revision) (OPCS-4.4) and codes
appropriate to the year of admission prior to OPCS-4.4 revision (Connecting for health,
2009). The OPCS-4 codes consist of four character codes. The first letter denotes the chapter
of the classification. The next two digits represent the section of the chapter and the final
digit represents the specific procedure within that chapter for example H04 Total excision of
colon and rectum represents the exact code within this section. H042 Panproctocolectomy
S and anastomosis of ileum to anus and creation of pouch HFQ can be found in
chapter H Lower Digestive tract, section H04 Total excision of colon and rectum and
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represent an ileoanal pouch procedure or restorative proctocolectomy. Prior to April 2007
there were up to twelve operation fields and four prior to April 2002. OPCS classifications
have undergone several iterations since its inception. OPCS 4.2 was valid until 31st March
2006. From April 2006 to March 2007, use of OPCS 4.3 became mandatory. From April
2007 to March 2009, OPCS 4.4 came into effect and finally since April 2009 OPCS 4.5 has
been use.
Diagnostic coding has used the ICD-10 since 1995. Similar to OPCS coding, diagnosis codes
are four characters with the letter and first two digits representing the relevant section and the
final digit specifying the exact classification. There are currently 20 diagnostic fields. Prior
to April 2007, there were fourteen fields and seven prior to April 2002.
In this study all codes were verified locally with the Imperial College NHS Trust coders, with
the published literature and where appropriate with the central National Clinical
Classifications helpdesk (National Coding Service).
HES Coding
Colorectal resection
OPCS codes
Right sided resection right hemicolectomy (H07)
extended right hemicolectomy and transverse colectomy (H06,
H08)
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Left sided resection left hemicolectomy (H09)
sigmoid colectomy (H10)
Hartmanns procedure (H33.5) in emergency studies
total colectomy panproctocolectomy (H04.1, H04.3, H04.8, H04.9)
total colectomy (H05)
colectomy of unspecified site (H11)
Rectal resection anterior resection
(H33.2, H33.3, H33.4, H33.6, H33.7, H33.8, H33.9)
abdominoperineal excision (APE) (H33.1)
Hartmanns procedure (H33.5) in elective studies
ICD10 codes
Malignant disease C18 C19 C20 C21 C26
Ulcerative colitis (UC), K51
Crohns disease, K50
Diverticular disease. K57
Further details about secondary coding is given in the relevant chapter.
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Restorative proctocolectomy
OPCS codes
H042 Total excision of colon and rectum, Panproctocolectomy and
anastomosis of ileum to anus and creation of pouch however further
qualified
anastomosis of ileum to anus not elsewhere classified
G725 Other connection of ileum, Anastomosis of ileum to anus and creation
of pouch however further qualified
ICD10 codes
Individual diagnoses were recoded into major diagnostic categories according to ICD 10 code
as follows: K51- Ulcerative colitis (UC), K50 - Crohns disease, C18 C19 C20 C21
C26 D37- Malignant disease, D010 D12-Benign colorectal tumours. The remaining
codes were classified as other diagnosis
Risk adjustment
Charlson comorbidity score
The Charlson co-morbidity index is derived from the secondary diagnosis codes as a marker
of co-morbidity. Charlson and colleagues used data collected in a cohort study in 1984 of
medical patients admitted to New York hospital to create a comorbidity index. This index
was then validated against a cohort of breast cancer patients to test its ability to predict
mortality (Charlson et al., 1987). They produced a weighted index of 19 conditions that took
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account not only of the number of comorbid conditions but also the relative severity of these
conditions using the relative risk of death from each condition.
Given that this index was validated amongst breast cancer patients, validation was required
for other specialities and for its use in administrative datasets. Ouellette and colleagues
validated the Charlson score for colorectal cancer patients (Ouellette et al., 2004). They
retrospectively reviewed patients undergoing a laparotomy for colorectal cancer over 4 years.
Higher scores correlated with longer length of stay, overall mortality and perioperative
mortality. DHoore and colleagues applied the Charlson index successfully to predict
mortality amongst patients with ischaemic heart disease, congestive heart failure, stroke or
bacterial pneumonia using administrative databases (D'Hoore et al., 1993). The area under
the receiver-operating curve was 0.83. They also examined the use of Charlson scoring to
predict mortality amongst patients admitted with ischaemic heart disease using an
administrative database in Quebec, Canada (D'Hoore et al., 1996). The authors found that the
Charlson index could be successfully applied to an administrative dataset to predict mortality.
In addition to the United States and Canada, the Charlson index has been applied to data in
other countries including Australia and Europe (Lu et al., 2011, Faiz et al., 2008b, Faiz et al.,
2010a, Pasternak et al., 2010, Thygesen et al., 2011). The original adaptations of Charlson
used the ICD-9 coding systems but subsequent studies were able to adapt it to the ICD10
version used on HES (Sundararajan et al., 2004). Nuttall and colleagues demonstrated that
Charlson scoring could be applied to English data using the HES dataset to predict short term
outcome and mortality following urological cancer surgery (Nuttall et al., 2006). Charlson
scoring has been used previously to predict postoperative complications following colorectal
and other surgical procedures (Kemp and Finlayson, 2008, Arrigo et al., 2011).
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Charlson scoring uses the secondary diagnosis fields present on HES to take account of other
comorbidities. Other scores such as the Physiological and Operative Severity Score for the
Enumeration of Mortality and Morbidity (POSSUM) scoring system (Copeland et al., 1991),
Portsmouth POSSUM (Prytherch et al., 1998) or colorectal POSSUM (Tekkis et al., 2004)
may provide greater risk adjustment. The variables required to derive these more specialised
comorbidity measures are not, however, available on the HES dataset.
The Charlson score has been categorised for the colorectal and pouch datasets. This
categorisation was used to improve power and make the scores more clinically meaningful.
The categories were chosen according to the relationship with mortality with each score.
The categories were as follows:
1. Those patients with a score of zero
2. Those patients with a score of between one and four
3. Those patients with a score greater than or equal to five.
Pouch procedure
1. Those patients with a score of less than or equal to two
2. Those patients with a score of greater than two.
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Carstairs index of deprivation
The Carstairs index of deprivation is a small-area deprivation score at the ward level and is
derived from the patients postcode contained in the HES dataset (Carstairs and Morris,
1989). This score is based on four factors derived from national census data. These factors
include overcrowding, unemployment, social class, and car ownership and are combined into
an unweighted score of the four variables. Patients are divided into quintiles according to the
Carstairs score. Other measures of social deprivation specifically designed for use in health
include the Townsend score and the Jarman score (Morris and Carstairs, 1991). The
Townsend and Carstairs indices are highly correlated. In a review of indices by Carstairs and
Morris, the Carstairs index was highly correlated with health measures such as the
standardized mortality ratio and permanent sickness (Morris and Carstairs, 1991). This score
is commonly used in outcome research using HES data to assess the impact of social
deprivation on health (Bagger et al., 2008, Al Murri et al., 2004, Pagano et al., 2009, Wu et
al., 2011, Mayer et al., 2011, Lazzarino et al., 2011). The inclusion of car ownership in the
score may not be relevant in all geographical locations such as larger cities.
Risk adjustment also included gender, admission status, diagnosis, type of resection and
where applicable use of laparoscopy.
Admission status was determined according to the ADMIMETH variable present on HES
and was coded as elective or emergency.
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Diagnosis was determined firstly by the primary diagnosis DIAG1. If DIAG1 did not
contain a diagnosis of colorectal cancer, diverticular disease or inflammatory bowel disease,
DIAG2 and DIAG3 were interrogated for these diagnoses. If not present, the diagnosis
was categorised as other. For analysis of pouch procedures, inflammatory bowel disease was
further categorised into Ulcerative colitis and Crohns disease.
Resection type for studies including emergency and elective admissions are categorised into
the following categories according to the OPCS codes above:
Right sided resections include right hemicolectomy, extended right hemicolectomy and
transverse colectomy.
Left sided resections include left hemicolectomy, sigmoid colectomy and Hartmanns
procedure.
Total colectomy includes panproctocolectomy and total colectomy and colectomy of
unspecified site
Rectal resection includes anterior resection and abdominoperineal excision (APE).
For those including elective or cancer procedures only then resections are categorised into the
following categories:
Right sided resections include right hemicolectomy, extended right hemicolectomy and
transverse colectomy.
Left sided resections include left hemicolectomy, sigmoid colectomy
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Total colectomy includes panproctocolectomy and total colectomy and colectomy of
unspecified site
Rectal resection includes anterior resection, abdominoperineal excision (APE) and
Hartmanns procedure.
Outcome measures
Some outcome measures are readily available on HES. These include 30 day in hospital
mortality, 365 day all cause mortality, 28 day readmission and length of stay. Other outcome
measures may be derived from HES data using longitudinal analysis. The methodology for
these measures is outlined in the relevant chapters.
30 day in hospital mortality is defined as death from any cause within hospital within 30 days
of admission. This does not include out of hospital deaths or death on a subsequent
admission.
365 day all cause mortality is defined as deaths within 365 days for any cause in and out of
hospital and are derived through linkage between HES records and the Office of National
Statistics.(HES/ONS methodology, 2002) Due to delays in linkage, this measure is only
available for patients admitted between 1st April 2000 and 31st March 2005.
Readmission is defined as readmission to the same Trust or any other trust in England within
28 days of discharge from hospital.
Length of stay (LOS) is the time in days that a patient remains in hospital during the primary
admission. A patient admitted and discharged on the same day would have an LOS of zero
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Ethical considerations
We have approval under Section 251 (formerly Section 60) granted by the National
Information Governance Board for Health and Social Care (formerly the Patient Information
Advisory Group). We have approval from the South East Research Ethics Committee.
Statistical considerations
Categorical variables were investigated using the Chi-squared test. Logistic regression
analysis was used to investigate the independent role of explanatory variables on outcome.
Linear regression was used to investigate LOS. LOS underwent logarithmic transformation
and back exponentiation for analysis. Cox regression analysis was used to explore the
independent predictors for time dependent outcome (pouch failure).
Statistical analyses were carried out using SPSS Version 16.0 to 18.0 as applicable
(Statistical Package for Social Sciences, SPSS, Chicago, Illinois, USA). Multilevel
modelling was performed using MLwiN Version 2.1 (2009) from the Centre for Multilevel
Modelling, University of Bristol (Rabash et al., 2010). Further details on the multilevel
models constructed are included in the relevant chapters.
For tests of significance, a p value of <0.05 was considered significant. For non-parametric
variables the median and interquartile range (IQR) are given.
Funnel plots with exact Poisson control limits were constructed using the web tool-
http://www.erpho.org.uk/topics/tools/funnel.aspx
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Volume
In this thesis volume has been considered in a number of ways according to the appropriate
dataset. This is discussed further in the relevant chapters.
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Chapter 5- Variation in patient factors
Introduction
When measuring performance and quality amongst providers, it is important to account for
differences in case mix amongst individual consultant teams and NHS Trusts. There may be
considerable variation in characteristics of patients operated on by different providers. In fact,
previous research has suggested that much of the variation seen in healthcare is at the patient
level (Osler et al., 2011). Osler and colleagues sought to assess the impact of patient and
hospital factors in a population of patients undergoing surgery for colorectal cancer in
Denmark on mortality. They suggested that, though hospitals varied significantly in
mortality, only 4.3% (based on the intraclass correlation) of the variation in mortality was
accounted for at the hospital level. The remaining variation was at the patient level. Friese
and colleagues showed that patient factors such as type of admission and cancer stage
differed significantly amongst National Cancer Institutes in the US (Friese et al., 2010). In
this study, failure to rescue rates were lower amongst the National Cancer Institutes than in
other studies. Some of these differences are likely to be due to the population differences of
those treated in these centres. Prior to discussing variation amongst providers, it is important
to acknowledge that there may be variation in patient factors among these providers. When
assessing variation at a provider level, consideration of patient level differences is important.
Datasets vary in the degree of risk adjustment possible from the included information. As
routinely collected datasets are not specifically designed for such comparative purposes,
some desirable factors are absent. Disease severity scoring is not contained within the HES
database. In particular, cancer stage, Hinchley grade or severity of inflammatory bowel
disease are not present in this database. Institutions that may have a specialist interest in
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advanced cancer or severe inflammatory bowel disease surgery may appear erroneously as
outliers on this database. This information may be available in the future through linkage
with other datasets such as cancer registries, which would allow improved risk stratification.
Identification of outlier status on such a routinely collected dataset should never be
considered as definitely signifying poor performance without further investigation to confirm
data accuracy and case mix.
This chapter serves to provide an important introduction to the datasets used in this research
and to assess the variation in patient factors across Trusts in both general colorectal and more
specialized colorectal surgery.
Aim
This chapter aims to describe variation in patient characteristics across providers amongst
colorectal resections and pouch patients.
Methods
All patients undergoing a colorectal resection between 2000 and 2008 on the HES database
were included in assessing variation in patients undergoing colorectal surgery.
When more specialized surgery was examined, all elective patients undergoing a pouch
procedure between 1996 and 2008 were included. The earlier study years were included due
to the small number of patients undergoing this procedure across England. Diagnoses were
assigned according to the ICD10 diagnoses described in the methods and in more detail
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below as appropriate. Those Trusts performing less than ten colorectal procedures during the
study period were omitted from the graphs describing variation in case mix (n=20 Trust,
n=37 patients).
Ethnicity was coded according to the HES classification. The following classes were
grouped together
1. White included British (White), Irish (White), Any other White background
2. Black included Caribbean (Black or Black British), African (Black or Black British),
Any other Black background
3. Indian subcontinent included Indian (Asian or Asian British), Pakistani (Asian or
Asian British), Bangladeshi (Asian or Asian British), Any other Asian background
4. Chinese (other ethnic group)
Figures 5.1 to 5.6 summarise the differences in patient characteristics across Trust. The total
height represents the total caseload with each coloured bar representing the number of
procedures belonging to that category within an institutions caseload. Where appropriate,
caterpillar plots show the mean percentage for that variable with the 95% confidence
intervals in each Trust.
Results
Of the 246,420 patients managed by Trusts performing greater than or equal to 10 resections
between 2000 and 2008, 158,812 (64.4%) patients underwent an elective resection. Trusts
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varied considerably in the proportion of procedures that were coded to an emergency
admission with a range of 52% to 100% elective workload. The Trust with a 100% elective
workload was of low volume with just 16 included resections over the eight-year study
period. Figure 5.1 shows the variation in the proportion of elective and emergency
admissions per Trust.
Figure 5.1: Variation in admission type (elective and emergency) by Trust for all colorectal
resections (percentage of elective admission with 95% confidence interval error bars).
1
0.9
Percentage elective caseload
0.8
0.7
0.6
0.5
0.4
0.3
RGC
RXH
RGR
RW3
RMP
RXC
RD1
RR1
RWW
RA9
RK5
RTH
RHM
RVR
RAE
RTR
RFF
RJC
RWJ
RJD
RGM
RQ6
RHW
REM
RAS
RGN
NHS Trusts
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Figure 5.2: Variation in Trust diagnosis for all colorectal resections by Trust of all patients
undergoing a colorectal resection.
4000
3500
3000
2500
Other
2000 DD
IBD
1500
Cancer
1000
500
0
Individual NHS Trusts
The most common diagnosis was that of colorectal cancer with a median percentage caseload
59.0% (IQR 55.3%-62.0%) per Trust. Figure 5.2 shows the variation between Trusts
according to diagnoses.
115

Figure 5.3 Variation in type of resection per Trust of all patients undergoing a colorectal
resection.
4000
3500
3000
2500
Total
2000
Rectal
1500
Left
1000 Right
500
0
RN3
RWE
RWA
RTD
RXC
RTR
RXR
RWG
RNL
RR7
RE9
RXL
RWY
RA7
RM2
RC1
RA4
RC3
RJF
RBQ
RXH
RFW
RLQ
RNS
RNQ
RVV
Figure 5.3 demonstrates the variation in type of resection that patients undergo in each Trust.
Right sided resections were the most common procedure undertaken (Table 5.1).
116

resection.
Elective
All procedures
N (%)
158842
Elective admission * (64.5%)
Resection type** right sided 80908 (32.8)

left sided 73162 (29.7)
rectal 68925 (28.0)
total 23462 (9.5)
Diagnosis Colorectal cancer 144536 (58.6)

IBD 20672 (8.4)
Diverticular disease 33034 (13.4)
other 48215 (19.6)
Age 17-54 475668 (19.3)

55-69 78867 (32.0)
70-79 75900 (30.8)
>79 44022 (17.9)
Charlson score 0 158265 (64.2)

1-4 23157 (9.4)
5 65035 (26.4)
Carstairs 1 (least deprived) 46647 (18.9)

deprivation
index*** 2 55290 (22.4)
3 53870 (21.9)
4 49139 (19.9)
5 (most deprived) 41318 (16.8)
Gender Male 124982 (50.7)

Female 121475 (49.3)
*150 patients did not have an admission status recorded

** Rectal resections included Hartmanns procedure
*** 193 patients did not have a Carstairs deprivation score recorded
117

Figure 5.4: Variation in Charlson scoring per Trust of all patients undergoing a colorectal
resection.
4000
3500
3000
2500
2000 Charlson >4
1500 Charlson 1-4

Charlson 0
1000
500
0
RN3
RWE
RWA
RTD
RXC
RTR
RXR
RWG
RNL
RNS
RE9
RXL
RWY
RNQ
RR7
RA7
RM2
RC1
RA4
RJF
RFW
RC3
RBQ
RXH
RVV
RLQ
Individual NHS Trust
The majority of patients had low comorbidity scores as measured by the Charlson score.
Figure 5.4 shows the variation in Charlson scores by NHS trust.
118

Figure 5.5: Variation in social deprivation by Trust of all patients undergoing a colorectal
resection
4000
3500
3000
2500
QUINTILE 5
2000 QUINTILE 4
QUINTILE 3
1500
QUINTILE 2
1000 QUINTILE 1
500
0
RN1
RWE
RX1
RXP
RHU
RJE
RVR
REM
RRF
RBD
RNJ
RW3
RM4
RPY
RYJ
RLN
RWH
RQ8
NT8
RNQ
RRK
RBT
5QT
Trusts varied in the degree of affluence of their patient populations as shown in Figure 5.5.
119

Figure 5.6: Variation in patient age by Trust of all patients undergoing a colorectal resection
4000
3500
3000
2500
>79
2000
70-79
1500 55-69
17-54
1000
500
0
RN3
RWE
RWA
RTD
RXC
RTR
RXR
RWG
RNL
RR7
RE9
RXL
RWY
RA7
RM2
RC1
RA4
RC3
RJF
RBQ
RXH
RFW
RLQ
RNS
RNQ
RVV
There was less variation in age of patients between Trusts as shown in Figure 5.6.
120

Of patients undergoing primary RPC, 55.4% (3198) were male. The median age of the entire
population was 38 years (IQR 28-50 years, n=5771) (Table 1). 4723 (81.8%) patients had no
associated co-morbidity (Charlson score = 0). Table 5.2 summarises the characteristics of
patients undergoing RPC included in this study. 87.7% (5063/5771) were assigned
diagnostic codes relating to the principal diagnostic categories listed in Table 5.2. The
remaining 12.3% (708/5771) were assigned to 154 separate primary diagnoses. The most
frequent codes in the other diagnostic category were; K914 and Z432 [Attention to
stoma (250/5771)]; K528 and K529 [Non infective gastroenteritis and colitis
(n=70/5771)]; K660 [Adhesions (n=22/5771)]; K572, K573 and K579 [Diverticular
disease (n=17/5771)]; Q431 [Hirschsprung's disease (12/5771)] and K566 [Obstruction
(9/5771)]. The number of RPCs carried out each year remained stable throughout the study
period. In 1996, 465 RPC were performed compared with 483 in 2007 (p=0.252).
121

Table 5.2: Characteristics of patients undergoing RPC between 1996 and 2008
Age Median 38 years
Frequency (percent)
<17 years 216 (3.7)
17-39 years 2882 (49.9)
40-59 years 1993 (34.5)
>59 years 680 (11.8)
Total 5771 (100)
Gender Male:Female 3198:2573
Charlson comorbidity score Frequency (percent)

0-2 5633 (97.6)
>2 138 (2.4)
Total 5771 (100)
Carstairs deprivation score Frequency (percent)

1 least deprived 1226 (21.2)
2 1322 (22.9)
3 1214 (21)
4 1063 (18.4)
5 most deprived 926 (16.0)
Unclassified 20 (0.3)
Total 5771 (100.0)
Diagnosis Frequency (percent)

UC 3934 (68.2)
Malignancy 619 (10.7)
Crohns disease 381 (6.6)
Benign 129 (2.2)
Other diagnosis 708 (12.3)
Total 5771 (100)
Ethnicity Frequency (percent)

White 2907 (50.4)
Indian subcontinent 176 (3.0)
Black 38 (0.7)
Chinese 4 (0.1)
Other/Unknown 2646 (45.8)
Total 5771 (100)
122

Summary
Variation exists at the patient level. This variation is particularly marked in terms of levels of
social deprivation, admission status and diagnosis. This variation in case mix may impact on
outcome. It is important when considering benchmarking performance and quality that this
variation is understood and accounted for as much as possible.
Patient factors, such as social deprivation, are often not amenable to alteration by the surgical
team and NHS Trust. It is therefore important to focus on the variation in factors that are
within the control of the NHS Trusts and consultant teams whilst acknowledging the
differences in patient factors that may impact on outcome.
In the following chapters, variation in NHS trust and consultant team structural factors such
as level of activity alongside process factors such as use of laparoscopy are described.
Following this, the differences in outcome that can be explained by variation at the patient,
and in structural and process factors are described as well as the variation in outcome that is
yet to be explained.
123

Chapter 6- Variation in Structural factors
Introduction
Patients represent one level when considering quality and performance measurement in
health care. Structural factors have been used as quality indicators in the US with some
healthcare funders stipulating that minimum surgical caseloads are required for
reimbursement (Leapfrog Group, 2007). In the UK, government bodies and surgical societies
have proposed minimum populations and volume of surgery for certain oncological
procedures. The Department of Health suggested centralizing Upper Gastrointestinal and
Hepato-biliary care in 2001 (Department of Health, 2001). The Association of Upper
Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS, 2010) have subsequently
proposed a minimum of 15-20 oesophago-gastric resections per year per surgeon in units of
4-6 surgeons (AUGIS, 2010). In the same report, AUGIS propose that each surgeon should
perform 12-16 pancreatic resections surgeon and 15-25 liver resections (10-15 major) per
year (AUGIS, 2010). The ACPGBI has also proposed minimum volume of colorectal cancer
resections of at least twenty elective and emergency colorectal cancer resection per year
(ACPGBI, 2007). The evidence base for this figure of twenty procedures is unclear. No such
minimum volumes have been suggested for benign surgery such as for IBD.
Measurement of caseload and stipulation of a minimum volume for certain procedures is an
attractive way of improving quality. Once initial restructuring issues are overcome, it would
be an easy measure to monitor as a surrogate for quality. However, its place is not
124

recognized across the board and increasing caseload indiscriminately without sufficient
evidence may have detrimental effects.
Both surgeon and hospital caseload may affect the quality of care offered in a hospital.
Institutional factors such as provision of critical care beds including size of Intensive Care
Unit (ICU), access to emergency theatres or nurse to patient ratios may affect the quality of
care experienced by patients. Little research has focused on variation in these structural
factors across NHS units.
This chapter seeks to establish if variation in structural factors, activity and infrastructure,
exists across England in both general and more specialized colorectal surgery.
Aim
This chapter aims to
1. Explore the variation in activity across surgeons and institution in colorectal surgery
in England.
2. Assess how activity has altered over time
3. Assess how many consultant teams meet the threshold of twenty cancer resections per
year in England.
4. Explore variation in institution infrastructure across these units.
125

Methods
Inclusions
1. All patients undergoing colorectal resection in England with a further analysis of
those patients undergoing a resection for cancer between 2000 and 2008.
2. Patients undergoing a restorative proctocolectomy for any diagnosis.
The consultant code was not used for emergency admissions. Analysis of whether consultant
teams met the twenty threshold suggested by the ACPGBI is based, therefore, on the elective
caseload. The elective caseload is used to predict overall caseload based on the relative
overall percentage of elective to emergency cancer procedures. As 75% of cancer resections
are elective, the cut off of fifteen elective colorectal resections per year per consultant team
was examined in lieu of the twenty suggested by the ACPGBI.
Institutional Infrastructural data
Data regarding the infrastructure available within NHS Trusts were derived from
http://www.performance.doh.gov.uk/hospitalactivity/data_requests/index.htm. Data were
averaged across the years where infrastructure data were available. Data concerning
radiology services including Computer Tomography (CT) scanning, Magnetic Resonance
Imaging (MRI), fluoroscopy and ultrasound scanning (USS) were averaged by the number of
beds per year. Critical care beds included high dependency (HDU) beds, Intensive Care Unit
(ICU) beds. Numbers of critical care beds are the number per Trust bed per year multiplied
by 100. These data were non parametric. Correlations were, therefore, performed using
Spearmanns correlation.
126

Results
All Colorectal resections
Between 1st April 2000 and 31st March 2008, 246457 patients who underwent a primary
colorectal resection in 175 English Trusts were included. 158842 (64.5%) patients
underwent resection during an elective admission and 35.5% (87465) represented emergency
admissions. 150 patients had no record of their admission status. Table 6.1 summarises the
characteristics of elective and emergency patients undergoing resection included in this
study. Those Trusts that undertook greater than or equal to ten procedures during the study
period performed a median of 187 procedures per year (IQR 132-257 cases per year, n=156
Trusts).
127

resection.
Elective Emergency p
n (%) n (%)
Resection type* right sided 45856 (28.9) 34957 (40.0)

left sided 38317 (24.1) 34823 (39.8)
<0.001
rectal 63315 (39.9) 5604 (6.4)
total 11354 (7.1) 12081 (13.8)
Diagnosis Cancer 111023 (69.9) 33489 (38.3)

IBD 11442 (7.2) 9201 (10.5)
<0.001
Diverticular disease 14113 (8.9) 18914 (21.6)
Other 22264 (14.0) 25861 (29.6)
Age 17-54 27522 (17.3) 20020 (22.9)

55-69 54944 (34.6) 23907 (27.3)
<0.001
70-79 51316 (32.3) 24581 (28.1)
>79 25060 (15.8) 18957 (21.7)
Charlson score 0 54574 (65.2) 54574 (62.4)

1-4 14836 (9.3) 8312 (9.5) <0.001
5 40443 (25.5) 24579 (28.1)
Carstairs 1 (least deprived) 31391 (19.8) 15224 (17.4)

deprivation 2
37045 (23.3) 18220 (20.8)
index**
<0.001
3 34910 (22.0) 18931 (21.6)
4 30679 (19.3) 18427 (21.1)
5 (most deprived) 24680 (15.5) 16608 (19.0)
Gender Male 84151 (53.0) 40815 (46.7)

<0.001
Female 74691 (47.0) 46650 (53.3)
*Left sided resections included Hartmanns procedure

** 192 patients did not have Carstairs deprivation scores recorded
128

6731 consultant teams were coded as having managed these elective and emergency patients.
For the analysis of variation at a consultant team level only elective patients were included.
3716 consultant teams were coded to managing 158842 elective patients. Of these 1557
performed greater than or equal to five resections over the study period. These consultant
teams managed a median of 13 procedures per year (IQR 3-33 cases per year, n=1557
consultant teams). Figure 6.1 shows the variation in all colorectal resection by NHS Trust
over the study period.
129

Figure 6.1: Variation in total volume of colorectal resection over the study period (8 years)
by 156 individual NHS Trust
4000
3500
3000
2500
2000
1500 Total Trust volume
1000
500
0
5P5
RV4
RCU
RAP
RMP
RN7
RC9
RM2
RNS
RVY
RWW
RNL
RKB
RTR
RWF
RF4
RXP
RQQ
RBQ
RLN
RVV
RAX
130

Cancer resections
Between 1st April 2000 and 31st March 2008, 144536 patients underwent an emergency or
elective colorectal resection for cancer in 160 NHS Trusts. Of these, 111023 (76.8%)
patients were coded to an elective admission and 33489 (23.2%) patients were coded to an
emergency admission. 26 patients did not have a valid admission status. 3651 consultant
teams were coded as having managed these elective and emergency patients. The consultant
code was not used for emergency patients. For elective patients, 2175 consultant teams
managed 111023 cancer patients undergoing resection. 1155 consultant teams performed
between 5 and 465 elective procedures over this period. 149 hospital providers performed
between 87 and 2161 colorectal resections over the eight-year study period. In those Trusts
that performed more than or equal to ten procedures over the study period, the median Trust
elective and emergency volume per year was 112 procedures (IQR 81-153 cases per year,
n=149 Trusts) with a median consultant team volume of 16 elective cancer cases per year
(IQR 5-28 cases per year, n=1155 consultant teams). Table 6.2 summarises the characteristic
of elective and emergency cancer patients included in this study. Figure 6.2 shows the
variation in elective cancer resection caseload per consultant team during the study period.
131

cancer resection.
Elective Emergency p
n (%) n (%)
Resection type* right sided 33283 (30.0) 17506 (52.3)

left sided 17552 (15.8) 5337 (15.9)
<0.001
rectal 56546 (50.9) 8117 (24.2)
total 3642 (3.3) 2529 (7.6)
Age 17-54 10550 (9.5) 3146 (9.4)

55-69 39080 (35.2) 9509 (28.4)
<0.001
70-79 40373 (36.4) 11222 (33.5)
>79 21020 (18.9) 9612 (28.7)
Charlson score 0 66243 (59.7) 16414 (49.0)

1-4 10053 (9.1) 2542 (7.6) <0.001
5 34727 (31.3) 14533 (34.1)
Carstairs 1 (least deprived) 22169 (20.0) 5961 (17.8)

deprivation 2
26202 (23.6) 7129 (21.3)
index**
<0.001
3 24593 (22.2) 7322 (21.9)
4 21167 (19.1) 6963 (20.8)
5 (most deprived) 16806 (15.1) 6101 (18.2)
Gender Male 63676 (57.4) 16715 (49.9)

<0.001
Female 47347 (42.6) 16774 (50.1)
* Rectal resections included Hartmanns procedure

** 99 patients did not have a Carstairs deprivation score recorded
132

Figure 6.2: Variation in elective colorectal cancer resection caseload per consultant team per
year over the study period.
500
450
400
350
300
250
200
150
100
50
0
Individual consultant teams
Each band of colour represents the volume performed in an individual year by each
consultant team with the total height representing the total volume of elective cancer
resections performed within the study period.
133

Changes in activity over time
There was no correlation between year of surgery and total provider resection activity or total
cancer resection activity after exclusion of those very low volume trusts [r=0.051, p=0.071
and r=0.043, p=0.134 respectively]. There was a small correlation between consultant team
elective cancer caseload per year and year of surgery [r=0.095, p<0.001]. As shown in
figure 6.3, the mean resection volume per year rose from 14.6 cases in 2000 per consultant
team to 18.8 cases per consultant team in 2007. The number of consultant teams reduced
over this period from 930 consultant teams in 2000 to 812 consultant teams in 2007
(r=-0.937, p=0.001).
Guideline of twenty cancer resection per year
75% of the overall cancer workload were admitted as elective admissions. To explore,
therefore, the twenty resection threshold suggested by the ACPGBI, the cut off of 15 elective
colorectal resections per year were examined per consultant team. Even with this lower
threshold, only 267 consultant teams met the threshold of 15 cancer resections in each year
that they performed resections.
134

Figure 6.3: Increase in mean consultant team elective colorectal cancer caseload over time
with 95% confidence interval error bars.
135

Pouch procedures
Between 1st April 1996 and 31st March 2008, 5771 patients underwent primary elective RPC
in 154 English NHS Trusts. 154 hospital providers performed between 1 and 611 primary
RPCs over the twelve-year study period. The twenty highest volume institutions carried out
49.4% (n=2848) of the total number. The median institution volume was 22 cases (IQR 11-39
cases, n=154 NHS trusts). 3878 (67.2%) procedures were assigned 499 individual consultant
team codes. Individual consultant team codes were only available from April 2000 to March
2008 and thus the surgeon volume spans only eight of the twelve years. Over this period,
individual consultants performed between 1 and 134 primary pouch procedures. Ninety-one
percent carried out 20 or fewer RPCs over the eight years and the median surgeon volume
was 4 cases (IQR 1-9 cases, n=499 surgeons) over eight years.
Patients undergoing pouch procedures were categorised according to the volume of primary
procedures carried out by their named consultant team or institution during the study period.
In the first instance these categories were apportioned in two ways as described in the
methodology section: categories A to C and into low volume (LV), medium volume (MV)
and high volume (HV). The latter were assigned to tertiles derived from ranking individual
patients. The characteristics of patients in each group are outlined in Table 6.3 and Table 6.4.
136

Table 6.3: Patient characteristics in each institutional volume category operated on between 1996 and 2008 *
1-14 procedures 15-31 procedures 32 procedures 1-39 procedures 40-100 procedures 101 procedures
A B C P value LV MV HV P value
Age
<17 years 31/402 (7.7) 23/1068 (2.2) 162/4301 (3.8) 66/1964(3.4) 61/1916 (3.2) 89/1891 (4.7)
17-39 years 192/402 (47.8) 524/1068 (49.1) 2166/4301 (50.4) 988/1964 (50.3) 947/1916 (49.4) 947/1891 (50.1)
p<0.001 p=0.208
40-59 years 131/402 (32.6) 391/1068 (36.6) 1471/4301 (34.2) 680/1964 (34.6) 672/1916 (35.1) 641/1891 (33.9)
>59 years 48/402(11.9) 130/1068 (12.2) 502/4301 (11.7) 230/1964 (11.7) 236/1916 (12.3) 214/1891 (11.3)
Gender
Male:Female 217:185 612:456 2369:1932 p=0.355 1090:874 857:1059 842:1049 p=0.988
0-2 392/402 (97.5) 1047/1068 (98.0) 4194/4301 (97.5) 1918/1964 (97.7) 1862/1916 (97.2) 1853/1891 (98.0)
p=0.602 p=0.259
>2 10/402 (2.5) 21/1068 (2.0) 107/4301 (2.5) 46/1964 (2.3) 54/1916 (2.8) 38/1891 (2.0)
Carstairs deprivation score
1 72/402 (17.9) 209/1068 (19.6) 945/4301 (22.0) 387/1964 (19.7) 389/1916 (20.3) 450/1891 (23.8)
2 83/402 (20.6) 247/1068 (23.1) 992/4301 (23.1) 467/1964 (23.8) 440/1916 (23.0) 415/1891 (21.9)
3 75/402 (18.7) 260/1068 (24.3) 879/4301 (20.4) 413/1964 (21.0) 407/1916 (21.2) 394/1891 (20.8)
p<0.001 p=0.016
4 86/402 (21.4) 213/1068 (19.9) 764/4301 (17.8) 380/1964 (19.3) 348/1916 (18.2) 335/1891 (17.7)
5 84/402 (20.9) 138/1068 (12.9) 704/4301 (16.4) 314/1964 (16.0) 319/1916 (16.6) 293/1891 (15.5)
Unclassified 2/402 (0.5) 1/1068 (0.1) 17/4301 (0.4) 3/1964 (0.2) 13/1916 (0.7) 4/1891 (0.2)
Diagnosis
UC 239/402 (59.5) 745/1068 (69.8) 2959/4301 (68.6) 1328/1964 (67.6) 1290/1916 (67.3) 1316/1891 (69.6)
Malignancy 52/402 (12.9) 94/1068 (8.8) 473/4301 (11.0) 193/1964 (9.8) 208/1916 (10.9) 218/1891 (11.5)
Crohns disease 12/402 (3.0) 27/1068 (2.5) 90/4301 (2.1) p=0.001 52/1964 (2.6) 43/1916 (2.2) 34/1891 (1.8) p=0.002
Benign 33/402 (8.2) 57/1068 (5.3) 291/4301 (6.8) 134/1964 (6.8) 110/1916 (5.7) 137/1891 (7.2)
Other diagnosis 66/402 (16.4) 145/1068 (13.6) 497/4301 (11.6) 257/1964 (13.1) 265/1916 (13.8) 186/1891 (9.8)

Table 6.4: Patient characteristics in each surgeon volume category of pouch patients operated on between 2000 and 2008*
1-2 procedures 3-6 procedures 7 procedures 1-10 procedures 11-28 procedures 29 procedures
A B C P value LV MV HV P value
Age
<17 years 18/266 (6.8) 24/554 (4.3) 98/3058 (3.2) 66/1331 (5.0) 27/1329 (2.0) 47/1218 (3.9)
p<0.001 p<0.001
17-39 years 88/266 (33.1) 276/554 (49.8) 1555/3058 (50.9) 610/1331 (45.8) 712/1329 (53.6) 597/1218 (49.0)
40-59 years 97/266 (36.5) 191/554 (34.5) 1067/3058 (34.9) 471/1331 (35.4) 443/1329 (33.3) 441/1218 (36.2)
>59 years 63/266 (23.7) 63/554 (11.4) 338/3058 (11.1) 184/1331 (13.8) 147/1329 (11.1) 133/1218 (10.9)
Gender
Male:Female 153:113 301:253 1722:1336 p=0.614 758:573 751:578 667:551 p=0.505
0-2 253/266 (95.1) 540/554 (97.5) 2990/3058 (97.8) 1290/1331 (96.9) 1303/1329 (98.0) 1190/1218 (97.7)
p=0.026 p=0.158
>2 13/266 (4.9) 14/554 (2.5) 68/3058 (2.2) 41/1331 (3.1) 26/1329 (2.0) 28/1218 (2.3)
Carstairs deprivation score
1 least deprived 51/266 (19.2) 123/554 (22.2) 656/3058 (21.5) 282/1331 (21.2) 261/1329 (19.6) 287/1218 (23.6)
2 49/266 (18.4) 133/554 (24.0) 721/3058 (23.6) 305/1331 (22.9) 319/1329 (24.0) 279/1218 (22.9)
3 54/266 (20.3) 118/554 (21.3) 633/3058 (20.7) 274/1331 (20.6) 272/1329 (20.5) 259/1218 (21.3)
p=0.333 p=0.594
4 54/266 (20.3) 95/884 (17.1) 554/3058 (18.1) 243/1331 (18.3) 250/1329 (18.8) 210/1218 (17.2)
5 most deprived 57/266 (21.4) 85/554 (15.3) 489/3058 (16.0) 225/1331 (16.9) 225/1329 (16.9) 181/1218 (14.9)
Unclassified 1/266 (0.4) 0/554 (0.0) 5/3058 (0.2) 2/1331 (0.2) 2/1329 (0.2) 2/1218 (0.20
Diagnosis
UC 138/266 (51.9) 356/554 (64.3) 2129/3058 (69.6) 834/1331 (62.7) 957/1329 (72.0) 832/1218 (68.3)
Malignancy 50/266 (18.8) 66/554 (11.9) 307/3058 (10.0) 169/1331 (12.7) 108/1329 (8.1) 146/1218 (12.0)
Crohns disease 12/266 (4.5) 9/554 (1.6) 72/3058 (2.4) p<0.001 37/1331 (2.8) 36/1329 (2.7) 20/1218 (1.6) p<0.001
Benign 14/266 (5.3) 34/554 (6.1) 197/3058 (6.4) 87/1331 (6.5) 67/1329 (5.0) 91/1218 (7.5)
Other diagnosis 52/266 (19.5) 89/554 (16.1) 353/3058 (11.5) 204/1331 (15.3) 161/1329 (12.1) 129/1218 (10.6)
*The number of procedures in the surgeon categories refers to those carried out over the period from 2000 to 2008.
138

Changes in activity over time
The number of procedures performed per year remained stable with 471 procedures
performed in 2000 and 483 performed in 2007. During this time the number of consultant
teams performing RPC rose from 166 in 2000 to 224 in 2007 [r=0.953, p<0.001]. As shown
in figures 6.4 and 6.5 the number of patients operated in low volume centres and by low
volume consultant teams increased (p<0.001 for both providers).
139

Figure 6.4: The percentage of patients undergoing RPC in each provider volume category
(LV, MV, HV) from 1996 to 2008
45.0%
40.0%
35.0%
30.0%
% of patients
25.0%
LV
20.0%
MV
15.0%
HV
10.0%
5.0%
.0%
Year of surgery
140

Figure 6.5: The percentage of patients undergoing RPC in each surgeon volume category
(LV, MV, HV) from 2000 to 2008
50.0%
45.0%
40.0%
35.0%
% of patients
30.0%
25.0% LV
MV
20.0%
HV
15.0%
10.0%
5.0%
.0%
2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08
Year of surgery
141

Institution infrastructure
Data on structural characteristics was available for 154 NHS Trusts. These data were missing
for two Trusts that performed ten procedures over the study period but no Trusts performing
pouch procedures.
The median inpatient bed number per institution was 733 (IQR 476-1005 beds). The median
critical bed number per 100 inpatient beds was 0.91 (IQR 0.72-1.26 beds). The median
number of CT scans, MRI and Ultrasound scans performed per inpatient bed was 15.86 (IQR
12.75-20.13), 6.57 (IQR 4.84-8.64) and 29.58 (IQR 23.85-37.73) respectively.
Unsurprisingly, larger institutions did perform more resections (r=0.800, p<0.001) and more
pouch procedures (r=0.407, p<0.001). The caseload of pouch procedures weakly correlated
with radiology services [number of CT scans performed per bed per year (Spearman Rho test
r=0.166, p=0.047), number of MRI performed per bed per year (Spearman Rho test r=0.232,
p<0.001), ultrasound scans performed per year (Spearman Rho test r=0.675, p=-0.035)]. The
caseload of RPC did correlate with number of critical care beds (Spearman Rho test r=0.336,
p<0.001) and theatres available (Spearman Rho test r=0.590, p<0.001). Overall resection
caseload correlated with theatre number but no other factors (Spearman Rho test r=0.0743,
p<0.001).
Summary
There was large variation in the activity of both Trusts and Consultant teams performing
colorectal resections and the more specialized procedure of pouch surgery. A low number of
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consultant teams performing colorectal resections consistently met with the adapted volume
threshold suggested by the ACPGBI. General colorectal caseload is increasing time
suggesting some centralisation of sevices is already taking place in England. The availability
of critical care facilities correlated with increased activity of more specialised pouch surgery.
Given these differences in structural factors and at a patient level, variation is likely to exist
in process factors and outcome amongst individual consultant teams and across institutions.
The next chapters seek to describe the variation in process factors and outcome measure as
well as investigate ways of reducing such variation.
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Chapter 7- Variation in process factors
Introduction
Structural measures are used to assess some aspects of quality of care. Measuring quality in
care needs a multifaceted approach. Process measures are often used as surrogate measures
of quality (Donabedian, 1980). They have been shown to directly influence outcome (Rubin
et al., 2001). Process measures reflect the care given across a patient population. These
measures are often applicable to the whole population and therefore occur with a higher
frequency than some outcome measures. In addition, by identifying areas where process
measures are poorly applied, it may be easier to pinpoint where care is lacking and what can
be done to improve quality and hence direct quality improvement programmes.
Process measures are often comprised of perioperative medication or assessment such as
preoperative staging magnetic resonance imaging in rectal cancer. Such measures are
difficult to derive from routinely collected datasets and require bespoke data collection.
Process measures such as choice of procedures are more easily collected using routinely
collected datasets. These measures are, however, more complex. The decision-making about
the most appropriate surgical intervention requires a significant amount of information such
as comorbid conditions, knowledge of the disease process itself and previous surgical history.
Some of this information is present on the routinely collected datasets but by no means all. It
is not possible to ascertain from the dataset whether the treatment selected for an individual
patient is the most appropriate treatment. There is, however, some guidance as to the
preferred treatments across a patient population. The ACPGBI have suggested that APE
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rates should be less than 30% (ACPGBI, 2007). This level recognises that in some patients.
APE is the most appropriate operation. For the majority of patients, however, restorative
surgery is preferable.
A valid process measure should correlate with other measures of quality or there should be a
general consensus that it represents such a valid measure. APEs for rectal cancer have been
suggested to have worse outcome than anterior resection. An APE necessitates a permanent
stoma. Tekkis and colleagues, in a study using ACPGBI bowel cancer audit project data,
found that circumferential margin involvement was significantly higher in patients selected
for APE when compared with those that underwent anterior resection (APE 16.7% and
anterior resection 7.5%) (Tekkis et al., 2005b). Following adjustment for Dukes stage and
whether the procedure was intended to be curative, APE continued to be associated with a
higher circumferential margin involvement [OR 3.3 (2.0-5.4)]. Haward and colleagues, using
the Northern and Yorkshire Cancer registry, demonstrated a survival advantage at 5 years
following anterior resection over APE (Haward et al., 2005). This may be improving over
time with a focus on improving rectal cancer outcome. Using HES data between 1996 and
2004, Tilney and colleagues found a reduction in use of APE over time but also suggested
that significant variation in institutional APE rates remained (Tilney et al., 2008). It should be
noted that this study included all patients assigned to a diagnosis code of colorectal cancer
rather than the ICD10 code of rectal cancer specifically. Morris and colleagues also found
that there were significant variations in England in APE rates amongst NHS Trusts and
suggested that steps needed to be taken to reduce such variation (Morris et al., 2008). Morris
et al, specifically used the C20 ICD10 diagnosis for rectal cancer and excluded other
cancers including those of the rectosigmoid. More recently, Nicholson and colleagues found
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significant inter centre variation in APE rates in Scotland with APE rates ranging from 38%
to 20% (Nicholson et al., 2011). Unlike previous authors, Nicholson et al found that this
inter-centre variation was not statistically significant. Any apparent unexplainable variation
in APE at a consultant team or institution level is undesirable.
It should be acknowledged that not all patients are amenable to undergoing an anterior
resection instead of APE. Patients may also choose to have an APE over an anterior
resection. Indeed, in those with very low rectal tumours or where anal sphincter function is
impaired, an APE may be impossible to avoid. Moreover, a Cochrane review in 2005 found
no difference in quality of life following APE and anterior resection (Pachler and Wille-
Jorgensen, 2005).
Increasingly, laparoscopy is being seen as the treatment of choice for colorectal resection for
most but not all patients. Minimally invasive surgery has been shown to be beneficial for
colorectal cancer surgery in randomised control trials (Lacy et al., 1995, Guillou et al., 2005,
Jayne et al., 2007, Jayne et al., 2010, Veldkamp et al., 2005). NICE guidelines suggested that
it should be offered in appropriate patients with colorectal cancer (NICE, 2006). It should be
stressed however that not all patients are suitable for laparoscopy and some procedures are
less technically challenging than others. However, given the NICE guidelines, it would be
reasonable to expect a similar level of use across NHS Trusts and geographical regions.
Some surgeons with highly specialized caseloads will continue to practice exclusively open
surgery but this does not apply to the majority. Given the apparent benefits and guidelines
for its use, laparoscopy may represent a useful process measure in the future for colorectal
resection. Its role in more specialised surgery such as RPC is less certain.
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This chapter focuses on the potential process measures of APE rate and use of minimally
invasive surgery. These measures are potentially ascertainable from the HES dataset and both
restorative and minimally invasive surgery have been associated with favorable patient
outcome.
Aim
This chapter seeks to explore variation in two measurable process measures amongst patients
undergoing colorectal surgery in England. Specifically, variation in APE rate and use of
minimally invasive surgery are examined at a consultant team and institutional level with use
of minimally invasive surgery being further assessed at a regional level.
Methods
Process measures examined were APE rate and use of the minimally invasive approach for
colorectal resection and pouch surgery.
APE rate
Elective rectal cancer resection patients were included in the APE study if they were assigned
to an ICD10 code of rectal cancer C20. To reduce the implications of possible erroneous
coding, rectosigmoid tumours C19 and anal cancers C21 were excluded when assessing
APE rate. This approach was previously used by Morris and colleagues (Morris et al., 2008).
Providers (individual consultant teams and NHS Trusts) were assigned an APE rate
according to the number of elective APE assigned to the provider divided by the total number
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of elective rectal cancer resections assigned to the provider. It is not possible to ascertain,
from HES, height from the anal verge for these patients.
Risk adjustment included comorbidity, age, social deprivation, use of laparoscopy, year of
surgery and gender.
Use of laparoscopy
All elective resections between 2002 and 2008 were included in the analysis. The study
began in 2002 as this was considered to be the year in which the minimal access approach for
colorectal resection began to be more widely disseminated.
Given that the NICE guidelines apply to and randomized control trials only included cancer
patients, subgroup analysis was performed including only the elective cancer resections.
For the regional comparison of rates of use of the minimal access approach, only elective
colorectal cancer resections in the study year 2007-2008 were included. This last study year
available on the dataset was felt to be the most appropriate comparison across regions as the
NICE guidelines for colorectal cancer resections were introduced in 2006. In this analysis,
patients were coded into regions according to their Strategic Health Authority (SHA). This
was overlayed onto a map of England.
Risk adjustment included comorbidity, age, use of laparoscopy, social deprivation, year of
surgery, type of resection and gender.
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Given the more recent use of the minimal access approach for pouch surgery, use of the
minimal access approach for all or part of restorative proctocolectomy was examined
separately. As more specialised high volume pouch surgeons may be more likely to make use
of laparoscopy, the role of activity in determining laparoscopic rate was assessed. Caseload
was considered as a categorical variable in tertiles according to the total pouch volume over
this study period.
Results
Variation in APE use
36714 patients who underwent an elective resection for rectal cancer were included. Figure
7.1 shows the variation in APE rate by consultant teams. 3.2% of teams (28/880) had
adjusted APE rates abovw the 3rd SD control limits. Figure 7.2 shows the variation in
adjusted APE rate by NHS Trusts. Of the 149 Trusts, 14 Trusts (9.4%) above the 3rd SD
control limits. There was a slight reduction in APE rates over time from 28.5% (1328/4663)
in 2000/1 to 24.7% (1187/3609) in 2007/08 as shown in figure 7.3.
149

Figure 7.1: Funnel plot of consultant team caseload and APE rates amongst patients with
rectal cancer
150

Figure 7.2: Funnel plot of NHS Trust caseload and APE rates amongst patients with rectal
cancer
151

Figure 7.3: Overall percentage APE use amongst rectal cancer patients over time
p<0.001
152

Use of laparoscopy in colorectal resection
Of the 121117 elective patients undergoing a resection between 2002 and 2008 included in
this analysis, 84620 underwent an elective resection for colorectal cancer. The overall
laparoscopy rate between 2002 and 2008 was 8.1% (9871/121117) and 7.7% (6554/84620)
for all elective resections and for cancer resections respectively. Between 2000 and 2008, the
use of laparoscopy increased exponentially for both cancer resections and total resections as
shown in Figure 7.4.
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Figure 7.4: Uptake of laparoscopic approach for all elective resections and elective colorectal
cancer resections
25%
20%
Percentage use of laparoscopy
15%
10% Total elective resection

Elective cancer resection
5%
0%
Year of surgery
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Regional use of minimal access approach
15246 patients who had undergone an elective colorectal cancer resection in 2007 were
included. Of these, 20.1% (3060/15246) patients were selected for the laparoscopic
approach. Table 7.1 shows the total number of cancer resections by each SHA. There was
significant variation in the percentage of colorectal resections selected for laparoscopy in
each SHA. This varied from 10.1% to 29.7% by SHA as shown in Figure 7.5. Following
adjustment for age, gender, level of comorbidity, social deprivation, and type of resection,
SHA continued to be a significant predictor of selection for the minimal access approach as
shown in Table 7.2.
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Table 7.1: Number of elective laparoscopic colorectal cancer resections by SHA in 2007.
Laparoscopic Total number of

SHA
Procedures resections
1 218 (10.1%) 2155
2 177 (13.0%) 1359
3 204 (12.9%) 1580
4 188 (19.5%) 965
5 401 (21.9%) 1831
6 299 (22.9%) 1304
7 365 (24.7%) 1475
8 478 (25.1%) 1908
9 399 (25.6%) 1556
10 331 (29.7%) 1113
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Table 7.2: Multiple logistic regression of use of minimal access surgery in elective colorectal
cancer resection including those patients undergoing resection in 2007.
Univariate Multivariate
Odds Odds
95% C.I. p 95% C.I. p
Ratio Ratio
Age 0.204
17-54 1.00
55-69 1.01 0.87 1.18 0.855
70-79 1.11 0.95 1.28 0.182
>79 1.10 0.94 1.29 0.254
Carstairs 0.394
deprivation 1 (least deprived) 1.00
index 2 1.07 0.95 1.20 0.298
3 1.01 0.89 1.14 0.890
4 0.95 0.84 1.08 0.451
5 (most deprived) 1.02 0.89 1.17 0.765
Gender Female vs male 1.13 1.03 1.21 0.008 1.04 0.95 1.12 0.412
Charlson <0.001 <0.001
score of co- 0 1.00 1.00
morbidity 1-4 0.93 0.83 1.06 0.281 0.96 0.85 1.09 0.517
5 0.76 0.69 0.83 <0.001 0.78 0.71 0.85 <0.001
Strategic <0.001 <0.001
Health 1 1.00 1.00
Authority 2 1.33 1.08 1.64 <0.001 1.32 1.07 1.63 0.011
3 1.32 1.08 1.61 0.008 1.29 1.05 1.58 0.015
4 2.15 1.74 2.66 0.008 2.14 1.73 2.64 <0.001
5 2.49 2.08 2.8 <0.001 2.46 2.06 2.94 <0.001
6 2.64 2.19 3.20 <0.001 2.59 2.14 3.14 <0.001
7 2.92 2.43 3.51 <0.001 2.87 2.39 3.45 <0.001
8 2.97 2.50 3.54 <0.001 2.97 2.49 3.54 <0.001
9 3.06 2.56 3.67 <0.001 3.04 2.54 3.65 <0.001
10 3.76 3.11 4.55 <0.001 3.71 3.06 4.49 <0.001
Type of <0.001 <0.001
resection right sided 1.00 1.00
left sided 0.91 0.81 1.03 0.141 0.95 0.83 1.07 0.001
Rectal 0.77 0.71 0.84 <0.001 0.76 0.69 0.83 <0.001
Total 0.42 0.31 0.58 <0.001 0.41 0.30 0.57 <0.001
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Figure 7.5: Variation in minimal access surgery rate amongst patients undergoing an elective
colorectal resection across SHA in 2007
158

Use of minimal access approach for pouch surgery
2946 primary pouch procedures were performed between 2002 and 2008 in England. 2.7%
(81/2946) were performed using laparoscopic assistance (at least in part). 41 consultant
teams in 33 institutions performed these laparoscopically assisted procedures. Table 7.3
shows the differences in use of laparoscopy in each pouch volume category.
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Table 7.3: Pouch laparoscopic use by volume category
Surgeon Procedure Laparoscopy P value

volume group number rate
A 1-2 3.6% (9/248)

procedures
B 3-6 4.3% (25/562)
procedures p=0.022
C >6 2.2% (24/2136)

procedures
Summary
This chapter confirms the considerable variation in APE use amongst colorectal cancer
patients at a consultant team and NHS trust level with decreased use of APE over time. The
use of the minimal access approach has increased significantly since 2002 for elective
colorectal cancer resection and its use is beginning to disseminate for laparoscopically
assisted pouch surgery. There is considerable geographical variation in the use of minimal
access surgery for colorectal cancer resection despite the introduction of NICE guideline
endorsing this form of surgery.
This and previous chapters have demonstrated variation at a patient level and in structure and
process measures. Such factors are likely to have an impact on outcome and be potentially
addressable to improve the quality of care. The next chapter establishes whether this variation
translates in variation in outcome and derives a new measure necessary to answer this
question.
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Chapter 8- Variation in outcome factors
Introduction
In the previous chapters, variation at a patient level and in structure and process factors in
colorectal surgery was demonstrated. Significant variation was observed between providers
in terms of patient case mix, differences in activity, use of laparoscopy and selection of rectal
cancer patients for APE. It is important to consider whether these differences translate into
genuine variation in outcome. On the HES dataset, certain outcome measures are readily
available. These include in-hospital mortality, length of stay and 28 day readmission. Other
measures such as all cause one-year mortality (available for procedures carried out between
1st April 2000 to 31st March 2004) are derived from HES linkage to the Office of National
Statistics dataset.(HES/ONS linkage methodology, 2002)
These measures have limitations. Mortality is a quality measure that has been historically
relied upon. It is uncommon, especially in elective surgical practice. Its use for quality and
performance benchmarking is therefore limited. A long audit period is required for it to be
statistically stable. Failures in the quality of performance may not necessarily lead to death.
To fully exploit the HES database, further outcome measures in addition to these traditional
measures are required. Using longitudinal analysis, it may be possible to derive new
measures. These measures may be short term, medium term or longer term. Derivation of
these measures will allow a more comprehensive assessment of the HES datasets use to
investigate variation in colorectal surgery. In this thesis, 28-day reoperation following
colorectal resection is explored as a possible short term outcome measure. Adhesion and
incisional herniae rates and pouch failure are examined as medium term measures and a long
161

term outcome measure respectively. These measures were chosen as they allowed
exploration of the diverse uses of HES data. In addition, they are clinically meaningful. It is
also likely that process factors such as laparoscopy and caseload may have an impact on these
outcome measures. Finally, some of these measures such as reoperation may prove valuable
measures of surgical performance when used alongside other established measures such as
mortality if data accuracy can be assured. Certainly, postoperative return to theatre
(reoperation) has been suggested as a useful quality marker in the US for general surgery
(Birkmeyer et al., 2001) and more recently for colorectal surgery (Morris et al., 2007a). In the
UK, it has also been described using HES data in the vascular context (Holt et al., 2009a).
When variation in subspecialised surgery is examined, procedure specific measures are
required including failure following restorative proctocolectomy.
This chapter will describe the derivation and variation in new outcome measures
(reoperation, adhesion, hernia and pouch failure rates). It will also look at variation in
established measures such as mortality. Finally, the impact of process factors (laparoscopy
and APE) on outcome will be examined.
Aim
This chapter seeks to
1. Demonstrate the derivation and potential use of novel colorectal specific short term
outcome metrics (28-day reoperation rates)
2. Demonstrate the derivation and potential use of novel colorectal specific medium
term outcome metrics (adhesion and incisional herniae rates)
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3. Demonstrate the derivation and potential use of novel colorectal specific long term
outcome metrics (pouch failure rates)
4. Assess differences in outcome at a patient level and according to structure and process
factors.
5. Describe existing variation in outcome in general and subspecialised colorectal (i.e.
ileal pouch) surgery.
6. Assess the impact of process factors (laparoscopy and APE) on outcome at a patient
level.
Methods
Short-term complications - Reoperation
Database inclusions and variable coding: all adult patients undergoing primary colorectal
resections were included from 1 April 2000 to 31 March 2008. Any patient who underwent a
colorectal resection between 1996 and 2000 was excluded from the analysis. The first
resection that the patient underwent between 2000 and 2008 was considered as the primary
resection.
Definition: Reoperation was defined as any reoperation for an intra abdominal procedure or
wound complication on the index admission or on a subsequent admission to hospital within
28 days of the initial resection. Reoperation rates were classified according to type of
operation. These were divided into laparotomy (considered as a reopening of abdomen,
washout of abdomen, small bowel resection, further colorectal resection, open procedure for
intra-abdominal abscess, division of adhesions and formation of stoma), stoma complications
(considered as an operation on a stoma excluding closure of stoma and stoma formation),
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wound complications requiring reoperation, and other reasons for reoperation were
considered as other. The codes used to define these procedures are shown in Table 8.1.
Any procedure code on the initial admission or within 28 days of the index procedure were
examined and the relevant intra abdominal or wound complications were identified and
included.
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Table 8.1: OPCS codes used to define reoperations following colorectal resection
Reoperation classification OPCS code

Laparotomy Reopening of abdomen T301 T302 T303 G281 G288 G332 G352 G362 G351
G532 G385 G633 H168 H622 T301 T302 T303 T308
T309 T331 T411 T414 T418 T419 T428 T431 T432
T361 T362 T365 T368 T369 T488 T384 T388 T398
T554 M372 P253 P258
Open procedure for abscess T341 T342 T343
Washout T461 T462 T463 T468 T469 T348 T349 H625
Small bowel operation G611 G692 G693 G694 G698 G699 G702 G712 G713
G714 G721 G723 G725 G731 G734 G738 G762 G763
G768 G784 G786 G788 G822 G828 G513 G584 G588
G589 G638 T374 G488 G674 G728 G781 G782 G824
G535 G538 G591 G634 G715
Colorectal resection H041 H051 H053 H058 H059 H061 H063 H062 H064
H068 H071 H072 H073 H074 H078 H079 H081 H082
H083 H084 H085 H088 H091 H092 H093 H094 H095
H098 H099 H101 H102 H103 H104 H105 H089 H108
H109 H298 H305 H308 H331 H332 H333 H334 H335
H336 H338 H339 H111 H112 H113 H114 H115 H118
H119 H122 H131 H135 H193 H198 H199 H624 H628
H161 H138 G722 H176 H178 H192 H478 H479 H299
Division of early adhesions T412 T413 T415 T423
Formation of stoma G741 G742 G743 G749 G748 H151 H152 H158 H159
Stoma complication H141 H142 H148 H149 H153 H155 H156 H163 G739
G751 G752 G754 G755 G758 G759 G601 G602 G608
G618 G733 G711 G718 G729 G789
Wound complication S608 S068 S069 S089 S242 S571 S573 S572 S574
S575 S577 S578 S579 T282 T283 S424 S428 T288
T289 S472 S474 S478 S421 S422 S423 S429 S434
S438 S476 S352 S358 S359 T313 T315 T316 T318
T774 T963 S628 S132 S152
Other Spleen/liver injury J692 J699 J724 J728 J021 J042 J183 J212 J241 J181
J185
Urological procedures M062 M151 M131 M132 M138 M168 M212 M218
M162 M193 M221 M264 M359 M373 M378 M379
M202 M258 M274 M335 M021 M025 M651 M763
M764 M191 M228 M136 M292
Repair of incisional hernia T252 T253 T259 T262 T272 T273 T278 T279 T312
EUA/operation on rectum H412 H418 H419 H464 H468 H469 H541 H568 H444
H448 Q552
Perineal operation N242 N248 N249 P111 P131 P138 H531 H558 H581
H582 H583 H588 H589
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Medium term complications
Database inclusions and variable coding: all patients older than 17 undergoing primary
colorectal resection were included from 1 April 2002 to 31 March 2008. The first resection
that the patient underwent between 2002 and 2008 was considered as the primary resection.
Any patient undergoing a colorectal resection between 1996 and 2002 were excluded from
this study.
For medium term complications, subsequent admissions were analysed for up to three years
following the initial resection. An admission with diagnosis in any field with an ICD10 code
of Incisional hernia and adhesions were included or a relevant operative code. Those
admissions where an operative intervention occurred were considered in the regression
analysis. The following codes were included:
Incisional hernia: ICD10 diagnosis codes: K43 Ventral hernia, K45 Other abdominal hernia,
K46 Unspecified abdominal hernia.
OPCS codes: T25 Primary repair of incisional hernia, T26 Repair of recurrent incisional
hernia, T27 Repair of other hernia of abdominal wall.
Adhesions: ICD10 diagnosis codes: K565 Intestinal adhesions [bands] with obstruction,
Peritoneal adhesions [bands] with intestinal obstruction, K566, Other and unspecified
intestinal obstruction K660 Peritoneal adhesions, N994 Postprocedural pelvic peritoneal
adhesions.
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OPCS codes: T412- Division of band of peritoneum, T413 Freeing of adhesions of
peritoneum, T415 Freeing of extensive adhesions of peritoneum, T423 Endoscopic division
of adhesions of peritoneum, T361 Omentectomy, Y181 Freeing of adhesions of organ.
Resections were categorised according to the site of resection (OPCS coding) as follows:
Right sided resection which included right hemicolectomy (H07) and extended right
hemicolectomy and transverse colectomy (H06, H08).
Left sided resection that included left hemicolectomy (H09), sigmoid colectomy (H10) and
Hartmanns procedure (H33.5).
Subtotal colectomy, panproctocolectomy (H04.1, H04.3, H04.8, H04.9) and total colectomy
(H05) and colectomy of unspecified site (H11) were considered together.
Rectal resection including anterior resection (H33.2, H33.3, H33.4, H33.6, H33.7, H33.8,
H33.9) and abdominoperineal resection (APE H33.1)
A laparoscopic procedure was considered to be any procedure associated with OPCS codes
Y50.8, Y75 or Y71.4. Y71.4 (failed minimal access) was introduced in 2006.
Procedures coded to failed minimal access were considered in the laparoscopic group for
analysis.
Individual diagnoses were recoded into major diagnostic categories according to ICD10 code
as follows: C18 C19 C20 C21 C26-Malignant disease, K51- Ulcerative colitis
(UC), K50 - Crohns disease, and K57 Diverticular disease.
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The remaining codes were classified as other. Patients were grouped into four age cohorts:
17-54, 55-69 and 70-79 and >79 years according to age at time of surgery. Charlson score
was considered in three categories 0, 1-4 and 5. A hospital trust may comprise several sites.
Due to mergers, Trust codes were unified to reflect their status as of April 2008.
Long term complication- Pouch failure
Database inclusions and variable coding: all primary elective RPCs were included from 1st
April 1996 to 31st March 2008. The Office of Population Censes and Surveys classification of
Surgical Operations and Procedures 4th revision (OPCS) codes are included as follows:
qualified
Patients were excluded if their first procedure, during the study period, was for revision
surgery.
Definition: Failure was defined as excision of the ileal reservoir or formation of ileostomy
with no subsequent reversal. If a patient had undergone both ileostomy formation and a
subsequent excision, the first date was selected as the pouch failure date. Failure rates are
presented for all patients.
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The codes used to define pouch failure and stoma formation and reversal are shown below.
OPCS codes used to define Excision of pouch
H661 Excision of ileoanal pouch
H468 Other specified operation on rectum
H331 Excision of rectum, Abdominoperineal excision of
rectum and end colostomy
H335 Excision of rectum, Rectosigmoidectomy and closure
of rectal stump and exteriorisation of bowel,
H338 Excision of rectum, Other specified, H339 Excision
of rectum, Unspecified.
OPCS codes used to define pouch revision:
H662 Revision of ileo-anal pouch
OPCS codes used to define reversal of ileostomy
G753 Attention to artificial opening into ileum, Closure of
ileostomy
G732 Attention to connection of ileum, Closure of
anastomosis of ileum,
H154 Other exteriorisation of colon, Closure of colostomy,
G733 Attention to connection of ileum, Resection of
ileostomy.
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OPCS codes used to define Ileostomy formation
G741 Continent ileostomy,
G742 Temporary ileostomy,
G743 Defunctioning ileostomy,
G748 Other specified,
G749 Other unspecified,
G751 Refashioning of ileostomy.
Of note both the H661 and H662 codes were first introduced in 2006
Individual diagnoses were recoded into major diagnostic categories according to ICD 10
code.
ICD-10 codes used to categorise primary diagnoses
K51 Ulcerative colitis (UC)
K50 Crohns disease
C18 C19 C20 C21 C26 D37 Malignant disease
D010 D12 Benign colorectal tumours
The remaining codes were classified as other diagnosis. Patients were grouped into four age
cohorts: <17, 17-39, 40-59 and >59 years according to age at time of surgery. We considered
that a Charlson score of greater than two would describe the more comorbid patient and those
patients with a score of less than or equal to two would represent those patients with few or
170

no comorbidities. Mortality at 30 days increased significantly in those patients with a
Charlson score of three.
Outcome variables: 30 day in-hospital and 365 day total postoperative mortality (for all
causes in both cases) were ascertained. Patients from the study years prior to 2000 and after
March 2005 were excluded from the analysis of 365 day mortality. Length of stay (LOS) is
the time (days) spent in hospital during the primary admission for RPC; a patient admitted
and discharged on the same day would have an LOS of zero. Median length of stay [+/-
interquartile range (IQR)] is referred to in unadjusted analyses. Readmission refers to
emergency (unplanned) readmission to hospital within 28 days for any reason.
Statistical methodology: Categorical variables were investigated using the Chi-squared test.
Logistic regression analysis was used to investigate bivariate variables. Factors with a
significance level of 0.1 on univariate analysis were included in the regression analyses.
Statistical analyses were carried out using SPSS Version 18.0 (Statistical Package for Social
Sciences, SPSS, Chicago, Illinois, USA). For tests of significance, p value of <0.05 was
considered significant. For non-parametric variables, the median and interquartile ranges
(IQR) are given. Funnel plots were constructed using the web tool:
http://www.erpho.org.uk/topics/tools/funnel.aspx. To reduce the potential impact of coding
errors and capture the true Trust and consultant team colorectal resection caseload for the
construction of the funnel plots, only trusts who performed greater than 10 resections and
consultant teams who performed greater than or equal to five resections over the period were
included.
171

Results
Defining novel outcome measures from HES and assessing variation in these
measures
Reoperation
Demographics
Between 1st April 2000 and 31st March 2008, 246469 patients who underwent a primary
colorectal resection in 175 English NHS Trusts were included. 158847 (64.4%) patients
underwent resection during an elective admission and 35.5% (87472/246269) represented
emergency admissions. 150 patients had no record of their admission status. Table 8.2
summarises the characteristics of elective and emergency patients undergoing resection
included in this study and the relative numbers of elective patients undergoing open and
laparoscopic procedures.
172

Table 8.2: Patient characteristics and type of surgery by approach for patients undergoing a
colorectal resection.
Elective Emergency
(n=158847) (n=87472)
Laparoscopic All approaches
approach Open approach p*
n (%) n (%) n (%)
Resection type right sided 3627 (35,8) 42229 (28.4) <0.001 34962 (40.0)
left sided 2237 (22.1) 36085 (24.3) 34825 (39.8)
rectal 3836 (37.9) 59479 (40.0) 5604 (6.4)
total 431 (4.3) 10923 (7.3) 12081 (13.8)
Total 10131 (6.4) 148716 (93.6) 87472 (100)
Diagnosis Colorectal cancer 6673 (65.9) 104352 (70.2) <0.001 33493 (38.3)
IBD 758 (7.5) 10684 (7.2) 9201 (10.5)
Diverticular disease 1051 (10.4) 13063 (8.8) 18915 (21.6)
other 1649 (16.3) 20617 (13.9) 25863 (29.6)
Total 10131 (6.4) 148716 (93.6) 87472 (100)
Age 17-54 1957 (19.3) 25568 (17.2) <0.001 20021 (22.9)

55-69 3409 (33.6) 51536 (34.7) 23909 (27.3)
70-79 3096 (30.6) 48221 (32.4) 24582 (28.1)
>79 1669 (16.5) 23391 (15.7) 18960 (21.7)
Total 10131 (6.4) 148716 (93.6) 87472 (100)
Charlson score 0 6908 (68.2) 96658 (65.0) <0.001 54581 (62.4)

1-4 1172 (11.6) 13665 (9.2) 8312 (9.5)
5 2051 (20.2) 38393 (25.8) 24579 (28.1)
Total 10131 (6.4) 148716 (93.6) 87472 (100)
Carstairs 1 (least deprived) 2285 (22.6) 29107 (19.6) <0.001 15225 (17.4)
deprivation index 2 2456 (24.2) 34589 (23.3) 18221 (20.8)
3 2216 (21.9) 32694 (22.0) 18932 (21.6)
4 1770 (17.5) 28910 (19.4) 18427 (21.1)
5 (most deprived) 1398 (13.8) 23285 (15.7) 16612 (19.0)
Total** 10126 (6.4) 148585 (93.6) 87417 (100)
Gender Male 4920 (48.6) 79234 (53.3) <0.001 40819 (46.7)

Female 5211 (51.4) 69482 (46.7) 46653 (53.3)
Total 10131 (6.4) 148716 (93.6) 87472 (100)
* p value refers to the comparison in patient demographics between the elective laparoscopic
versus open groups.
** 55 emergency patients and 137 (6 laparoscopic and 131 patients in the open group)
patients did not have social deprivation status recorded.
173

The overall postoperative reoperation rate for all patients undergoing colorectal resection
irrespective of admission status was 6.5% (15986/246469). 13227 (82.7%) of these required
a reoperation on their primary admission. The remaining 2759 patients underwent a
subsequent admission that necessitated a reoperation. Emergency patients experienced
slightly higher rates of reoperation than elective [7.0% (6156/87472) vs 6.2% (9819/158847),
p<0.001]. A total of 11536 (4.7%) patients underwent re-laparotomy following colorectal
resection. 0.6% (1560/246469) experienced a subsequent stoma-related complication
requiring surgery. 3861 (1.6%) had a wound complication necessitating reoperation. Table
8.3 shows the procedures included as reoperations.
174

Table 8.3: Reoperation following colorectal resections for patients undergoing laparoscopic
and open procedures.
Elective Emergency
Laparoscopic Open Total All
p*
approach approach elective approaches
n (%) n (%) n (%) n (%)
Any reoperation 718 (7.1) 9413 (6.1) 9819 (6.2) <0.001 6156 (7.0)
Laparotomy Overall 541 (5.3) 6601 (4.4) 7142 (4.5) <0.001 4387 (5.0)
Reopening of 1733 (2.0)
129 (1.3) 2488 (1.7) 2617 (1.6) 0.002
abdomen
Open procedure for 264 (0.3)
31 (0.3) 432 (0.3) 463 (0.3) 0.779
abscess
Washout 127 (1.3) 1358 (0.9) 1485 (0.9) 0.001 1015 (1.2)
Small bowel 644 (0.7)
105 (1.0) 861 (0.6) 966 (0.6) <0.001
operation
Colorectal resection 166 (1.6) 1495 (1.0) 1661 (1.0) <0.001 944 (1.1)
Division of early 381 (0.4)
47 (0.5) 713 (0.5) 760 (0.5) 0.827
adhesions
Formation of stoma 241 (2.4) 2355 (1.6) 2596 (1.6) <0.001 1202 (1.4)
Stoma complication 50 (0.5) 654 (0.4) 704 (0.4) 0.430 856 (1.0)
Wound complication 145 (1.4) 2098 (1.4) 2243 (1.4) 0.866 1616 (1.8)
Other Spleen/liver injury 4 (0.0) 86 (0.1) 90 (0.1) 0.453 80 (0.1)

Urological 97 (0.1)
11 (0.1) 181 (0.1) 192 (0.1) 0.713
procedures
Repair of incisional 30 (0.0)
36 (0.4) 48 (0.0) 84 (0.0) <0.001
hernia
EUA/operation on 101 (0.1)
32 (0.3) 383 (0.3) 415 (0.3) 0.266
rectum
Perineal operation 18 (0.2) 402 (0.3) 396 (0.2) 0.077 56 (0.1)
*p value refers to the comparison in patient demographics between the laparoscopic versus
open groups.
175

Patient characteristics and reoperation
Table 8.4 demonstrates the characteristics of elective and emergency patients who required
reoperation. Table 8.5 describes the predictors of reoperation in patients undergoing
colorectal resection. Table 8.5 also includes multiple regression analyses for patients
undergoing re-intervention for laparotomy specifically. On multiple regression analysis,
younger age, a diagnosis of inflammatory bowel disease, increasing co-morbidity, male
gender, rectal and subtotal resection, the laparoscopic approach and emergency admission
status were independent predictors of both reoperation and laparotomy following surgery
(Table 8.5). Increasing social deprivation predicted a higher reoperation rate but was not
significant for laparotomy rate.
176

Table 8.4: Patient characteristics of those patients who necessitated a reoperation in the
postoperative period.
Elective Emergency
Reoperation No reoperation Reoperation No reoperation
n (%) n (%) p n (%) n (%) p
Resection Right sided 1974 (4.3) 43882 (95.7) <0.001 2181 (6.2) 32781 (93.8) <0.001
type Left sided 2284 (6.0) 36038 (94.0) 2546 (7.3) 32279 (92.7)
Rectal 4659 (7.4) 58656 (92.6) 428 (7.6) 5176 (92.4)
Subtotal/total 902 (7.9) 10452 (92.1) 1001 (8.3) 11080 (91.7)
Diagnosis Colorectal cancer 6566 (5.9) 104459 (94.1) <0.001 1983 (5.9) 31510 (94.1) <0.001
IBD 782 (6.8) 10660 (93.2) 739 (8.0) 8462 (92.0)
Diverticular 845 (6.0) 13269 (94.0) 1335 (7.1) 17580 (92.9)
Other 1626 (7.3) 20640 (92.7) 2099 (8.1) 23764 (91.9)
Age 17-54 1847 (6.7) 25678 (93.3) <0.001 1570 (7.8) 18451 (92.2) <0.001
55-69 3576 (6.5) 51369 (93.5) 1868 (7.8) 22041 (92.2)
70-79 3218 (6.3) 48099 (93.7) 1805 (7.3) 22777 (92.6)
>79 1178 (4.7) 23882 (95.3) 913 (4.8) 18047 (95.2)
Charlson 0 5880 (5.7) 97686(94.3) <0.001 3725 (6.8) 50856 (93.2) 0.001
score 1-4 974 (6.6) 13863 (93.4) 576 (6.9) 7736 (93.1)
5 2965 (7.3) 37479 (92.7) 1855 (7.5) 22724 (92.5)
1 (least deprived) 1849 (5.9) 29543 (94.1) <0.001 1037 (6.8) 14188 (93.2) 0.044
2 2175 (5.9) 34870 (94.1) 1221 (6.7) 17000 (93.3)
Carstairs 3 2161 (6.2) 32749 (93.7) 1319 (7.0) 17613 (93.0)
4 1929 (6.3) 28751 (93.1) 1353 (7.3) 17074 (92.7)
5 (most deprived) 1697 (6.9) 22986 (93.1) 1223 (7.4) 15389 (92.6)
Gender Male 6080 (7.2) 78074 (92.8) <0.001 3164 (7.8) 37655 (92.2) <0.001
Female 3739 (5.0) 70954 (95.0) 2992 (6.6) 43661 (93.6)
177

Table 8.5: Multiple regression analysis for reoperation and laparotomy amongst elective and
emergency patients.
Co factors All reoperation Laparotomy

Odds Odds
95% CI p value 95% CI p
ratio ratio
Age <0.001 <0.001
17-54 1.00 1.00
55-69 0.98 0.94 1.03 0.474 0.94 0.89 0.99 0.022
70-79 0.96 0.91 1.01 0.109 0.93 0.88 0.99 0.013
>79 0.70 0.66 0.74 <0.001 0.68 0.63 0.73 <0.001
Diagnosis <0.001 <0.001
Colorectal Cancer 1.00 1.00
Inflammatory Bowel
1.33 1.24 1.42 <0.001 1.18 1.09 1.28 <0.001
Disease
Diverticular Disease 1.12 1.06 1.18 <0.001 1.04 0.97 1.11 0.280
Other 1.40 1.34 1.46 <0.001 1.35 1.28 1.42 <0.001
Charlson
<0.001 <0.001
score
0 1.00 1.00
1-4 1.10 1.04 1.17 0.001 1.01 0.94 1.08 0.768
5 1.34 1.29 1.39 <0.001 1.35 1.29 1.41 <0.001
Gender female vs male 0.75 0.73 0.78 <0.001 0.74 0.71 0.77 <0.001
Social Deprivation <0.001
1 Least deprived 1.00
2 1.00 0.95 1.05 0.973
3 1.06 1.01 1.11 0.032
4 1.09 1.04 1.15 0.001
5 Most deprived 1.14 1.08 1.20 <0.001
Site of resection <0.001 <0.001
Right sided 1.00 1.00
Left sided 1.31 1.25 1.37 <0.001 1.18 1.12 1.25 <0.001
Rectal 1.63 1.56 1.71 <0.001 1.37 1.29 1.44 <0.001
Total 1.44 1.35 1.52 <0.001 1.37 1.28 1.47 <0.001
Surgical Laparoscopy versus
1.11 1.03 1.20 0.006 1.16 1.06 1.26 0.001
approach open
Admission Emergency vs
1.21 1.17 1.26 <0.001 1.16 1.11 1.21 <0.001
status Elective
Year of
(continuous variable) 1.03 1.03 1.04 <0.001 1.03 1.02 1.04 <0.001
surgery
178

Variation in reoperation between surgeon and Trusts
Exclusion of trust and surgeon codes that failed to meet the minimum volume inclusion
criteria equated to 19 Trusts [37 patients (0.02%)] and 4185 consultant codes [6853 patients
(2.8%)] respectively. 72.2% of patients excluded in the analysis of surgeon codes were
assigned to an emergency admission.
For included consultant teams elective reoperation rates varied between 0% and 80%.
Variation between Trusts was between 0% and 17%. Figures 8.1 and 8.2 show funnel plots of
the adjusted reoperation rates amongst consultant teams and NHS Trusts respectively. Wide
variation in reoperation rates can be observed across all volume caseloads.
Twenty-two of the 156 included Trusts had adjusted reoperation rates outside (i.e. above) the
99.8% control limit, which corresponds to 3 standard deviations above the mean. For 156
Trusts, 0.16 Trust outliers at this threshold could be expected to arise through chance alone,
assuming a purely binomial distribution for the reoperations. Eleven (0.7%) of the 1557
included consultant teams had elective reoperation rates above the 99.8% control limit and
1.6 consultant team outliers at this threshold could be expected through chance alone. Even
at a high caseload there was however significant variation in both the Trust and surgeon team
reoperation rates. There was a five-fold difference in highest and lowest (14.9% vs 2.8%)
elective reoperation rates amongst surgical teams performing greater than 500 procedures.
There was a threefold difference in reoperation rates in Trusts performing over 2500
procedures throughout the study period (11.5% vs 3.7%).
179

Figure 8.1: Funnel plot of adjusted reoperation rates for elective colorectal resectional
procedures for individual consultant teams by volume of elective surgery.
180

Figure 8.2: Funnel plot of adjusted reoperation rates for both emergency and elective
colorectal resectional procedures for individual NHS Trusts by volume.
181

Laparoscopy and reoperation
Overall, for both elective and emergency patients, those who had a resection attempted using
a minimal access approach had a marginally higher rate of reoperation than those having an
open approach [Laparoscopic 7.0% (799/11359), open 6.5% (15187/235110), p=0.015].
Table 8.2 shows the reasons for reoperation for elective laparoscopic and open groups.
Correlation with other outcome measures
Elective and emergency patients who experienced a complication requiring reoperation
during their initial admission had a prolonged median LOS [elective patients: reoperation 27
days (IQR 17-43 days, n=7873); No reoperation 11 days (9-16 days, n=150974), p<0.001;
emergency patients: reoperation 34 days (IQR 21-55 days, n=5401); No reoperation 17 days
(11-28 days, n=82071, p<0.001] and a higher rate of postoperative mortality [elective
patients: reoperation 938/7873 (11.9%), no reoperation 4399/150974 (2.9%), p<0.001;
emergency patients: reoperation 1251/5346 (23.4%), no reoperation 12511/82126 (15.2%),
p<0.001]. One year mortality was available from April 2000 to March 2004. Those elective
and emergency patients who experienced a complication requiring reoperation either on the
index admission or a subsequent admission within 28 days of surgery demonstrated an
increased one year mortality [elective patients: reoperation 1353/57546 (23.9%), no
reoperation 10162/89800 (11.3%), p<0.001; emergency patients: reoperation 1477/3693
(40.0%), no reoperation 15030/50822 (29.6%), p<0.001]. Elective patients who required an
reoperation on the index admission had a higher emergency readmission rate within 28 days
of discharge following this index admission (reoperation 947/7873 (12.0%), no reoperation
13777/150974 (9.1%), p<0.001].
182

Medium term outcomes
Incisional hernia and adhesion rates
Variation at a patient level
187148 patients were included between 1st April 2002 and 31st March 2008. Table 8.6 shows
the characteristic of these patients. Patients were followed up until three years or the end of
the study period. The median follow up was 987 days (IQR 406-1095, n=187148).
183

Table 8.6: Descriptives of elective patients undergoing colorectal resection between 2002 and
2008 included for analysis of medium term adhesion and herniae rates.
Laparoscopic Open
approach approach p value
n (%) n (%)
Resection type right sided 4137 (37.6) 57888 (32.9) <0.001
left sided 2462 (22.4) 52327 (29.7)
rectal 3860 (35.0) 48978 (27.8)
total 554 (5.0) 16942 (9.6)
Diagnosis Colorectal cancer 6938 (63.0) 102310 (58.1) <0.001
IBD 931 (8.5) 14671 (8.3)
Diverticular disease 1217 (11.1) 23955 (13.6)
other 1927 (17.5) 35199 (20.0)
Age 17-54 2315 (21.0) 33990 (19.3) <0.001
55-69 3567 (32.4) 56696 (32.2)
70-79 3273 (29.7) 53569 (30.4)
>79 1858 (16.9) 31880 (18.1)
Charlson score 0 7514 (68.2) 110546 (62.8) <0.001
1-4 1271 (11.5) 17688 (10.0)
5 2228 (20.2) 47901 (27.2)
Carstairs 1 (least deprived) 2425 (22.1) 33608 (19.1) <0.001
deprivation index 2 2666 (24.2) 39549 (22.5)
3 2410 (21.9) 38550 (21.9)
4 1935 (17.6) 34866 (19.8)
5 (most deprived) 1561 (14.2) 29420 (16.7)
Admission status Elective 9871(89.6) 111246 (63.3) <0.001
Emergency 1140 (10.4) 64777 (36.8)
Gender Male 5344 (48.5) 89648 (50.9) <0.001
Female 5669 (51.5) 86487 (49.1)
184

Incisional herniae rates
During the study period, 4.7% (8885/187148) patients were admitted with a diagnosis of
incisional hernia or underwent a procedure for repair of an incisional hernia. 80.6%
(7160/8885) of these patients underwent an operative repair of hernia. This equates to 3.8%
of all patients undergoing colorectal resection. Patients selected for the laparoscopic approach
had higher rates of operative intervention for incisional hernia than those selected for the
open approach [laparoscopic 4.2% (465/11013) vs open 3.8% (6695/176135), p=0.025].
Table 8.7 shows the readmissions requiring operative intervention for incisional hernia and
adhesions in the laparoscopic and open groups. On multiple regression analysis, use of
laparoscopy was not a predictor of operative repair for incisional herniae [OR 1.09 (CI 0.99-
1.21), p=0.079]. Table 8.8 shows the multiple regression analysis for operative
reintervention for incisional hernia.
185

Table 8.7: Rates of re-intervention for adhesions and incisional hernia repairs following
laparoscopic and open resection at one, two and three year post surgery.
Laparoscopic
Open Approach p value
approach
Incisional hernia
repair
One year 1.5% (163/11013) 0.9% (1655/176135) <0.001
Two year 3.6% (394/11013) 2.9% (5029/176135) <0.001
Three year 4.2% (465/11013) 3.8% (6688/176135) 0.024
Division of
adhesions
One year 1.5% (160/11013) 1.8% (3208/176135) 0.005
Two year 2.5% (270/11013) 3.0% (5351/176135) <0.001
Three year 2.8% (305/11013) 3.6% (6325/176135) <0.001
186

Table 8.8: Multiple regression analysis of operative reintervention for incisional hernia and
adhesion
Incisional hernia repair Division of adhesions
Odds Odds
95% C.I. p value 95% C.I. p value
Ratio Ratio
Laparoscopic vs
Surgical approach 1.09 0.99 1.21 0.083 0.80 0.71 0.90 <0.001
open
Charlson score of <0.001 <0.001
co-morbidity 0 1.00 1.00
1-4 0.98 0.91 1.06 0.617 0.99 0.91 1.08 0.817
5 0.63 0.59 0.68 <0.001 0.86 0.80 0.91 <0.001
Age <0.001 <0.001
17-54 1.00 1.00
55-69 1.09 1.03 1.17 0.007 0.75 0.71 0.80 <0.001
70-79 0.79 0.73 0.84 <0.001 0.49 0.46 0.53 <0.001
>79 0.28 0.25 0.32 <0.001 0.26 0.23 0.28 <0.001
Year of surgery <0.001 0.001
2002 1.00 1.00
2003 1.14 1.04 1.24 0.005 1.07 0.98 1.17 0.155
2004 1.23 1.13 1.34 <0.001 1.15 1.05 1.26 0.003
2005 1.42 1.30 1.54 <0.001 1.27 1.17 1.39 <0.001
2006 1.39 1.28 1.51 <0.001 1.27 1.16 1.38 <0.001
2007 1.12 1.03 1.22 0.012 1.22 1.11 1.33 <0.001
Gender Female vs Male 0.78 0.74 0.82 <0.001 1.13 1.07 1.19 <0.001
Emergency vs
Admission status 1.07 1.01 1.13 0.027 1.49 1.41 1.58 <0.001
Elective
Diagnosis <0.001 <0.001
Cancer 1.00 1.00
IBD 1.11 0.99 1.23 0.072 1.31 1.19 1.44 <0.001
Diverticular Disease 2.18 2.04 2.34 <0.001 1.08 1.00 1.17 0.045
Other 1.21 1.13 1.30 <0.001 0.94 0.88 1.01 0.088
Carstairs Index of social deprivation 0.001
1 (least deprived) 1.00
2 0.98 0.91 1.06 0.570
3 0.97 0.90 1.04 0.379
4 0.93 0.86 1.00 0.060
5 (most deprived) 0.83 0.76 0.90 <0.001
Type of resection <0.001 <0.001
right sided 1.00 1.00
left sided 1.45 1.35 1.55 <0.001 1.89 1.76 2.04 <0.001
rectal 1.70 1.59 1.83 <0.001 1.95 1.80 2.10 <0.001
total 1.02 0.92 1.13 0.667 1.92 1.76 2.10 <0.001
Reoperation 1.56 1.44 1.69 <0.001 2.16 2.00 2.32 <0.001
187

Adhesion related admissions
During the study period, 8.1% (15125/187148) patients were admitted with a diagnosis of
adhesions or underwent a procedure for division of adhesions. Of these patients, 43.9%
(6637/15125) required an operative intervention for division of adhesions. Overall, 3.5% of
patients undergoing colorectal resection required division of adhesions within 3 years of their
primary procedure. Patients selected for a laparoscopic procedure had lower rates of
admissions with a diagnosis of adhesion [laparoscopic 6.3% (692/11013) open 8.2%
(14433/176135), p<0.001] and lower rates of reintervention for adhesions than those
undergoing an open procedure [laparoscopic 2.8% (305/11013) open 3.6% (6332/176135),
p<0.001]. On multiple regression analysis, patients selected for a laparoscopic procedure had
lower adhesion rates [OR 0.80 (CI 0.71-0.90), <0.001]. Table 8.8 shows the multiple
regression analysis for operative reintervention for adhesion rates.
For those patients admitted with adhesions, similar numbers in the laparoscopic and open
groups required surgical reintervention [laparoscopic 44.1% (305/692) open 43.9%
(6332/14433), p=0.916].
Patients who suffered a complication requiring reoperation in the postoperative period were
more likely to have operative reintervention for adhesions than those who did not experience
a complication in the postoperative period [reoperation 13.1% (1639/12481) No reoperation
7.7% (13486/174667), p<0.001].
188

Variation at an institutional level of incisional hernia and adhesion rates
Incisional hernia rates varied between 0 and 9% at an institutional level. Adhesion rates
varied marginally greater at an institutional level between 0 and 14%. Figures 8.3 and 8.4
show the variation in incisional hernia and adhesional hernia rate respectively.
Figure 8.3: Variation in incisional hernia rates following colorectal resection for each NHS
Trust with 95% confidence intervals
Adhesion
rate
(%)
NHS Trust
189

Figure 8.4: Variation in adhesion rates following colorectal resection for each NHS Trust
with 95% confidence intervals
Adhesion
rate
(%)
NHS Trust
190

Longer term outcome measures
Pouch failure rates
Of the entire patient series, 6.4% (372/5771) patients experienced failure during the study
period. The median follow up period was 65 (IQR 28-106) months of 5731. 40 patients were
excluded due to incomplete data about the timing of surgery. The median time to failure was
9.4 months (IQR 2.5-23.4 months) and 59% of failure (221/372) occurred in the first year
after surgery. 5.8% (339/5771) of patients underwent an indefinite ileostomy and 1.1%
(65/5771) an excision of the pouch. 33 patients were coded to both excision of pouch and
formation of ileostomy. Only four patients were given the revision of ileostomy code but
this was only introduced in 2006. 57.6% (3322/5771) of patients underwent a definite
subsequent reversal of the ileostomy following the pouch procedure. Of these 5.5%
(182/3322) experienced failure with 29 patients being coded to having an excision of pouch
and 168 patients having a further ileostomy performed without subsequent reversal during the
study period. Table 8.9 summarises the characteristics of patients who experienced failure.
191

Table 8.9: Characteristics of restorative proctocolectomy patients who experienced failure

(372/5771) compared with those who did not
Patients who Patients who did not

experienced failure experience failure
Age Median 40 years Median 38 years
Frequency (percent) Frequency (percent)
<17 years 7 (1.9) 209 (3.9)
17-39 years 169 (45.4) 2713 (50.3)
40-59 years 156 (41.9) 1837 (34.0)
>59 years 40 (10.8) 640 (11.9)
Total 372 (100) 5399 (100.0)
Gender Male:Female 199:173 (53.5:46.5) 2999:2400 (55.5:44.5)
Charlson comorbidity
Frequency (percent) Frequency (percent)
score
0-2 361 (97.0) 5272 (97.6)
>2 11 (3.0) 127 (2.4)
Total 372 (100) 5399 (100.0)
Carstairs deprivation score Frequency (percent) Frequency (percent)
1 least deprived 61 (16.4) 1165 (21.6)
2 81 (21.8) 1241 (23.0)
3 91 (24.5) 1123 (20.8)
4 73 (19.6) 990 (18.3)
5 most deprived 63 (16.9) 863 (16.0)
Unclassified 3 (0.8) 17 (0.8)
Total 372 (100.0) 5399 (100.0)
Diagnosis Frequency (percent) Frequency (percent)
UC 254 (68.3) 3680 (68.2)
Malignancy 39 (10.5) 580 (10.7)
Crohns disease 10 (2.7) 119 (2.2)
Benign 23 (6.2) 358 (6.6)
Other diagnosis 46 (12.4) 662 (12.3)
Total 372 (100) 5399 (100.0)
192

Patients aged between 40 and 60 years were most likely to experience failure [Age 40-59
7.8% (156/1993), 17-39 years 5.9% (169/2882), 60 5.9% (40/680), <17 3.2% (7/216),
p=0.008]. There was no relationship between diagnosis (p=0.974), level of comorbidity
[(Charlson score), p=0.460], social deprivation (p=0.118) or gender (p=0.441) and failure in
unadjusted analyses. In Cox regression analysis, age and higher provider volume were
associated reduced pouch failure (Table 8.10). The role of volume will be discussed further
in the following chapter.
193

Table 8.10: Unifactorial and Multiple Cox regression analysis for pouch failure
Unifactorial analysis Multiple Regression analysis
Odds 95% CI for Odds 95% CI for

p p
Ratio Odds Ratio Ratio Odds Ratio
Cofactor Lower Upper Lower Upper

Gender
Female (compared with
1.07 0.87 1.31 0.520
male)
Diagnosis 0.948
UC 1.00
Malignant disease 0.98 0.70 1.37 0.882
Crohns disease 1.25 0.66 2.35 0.490
Benign disease 0.92 0.60 1.41 0.707
Other diseases 1.04 0.76 1.42 0.831
Age cohort 0.008 0.009
Age <17* 1.00 1.00
Age 17- 39 years 1.84 0.86 3.92 0.114 1.80 0.85 3.84 0.127
Age 40-59 years 2.50 1.17 5.32 0.018 2.44 1.14 5.20 0.021
Age >59 years 1.87 0.84 4.18 0.127 1.82 0.81 4.06 0.145
Charlson 2 * 1.00
Charlson 3 1.31 0.72 2.39 0.378
Carstairs index 0.112
1 least deprived* 1.00
2 1.24 0.89 1.73 0.203
3 1.51 1.09 2.09 0.013
4 1.39 0.99 1.96 0.056
5 Most deprived 1.39 0.97 1.97 0.070
6 Unclassified 2.95 0.93 9.41 0.067
Provider Volume 0.015 0.018
LV 1-39 procedures* 1.00 1.00
MV 40-100 procedures 1.04 0.82 1.32 0.720 1.04 0.82 1.32 0.741
HV >100 procedures 0.73 0.56 0.95 0.018 0.73 0.57 0.95 0.019
Consultant team volume 0.451
LV 1-11 procedures* 1.00
MV 12-28 procedures 1.01 0.73 1.38 0.976
HV >28 procedures 0.83 0.59 1.16 0.277
*reference group
194

Considerable variation in Trust failure rates was demonstrated in the funnel plot shown in
Figure 8.5.
Patients who had a longer LOS for the primary procedure and those readmitted within 28
days after discharge following the primary procedure were significantly more likely to
experience failure [Readmitted within 28 days: failure rate 9.9% (125/1269), not readmitted
within 28 days: failure rate 5.5% (247/4502), p<0.001. The median LOS of those who
experienced failure was 13.5 days (IQR 10-21 days, n=372) compared with 12 days (IQR 9-
15 days, n=5329) for those who did experience failure, p<0.001].
195

Figure 8.5: Funnel plot of pouch failure rates by NHS Trust.
*An institution performing a single procedure during the study period with a 100% failure rate was excluded.
196

Variation in established colorectal outcome measures
Variation in colorectal resection outcome - Mortality
Of the elective colorectal resection patients, 3.4% (5337/158842) died in hospital within 30
days of admission. The 365 day elective mortality (available from April 2000 to March 2005
only) was 12.1% (11515/95341). The 30 day mortality [15.7% (13761/87465), p<0.001] and
365 day mortality [30.3% (16505/54508), p<0.001] were both higher for patients coded to an
emergency admission. Table 8.11 shows the variation in 30 day and 365 day mortality
amongst colorectal resection patients.
There was a slight reduction in one year mortality and 30 day mortality over time for both
emergency and elective surgery (Table 8.11).
Patients with increasing age, a diagnosis of cancer, the open approach and increasing social
deprivation and increasing comorbidity had higher 30 day and 365 day mortality (Table
8.11).
Table 8.12 shows the multiple regression analysis for both 30 day and 365 day mortality. An
open approach, increasing comorbidity, increasing age, earlier study year, female gender, an
emergency admission, increasing social deprivation were independent predictors of an
increased 30 day and 365 day mortality.
197

Table 8.11: Variation in 30 day and 365 day mortality amongst elective and emergency
colorectal resection patients (unadjusted analysis).
30 day mortality 365 day mortality
Elective Emergency Elective Emergency
n (%) p n (%) p n (%) p n (%) p
Surgical Open 5163 (3.5) 13672 (15.9) 11423 (12.2) 16428 (30.3)
approach Use of 174 (1.7) <0.001 89 (7.3) <0.001 92 (5.3) <0.001 77 (22.2) 0.001
laparoscopy
Resection type right sided 1642 (3.6) 4639 (13.3) 3717 (14.0) 6635 (30.7)
left sided 909 (3.0) 6189 (17.8) 1969 (10.3) 6684 (30.8)
<0.001 <0.001 <0.001 <0.001
rectal 2310 (3.2) 667 (11.9) 5086 (12.0) 944 (27.0)
total 476 (4.2) 2266 (18.8) 743 (10.2) 2242 (29.2)
Diagnosis Colorectal 3732 (3.4) 4699 (14.0) 8975 (13.5) 7789 (35.1)
cancer
IBD 105 (0.9) 508 (5.5) 166 (2.3) 529 (9.1)
<0.001 <0.001 <0.001 <0.001
Diverticular 392 (2.8) 3101 (16.4) 556 (6.5) 2915 (25.0)
disease
other 1108 (5.0) 5453 (21.1) 1818 (13.7) 5272 (34.5)
Age 17-54 173 (0.6) 587 (2.9) 683 (4.1) 1044 (8.5)
55-69 939 (1.7) 2500 (10.5) 2871 (8.8) 3515 (23.9)
<0.001 <0.001 <0.001 <0.001
70-79 2208 (4.3) 4859 (19.8) 4640 (14.9) 5914 (37.1)
>79 2017 (8.0) 5815 (30.7) 3321 (22.5) 6032 (50.8)
Charlson score 0 1845 (1.8) 5833 (10.7) 4711 (7.4) 7332 (20.9)
1-4 540 (3.6) <0.001 1461 (17.6) <0.001 867 (11.4) <0.001 1359 (30.0) <0.001
5 2952 (7.3) 6467 (26.3) 5937 (24.9) 7814 (52.4)
Carstairs 1 (least 855 (2.7) 1932 (12.7) 1939 (10.6) 2452 (26.3)
deprivation deprived)
index 2 1127 (3.0) 2642 (14.5) 2504 (11.4) 3295 (29.0)
3 1213 (3.5) <0.001 2977 (15.7) <0.001 2538 (12.1) <0.001 3571 (30.3) <0.001
4 1112 (3.6) 3171 (17.2) 2399 (12.8) 3746 (32.2)
5 (most 1029 (4.2) 3031 (18.3) 2130 (14.0) 3426 (33.1)
deprived)
Gender Male 3317 (3.9) 5915 (14.5) 6632 (13.1) 7392 (29.1)
<0.001 <0.001 <0.001 <0.001
Female 2020 (2.7) 7846 (16.8) 4883 (10.9) 9113 (31.4)
Year of Surgery 2000 718 (3.7) 1730 (16.4) 2442 (12.7) 3292 (31.2)
2001 676 (3.7) 1744 (15.8) 2297 (12.5) 3344 (30.4)
2002 691 (3.6) 1752 (16.2) 2326 (12.2) 0.001 3327 (30.7) 0.032
2003 644 (3.6) 1769 (16.1) 2214 (11.5) 3256 (30.7)
<0.001 <0.001
2004 692 (3.6) 1793 (16.1) 226 (11.6) 3286 (29.5)
2005 686 (3.3) 1743 (15.2)
2006 634 (3.0) 1707 (15.9)
2007 596 (2.7) 1523 (14.1)
*Includes patients admitted between 2000 and 2005 for a resection.
198

Table 8.12: Variation in 30 day and 365 day mortality amongst elective and emergency
colorectal resection patients (multiple regression analysis).
30 day mortality 365 day mortality*
Odds Odds
95% C.I. p 95% C.I. p
Ratio Ratio
Laparoscopic vs
Surgical approach 0.56 0.49 0.63 <0.001 0.56 0.47 0.66 <0.001
open
Charlson score of <0.001 <0.001
1-4 1.62 1.54 1.72 <0.001 1.44 1.37 1.52 <0.001
5 3.04 2.93 3.15 <0.001 3.59 3.48 3.70 <0.001
Age <0.001 <0.001
17-54 1.00 1.00
55-69 3.16 2.91 3.43 <0.001 2.29 2.16 2.43 <0.001
70-79 7.01 6.48 7.59 <0.001 4.11 3.89 4.36 <0.001
>79 13.94 12.86 15.10 <0.001 7.16 6.75 7.60 <0.001
Year of surgery <0.001 0.001
2000 1.00 1.00
2001 0.94 0.88 1.00 0.063 0.96 0.91 1.00 0.046
2002 0.93 0.88 0.99 0.030 0.93 0.89 0.97 0.001
2003 0.92 0.86 0.98 0.008 0.89 0.85 0.93 <0.001
2004 0.92 0.86 0.98 0.007 0.87 0.83 0.91 <0.001
2005 0.84 0.79 0.89 <0.001
2006 0.84 0.79 0.90 <0.001
2007 0.73 0.68 0.78 <0.001
Emergency vs
Admission status 3.85 3.71 4.00 <0.001 2.99 2.89 3.09 <0.001
Elective
Diagnosis <0.001 <0.001
Cancer 1.00 1.00
IBD 1.10 1.00 1.21 0.054 0.50 0.45 0.54 <0.001
Diverticular Disease 1.62 1.54 1.70 <0.001 0.84 0.80 0.88 <0.001
Other 2.53 2.44 2.64 <0.001 1.54 1.48 1.60 <0.001
Carstairs Index of social deprivation <0.001 <0.001
1 (least deprived) 1.00 1.00
2 1.09 1.04 1.15 0.001 1.06 1.01 1.11 0.013
3 1.21 1.15 1.28 <0.001 1.13 1.08 1.19 <0.001
4 1.32 1.25 1.39 <0.001 1.22 1.67 1.28 <0.001
5 (most deprived) 1.51 1.43 1.60 <0.001 1.36 1.30 1.43 <0.001
Type of resection <0.001 <0.001
left sided 1.23 1.19 1.29 <0.001 1.04 1.00 1.08 0.050
rectal 0.88 0.84 0.93 <0.001 0.78 0.75 0.82 <0.001
total 1.90 1.80 2.01 <0.001 1.40 1.33 1.48 <0.001
*Includes patients admitted between 2000 and 2005 for a resection.
199

Variation at an institutional level
Figure 8.6 shows the variation in unadjusted mortality rates per NHS Trust for patients
undergoing a colorectal resection.
Figure 8.6: Variation in 30 day mortality following colorectal resection for each NHS Trust
with 95% confidence intervals
30 day
mortality
(%)
NHS Trust
200

Variation in colorectal resection outcome amongst patients- Readmission and length of stay
Readmission
The overall readmission rate for patients undergoing colorectal resection was 9.2%
(22737/246457). There were no differences in readmission rates between elective and
emergency admissions [elective 9.3% (14724/158842) emergency 9.1% (7991/87465),
p=0.272].
Readmission rates varied little from 8% to 13% per NHS Trust. Figure 8.7 shows this
variation in readmission rates.
201

Figure 8.7: Mean readmission rates following colorectal resection with 95% confidence
intervals per NHS Trust.
Readmission
(%)
NHS Trust
202

LOS
The mean logarithm LOS with back exponentiation was 14.3 days (SD 2.0) with emergency
admissions having a longer LOS than elective admissions [elective 12.6 (1.8), emergency
17.9 (2.3), p<0.001]. Table 8.13 shows the variation in LOS for elective and emergency
colorectal resection with patient characteristics.
Selection for the open approach, increasing age, comorbidity and social deprivation, female
gender, and a diagnosis of IBD were predictors for prolonged LOS (Table 8.13).
Variation at an institutional level
There was limited variation in LOS at an institutional level (Figure 8.8). In this graph, the
Trust with the longest LOS only performed 10 resections during the study period.
203

Table 8.13: Univariate and Multiple regression analysis of log LOS with back
exponentiation.
Univariate Multivariate
Relative Relative
95% C.I. p 95% C.I. p
risk risk
Laparoscopic vs
Surgical approach
open 0.60 0.59 0.61 <0.001 0.71 0.70 0.72 <0.001
Charlson score of
1-4 0.89 0.89 0.90 <0.001 0.94 0.93 0.94 <0.001
5 0.88 0.98 1.00 0.013 1.01 1.00 1.02 0.030
Age
17-54 1.00 1.00
55-69 1.09 1.08 1.09 <0.001 1.15 1.14 1.16 <0.001
70-79 1.25 1.24 1.26 <0.001 1.32 1.30 1.33 <0.001
>79 1.40 1.39 1.41 <0.001 1.44 1.43 1.46 <0.001
Year of surgery 0.97 0.97 0.97 <0.001 0.98 0.97 0.98 <0.001
Emergency vs
Admission status
Elective 1.43 1.42 1.43 <0.001 1.43 1.42 1.44 <0.001
Diagnosis
Cancer 1.00 1.00
IBD 1.03 1.02 1.04 <0.001 1.12 1.11 1.13 <0.001
Diverticular Disease 1.08 1.07 1.09 <0.001 0.96 0.95 0.97 <0.001
Other 1.04 1.03 1.04 <0.001 0.99 0.98 0.99 <0.001
Carstairs Index of social deprivation
1 (least deprived) 1.00 1.00
2 1.04 1.03 1.05 <0.001 1.03 1.02 1.03 <0.001
3 1.09 1.08 1.02 <0.001 1.06 1.05 1.07 <0.001
4 1.13 1.12 1.14 <0.001 1.09 1.08 1.10 <0.001
5 (most deprived) 1.19 1.18 1.21 <0.001 1.15 1.14 1.16 <0.001
Type of resection <0.001
left sided 1.16 1.15 1.17 <0.001 1.15 1.15 1.16 <0.001
rectal 1.05 1.04 1.06 <0.001 1.22 1.21 1.23 <0.001
total 1.31 1.30 1.32 <0.001 1.30 1.28 1.31 <0.001
204

Figure 8.8: Variation in LOS amongst colorectal resection patients by NHS Trust with 95%
confidence intervals.
80
70
*
60
50
LOS (days)
40
30
20
10
0
RLU
RX1
RBZ
RCB
RTF
RH8
RCF
RWP
RTD
RVL
RWW
RFF
RJL
RJ7
RMC
RYJ
RAL
RWJ
RQX
NT8
RNH
RHQ
RGQ
RTK
RGT
RVV
NHS Trust
95% CIs
*low volume Trust performing ten elective and emergency procedures
205

Variation in established outcome amongst pouch patients
Twenty-eight (0.5%) patients died in hospital within 30 days of admission. The 365 day
mortality (available from April 2000 to March 2005 only) was 1.5% (35/2395). The 30-day
mortality was greater in patients over 60 years [age: 1-16 years=0.5% (1/216), 17-39
years=<0.1% (1/2882), 40-59 years=0.3% (5/1993) and 60 years=3.1% (21/680), p<0.001].
Unsurprisingly, a higher 365 day mortality was also observed in patients over 60 years [age:
1-16 years=1.2% (1/82), 17-39 years=0.5% (6/1172), 40-59 years=1.2% (10/846) and 60
years and over=6.1% (38/295), p<0.001]. Both the 30 day in hospital mortality and 365 day
mortality were significantly higher in patients with a Charlson score 3 [30 day mortality:
Charlson2 0.4% (22/5663), Charlson3 4.3% (6/138) p<0.001; 365 mortality: Charlson2
1.1% (25/2338), Charlson3 17.5% (10/57) p<0.001]. The 30-day mortality of patients over
60 years was 2.5% (15/607) with a Charlson score of 2 and 8.2% (6/73) with a Charlson
score of 3, (p=0.007). In patients aged 60 years or over, the 365 day mortality was 4.5%
(12/264) and 19.4% (4/31) for Charlson scores of 2 and 3 (p=0.001).
Patients with a diagnosis of malignant disease had a higher 30 day and 365 day mortality than
patients in other diagnostic categories [30 day mortality; malignancy=1.8% (11/617), UC=
0.1% (4/3934), Crohns disease= 0.0% (0/129), benign = 0.0% (0/381), other diagnosis
1.8% (13/708), p<0.001; 365 day mortality: malignancy=6.6% (19/287), UC = 0.5%
(8/1593), Crohns disease= 1.8% (1/55), benign = 0.0% (0/153), other diagnosis 2.3%
(7/307), p<0.001]. Within the category of other, diverticular disease and Hirschsprungs
disease demonstrated higher mortality at 30 days [30 day mortality; attention to stoma=0.4%
206

(1/250), noninfective gastroenteritis=1.4% (1/70), adhesions=0% (0/22), diverticular disease=
11.8% (2/17), Hirschsprung's disease=8.3% (1/12), obstruction=0% (0/9), p=0.001].
Age (p<0.001), diagnosis (p<0.001), comorbidity (p=0.019) and social deprivation (p=0.046)
were positively associated with 30 day postoperative mortality on multivariate logistic
regression. Diagnosis (p=0001) and the comorbidity index (p<0.001) were independently
associated with 365 day mortality on multiple logistic regression. A Charlson score>2 had an
odds ratio of 19.69 (C.I. 8.95-43.29, p<0.001) compared to a Charlson score of 2. A
diagnosis of malignancy had odds ratio of 8.28 (CI 3.23-21.27, p<0.001) compared with a
diagnosis of UC.
Length of stay and 28-day readmissions:
The median length of stay (LOS) following RPC was 12 days (IQR: 9-15 days, n=5771). In
total, 1269 (22.0%) patients were readmitted within 28-days of discharge. Median LOS
increased with advancing age [age 16 years: 10 days (IQR 8-13 days, n=216); age 17-39
years: 11 days (IQR 9-14 days, n=2882); age 40-59 years: 12 days (IQR 10-16 days,
n=1993); age 60 years: 14 days (IQR 10-20 days, n=680), p<0.001]. It was significantly
longer in patients with significant comorbidity [Charlson score 2: 12 days (IQR 9-15 days,
n=5633); Charlson score 3: 15 days (IQR 11-22 days, n=138), p<0.001)]. The median LOS
for female patients was less than for males [female 11 days (IQR 9-15 days, n= 2573): male
12 days (IQR 9-16 days, n=3198 (p=0.054)]. A malignant diagnosis was associated with a
significantly longer median inpatient stay [malignant = 13 days (IQR 11-18 days, n=617);
207

UC= 11.5 days (IQR 9-15 days, n=3934); benign tumour diagnosis = median stay 11 days
(IQR 9-15 days, n=383); Crohns disease= 11 days (IQR 9-15 days, n=129); other
diagnosis= 11 days (IQR 9-15 days, n=708), p<0.001].
Social deprivation was associated with a one day increase in median LOS [Carstairs 1 (least
deprived) =11 days (IQR 9-15 days, n=1226), Carstairs 2=11 days (IQR 9-15 days,n=1322),
Carstairs 3=12 days (IQR 9-16 days,n=1214), Carstairs 4=12 days (IQR 9-15 days, n=1063),
Carstairs 5 (most deprived)=12 days (IQR 9-16 days, n=926, Unclassified=12 days (IQR 10-
17 days n=20), p<0.001]. During the study period there was a reduction in LOS from 12 to 10
days (p<0.001).
Readmissions within 28-days were greater amongst females [female 25.5% (656/2573); male
19.2% (613/3198), p<0.001]. Patients with a diagnosis of malignancy were significantly less
likely to be readmitted within 28 days [malignant diagnosis=16.3% (101/619), benign tumour
diagnosis=23.1% (88/381), Crohns disease= 24.8% (32/129), UC=22.9% (899/3934), other
diagnosis 21.0% (149/708), p=0.007]. Readmissions within 28 days increased over the study
period from 18.1% in 1996 to 28.6% in 2007 (p=0.003). Gender was an independent
predictor for readmission on multivariate regression analysis with women being more likely
to be readmitted [odds ratio 1.44 (CI 1.27-1.64), p<0.001].
208

Table 9.11 shows the linear regression analysis for LOS following a primary RPC.
Increasing co-morbidity, later discharge year, younger age and both high provider and
surgeon caseload were independent predictors of a shorter LOS.
The differences in infrastructure amongst outliers for mortality and reoperation will be
discussed in the following chapter.
The impact of process factors on outcome

Use of laparoscopy and outcome
Thus far in this thesis, selection for laparoscopy has been associated with reduced mortality
(Table 8.12) and a shorter LOS (Table 8.13). These improved perioperative outcome may be
offset by a possible small increase in reoperation rate (Table 8.5). In the medium term,
selection for the minimal access approach may be associated with a reduced adhesion rate
(table 8.8).
Outcome from laparoscopic restorative proctocolectomy in the early years of its introduction
2,946 primary pouches procedures were performed between 1st April 2002 and 31st March
2008. 2.7% (81/2946) were performed with laparoscopic assistance by 41 surgeons in 33
institutions. There were no differences in terms of patient age, gender, diagnosis, level of
comorbidity or social deprivation between those selected for the open and laparoscopic
technique (p=0.137, p=0.185, p=0.164, p=0.965, and p=0.576 respectively). No deaths were
recorded at 1-year following laparoscopic procedures. A higher proportion of patients were
209

readmitted within 28-days following laparoscopic compared with open surgery [34.6%
(28/81) versus 23.6% (676/2885) respectively, p=0.022]. Hospital stay was shorter following
laparoscopic pouch surgery compared with the conventional technique [10 days (IQR=7-15
days,n=81) versus 11 days (IQR=8-15 days,n=2865) respectively, p=0.020].
Rectal procedures-APE and outcome
36,714 patients who underwent an elective resection coded to a primary diagnosis of rectal
cancer were included. Of these, 26.1% (9574/36714) had an APE resection. 63.3%
(23224/36714) of rectal cancer patients were coded to an anterior resection. 7.4%
(2722/36714) of patients were coded to a Hartmanns procedure. More patients who
underwent APE were from areas of higher social deprivation [Carstairs score 5 (most
deprived) APE 17.3% (1655/9574), Other procedure 14.8% (4021/27140), p<0.001]. Patients
selected for APE had a lower 30-day mortality and 28-day unplanned readmission rate [30-
day mortality - APE 2.7% (256/9574), Other procedure 3.3% (896/27140), p=0.002, 28 day
readmission - APE 9.9% (948/9574), Other procedure 11.6% (3152/27140), p<0.001].
Patients undergoing APE had a higher return to theatre rate in the postoperative period [APE
10.0% (957/9574), Other procedure 7.8% (2130/27140), p<0.001].
Summary
We have shown that it is possible to derive new outcome measures from HES data using
longitudinal analysis. The methodology underpinning these novel measures is widely
applicable to other surgical specialities. Significant variation in these measures has been
demonstrated amongst patients and providers. In addition we have shown the interplay
210

between process (in terms of APE rate and use of laparoscopy) and outcome measures in
general colorectal surgery and in the more specialised pouch procedure.
This thesis reports national reoperation rates following major colorectal resection in England.
Reoperation represents a new possible performance measure that can be derived from
existing data sources. Moreover, we have demonstrated the feasibility of using routinely
collected data to benchmark institutional and surgeon reoperation rates on a national scale.
We have demonstrated substantial variation in reoperation rates between providers of
colorectal services as well as in pouch surgery. In an equal healthcare system such as the
NHS, quality improvement is necessary to reduce unwanted variation in outcome.
211

Chapter 9- Reducing variation in outcome following colorectal surgery in
England- the role of volume in determining outcome
Introduction
The previous chapters have demonstrated considerable variation in patient characteristics
managed by providers. Chapter 6 showed that the activity of general colorectal (index
procedure colorectal resection) and more specialised colorectal surgery (index procedure
RPC) varies considerably amongst providers. Chapter 7 showed differences in terms of
process factors including use of laparoscopy and APE rates amongst providers. Chapter 8
described variation in outcome measure (reoperation, adhesion and incisional hernia rates and
more specialised colorectal outcome in terms of pouch failure, mortality and LOS).
Demonstration of variation and some of the underlying variation will not in itself lead to an
improvement in patient care. There is an increasing vogue towards centralising elective
surgical services through generally increasing surgical caseload and thereby improve the
quality of surgical provision. It may be that increasing caseload may be an effective strategy
for reducing the demonstrable variation. This study examines whether increasing caseload
in general colorectal as well as in more specialised colorectal procedures reduces this
variation and therefore could be used to improve outcome and patient care.
In the US, several studies have demonstrated improved outcome at both a surgeon and
institution level (Hodgson et al., 2003, Schrag et al., 2002, Billingsley et al., 2007).
However, not all studies have shown a clear benefit to higher caseload (Faiz et al., 2010a). In
212

the UK, the relationship between volume and outcome in elective colorectal cancer surgery
has not been explored at a national level.
Using a regional dataset, Borowski and colleagues demonstrated lower perioperative
mortality, lower anastomotic leak rate and higher use of restorative rectal surgery amongst
higher volume surgeons in the North of England (Borowski et al., 2007, Borowski et al.,
2010). However, an earlier study using the North West cancer registry failed to find such an
association between volume and improved outcome (Parry et al., 1999). Morris and
colleagues in two studies, using regional cancer registry data and HES data, found higher use
of APE amongst higher volume surgeons for rectal cancer (Morris et al., 2010, Morris et al.,
2008). Though APE is the appropriate procedure of choice in some patients with low rectal
cancers, APE has been associated with poorer oncological outcome (Wibe et al., 2004,
Haward et al., 2005). The ACPGBI suggest that surgeons who performed elective colorectal
cancer procedures should perform at least twenty elective or emergency cancer resections per
year (ACPGBI, 2007). This guideline places the emphasis on colorectal cancer resections. It
has not been addressed in studies whether a surgeon that performs a high volume of
resections for diverticular disease or inflammatory bowel disease may have equivalent
outcome to a high volume cancer surgeon. Given the considerable reconfiguration of surgical
services required to centralise one of the most common colorectal procedures and possible
disadvantages to patients, it is necessary to ensure that adequate evidence of the advantages
of higher surgical volume at the national level exists prior to undertaking such a
reconfiguration.
213

Minimally invasive techniques have revolutionised colorectal surgical practice. Colorectal
patients undergoing laparoscopic surgery have reduced postoperative pain, a shorter length of
stay and a quicker return to normal levels of activity (Abraham et al., 2004, Schwenk et al.,
2005, Faiz et al., 2009). Furthermore, oncological data have suggested equivalent outcome
following laparoscopic surgery and the open approach for colorectal cancer (Jayne et al.,
2010, Jayne et al., 2007, Bonjer et al., 2007). The relationship between caseload and outcome
following the laparoscopic approach is, however, not well understood. The learning curve
for laparoscopic colorectal surgery is long and complex (Tekkis et al., 2005c, Schlachta et al.,
2001, Finlayson and Birkmeyer, 1997). Yasunaga and colleagues demonstrated that increased
surgeon caseload volume in laparoscopic colectomy was associated with shorter operating
times, but had no significant impact on postoperative complication rates nor was hospital
volume associated with post-operative morbidity (Yasunaga et al., 2009). This study used
self-reported data from the Japanese Surgical Society website. Voluntary reporting to clinical
registries may be associated with some degree of bias (Almoudaris et al., 2010b). Using
administrative data, Kuwabara and colleagues reported that hospital volume of laparoscopic
colectomy was not associated with increasing risk of post-operative complications(Kuwabara
et al., 2009). Using data from the Clinical Outcomes of Surgical Therapy (COST) study,
Larson showed that high surgeon volume had shorter operating times, longer distal resection
margins and greater lymph node yields, but no difference in terms of complications,
conversion rates or 5-year survival (Larson et al., 2008). Prior to inclusion in this study
surgeons were credentialed to establish a minimum volume and competency. The Colon
Cancer Laparoscopic or Open Resection (COLOR) study group investigated the impact of
hospital volume on outcome in a trial population of colonic cancer patients (Kuhry et al.,
2005). Hospitals with high volume practice demonstrated shorter operating times, fewer
214

conversions to the open approach, shorter length of stay and a reduced number of
complications. These data are from clinical trials where surgeon participants are generally
expert or in the case of the COST trial credentialed prior to inclusion. In contrast to
purpose-built clinical databases or trial data, routinely collected data have been used to
investigate the volume-outcome relationship in surgery in the United States and Holland
(Birkmeyer et al., 2002, van Lanschot et al., 2001).
General colorectal surgery, including colorectal resection, makes up the mainstay of
colorectal practice. More specialised surgery, such as pouch surgery, often involves smaller
numbers and has increased complexity. The role of volume in reducing variation in practice
and outcome in subspecialised surgery may be different than for general colorectal surgery.
Such a relationship may be magnified and therefore ought to be explored separately.
Restorative proctocolectomy with ileal reservoir (RPC) described in 1978 (Parks and
Nicholls, 1978) has become the operation of choice for patients with ulcerative colitis (UC)
requiring surgery and for some with familial adenomatosis polyposis (FAP). Various
modifications of the operation including experimentation with various pouch configurations
(Utsunomiya et al., 1980, Nicholls and Lubowski, 1987, Fonkalsrud et al., 1988) have been
made over the last thirty years.
Several studies have reported the short and long-term outcome following RPC (Hueting et al.,
2005, Tulchinsky et al., 2003). Despite its widespread acceptance and use, considerable
postoperative morbidity has been reported in a large series, with more than 60% of patients
experiencing complications (Fazio et al., 1995). Surgical results have improved with
215

increased operative experience (Fleshman et al., 1988, Marcello et al., 1993, Tekkis et al.,
2005a).
The United Kingdom (UK) National Inflammatory Bowel Disease (IBD) Audit in 2006
reported that institutional median volume was four RPCs performed per year (IBD Audit,
2006). The low volumes carried out by most individual surgeons has resulted in little
published information from low volume centres. One approach to achieving the sample sizes
required for the meaningful analysis of outcome is to use either national clinical registry
and/or national administrative datasets. The UK National Ileal Pouch registry has collected
data from participating units since 2004 (Tekkis et al., 2009). In 2006, ten units had
submitted their data on 2491 patients. There was a failure rate of 7.7% over a median follow
up period of 53 months after a primary procedure. This rose to 27% following salvage
surgery. It was unclear whether surgical caseload was related to failure or function including
urgency or incontinence (Tekkis et al., 2009). For technically challenging surgery with
difficult decision making, one can hypothesis that higher surgical caseload will translate into
improved outcomes. With such low activity levels reported in previous audit, is there a role
for centralising services into dedicated pouch centres?
Variation in patient factors, structural factors, processes and outcome amongst providers has
been demonstrated previously. How can these differences be negated to improve patient
care? Is increasing surgical caseload amongst surgeons and Trusts one feasible means of
improving outcome? If such a volume relationship does exist, to which colorectal services
should it apply and at what level?
216

HES data have been used previously to examine current activity and the role of volume in
determining outcome in other specialties including upper gastrointestinal and hepatobiliary
surgery(Al-Sarira et al., 2007, Leigh et al., 2009, Pal et al., 2008), urology (Hanchanale et al.,
2010, Judge et al., 2007, Mayer et al., 2010, Mayer et al., 2009a, McCabe et al., 2005,
McCabe et al., 2007, Nuttall et al., 2005), vascular surgery (Holt et al., 2007a, Holt et al.,
2007b) (Holt et al., 2009b, Jibawi et al., 2006) and orthopaedics (Judge et al., 2006). Table
9.1 summarises the findings of these studies.
Using the outcome measures demonstrated for general colorectal surgery derived in Chapter
8 (reoperation) and for more specialised colorectal procedures (pouch failure), alongside
established measures such as mortality, it will be feasible to examine the role of caseload in
improving outcome and reducing variation. Furthermore, it may be possible to investigate
the role of volume in reducing variation in process factors such as APE.
217

Table 9.1:Previous research examining surgical provision and impact of caseload on outcome using HES data.
First author Publication Study Speciality Diagnosis and Procedure Definition of volume Findings
year year
Al-Sarira(Al-Sarira et al., 2007) 2007 1997- Upper Cancer Hospital volume Fewer centres performing surgery
2004 gastrointestinal Oesophagectomy Quintiles per year Increasing number of procedures in
1-9, 10-19, 20-29, 30-39, 40 high volume centres
Pal(Pal et al., 2008) 2008 1999- Upper All diagnoses Hospital volume Reduced unadjusted mortality in higher
2005 gastrointestinal Quartiles over study (6 years) volume centres for oesophagectomy and
pancreaticoduodenectomy
HV LV p value
Oesophagectomy, 1-66, 66-122, 132-231, 235-368 4.0% 7.8% 0.007
Gastrectomy, 1-44, 45-68, 69-100, 101-244 6.7% 5.6% NS
Pancreaticoduodenectomy 1-43, 46-77, 81-144, 173-317 3.8% 6.5% 0.016
Liver resection 1-197, 211-301, 318-503, 589-685 2.0% 3.1% NS
Leigh(Leigh et al., 2009) 2009 1998- Upper Cancer Hospital volume 30 day mortality Low volume compared
2003 gastrointestinal Oesophagectomy Low volume <100 cases over study to high volume OR 1.62 (1.38-1.91)
High volume 100 cases over study 90 day mortality Low volume compared
Cardiothoracic versus General to high volume OR 1.55 (1.35- 1.77)
Surgeon
Nuttall(Nuttall et al., 2005) 2005 1995- Urology Radical cystectomy Mean volumes per year No evidence for centralisation during
2002 study period.
McCabe(McCabe et al., 2005) 2005 1998- Urology Radical cystectomy Minimum threshold per hospital 11 procedures per year
2003
McCabe(McCabe et al., 2007) 2007 1998- Urology Radical cystectomy Minimum threshold per surgeon 8 procedures per year
2003
Judge(Judge et al., 2007) 2007 1997- Urology Prostate cancer Hospital volume Reduced LOS and readmissions in high
2004 Radical prostatectomy Quintiles per year volume
114, 1522, 2332, 3345, 4693 No significant relationship between
mortality and complications
Mayer(Mayer et al., 2009a) 2009 2000- Urology Radical cystectomy Minimal case volume as per Increase in number of centres reaching
2007 Radical prostatectomy recommendations (50 cases per volume threshold.
year)
Hachanale(Hanchanale et al., 2010) 2010 1998- Urology Prostate Cancer Surgeon and hospital volume High volume surgeons and hospitals
2005 Radical prostatectomy High and low volume based on 50th had lower mortality and a shorter LOS
centile per year
26 for hospital and 16 for surgeon
218

Table 9.1:Previous research examining surgical provision and impact of caseload on outcome using HES data contd.
First author Publication Study Speciality Diagnosis and Procedure Definition of volume Findings
year year
Mayer(Mayer et al., 2010) 2010 2000- Urology Radical cystectomy Surgeon and hospital volume Higher mortality amongst medium
2007 Tertiles per year volume institutions
2-10, 20-16, 16 No surgeon volume relationship
Mayer(Mayer et al., 2011) 2011 2000- Urology Radical cystectomy Hospital and surgeon volume Low volume institution had lower
2007 Tertiles per year reintervention rate.
High volume surgeons had reduced
early reinterventions (OR, 0.68; 95%
CI, 0.510.91;P=0.01)
Jibawi(Jibawi et al., 2006) 2006 1997- Vascular Open AAA repair Minimum threshold 14 procedures per year
2002
Holt(Holt et al., 2007a) 2007 2000- Vascular Open AAA repair Hospital volume Reduced mortality and shorter LOS for
2005 Quintiles over study (5 years) elective and non ruptured urgent
0-7.2 repairs.
7.3-12.6 There was no relationship for ruptured
12.7-19.4 repairs.
19.5-32
>32
Holt(Holt et al., 2007b) 2007 2000- Vascular Extra-cranial atherosclerotic Hospital volume Reduced mortality in high volume
2005 arterial disease Quintiles per year centres in elective procedures OR
Carotid Endarterectomy 1-9.4, 9.5-17.2, 17.3-34.6, 34.7- 0.898 (0.808-0.99)
52.2, 52.3-95.6 Decreased LOS in higher volume
centres for elective and emergency
admissions (p<0.001)
No relationship with complications
Holt(Holt et al., 2009b) 2009 2005- Vascular AAA Hospital volume 13% reduction in odds mortality for
2007 Endovascular AAA repair Quintiles per year each additional 20 cases performed.
Judge(Judge et al., 2006) 2006 1997- Orthopaedic Total knee (TKR) and total Hospital volume Trend for more procedures in higher
2002 hip (THR) arthroplasty Five clinically sensible categories volume centres
per year Low volume Trusts have higher
150, 51100, 101250, 251500, mortality for THR OR 1.98 (1.133.47)
>500 and TKR OR 1.72 (0.763.89)
Hospital orthopaedic training status Reduced LOS following THR and
219

TKR but no difference in readmission

or revision rates
Training centres had reduced mortality
following THR and possible reduced
revision rate following TKR, reduced
readmission following THR and TKR
but no difference in LOS for THR or
TKR.
NS- Non significant

OR- Odds Ratio
220

Aims
This chapter aims to
1. Assess whether there is a relationship between surgeon or hospital caseload and
elective colorectal cancer resection outcome using national data.
2. Assess the relevance of the suggested threshold of twenty colorectal cancer resections
per annum in determining postoperative outcome.
3. Address whether overall elective resection volume (i.e. inclusion of benign and
malignant) impacts on outcome.
4. Evaluate the role of caseload in determining rectal resection outcome and choice of
surgery for rectal cancer (APE rate).
5. To explore whether a volume tipping point can be identified, if a volume outcome
relationship is demonstrated.
6. Explore the role of volume in determining outcome from more specialised colorectal
care in particular following laparoscopic surgery and restorative proctocoloectomy.
Methods
Colorectal resections
Database inclusions and variable coding: all adult patients undergoing primary elective
colorectal resections were included from 1st April 2000 to 31st March 2008. Any patients who
underwent a colorectal resection between 1996 and 2000 were excluded from the analysis.
The first resection that the patient underwent between 2000 and 2008 was considered as the
primary resection.
221

Surgical procedures were categorised as follows:
Right-sided resections that included right hemicolectomy and extended right hemicolectomy
and transverse colectomy
Left-sided resections that included left hemicolectomy and sigmoid colectomy
Rectal resections included anterior resection, Hartmanns procedures and abdominoperineal
resection (APE)
Subtotal colectomy, panproctocolectomy and total colectomy and colectomy of unspecified
site were considered together.
OPCS codes for each procedure is shown in Table 9.2.
A laparoscopic procedure was considered as any procedure associated with OPCS codes
Y50.8, Y75 or Y71.4. Y71.4 (failed minimal access) was introduced in 2006. Patients
coded to the failed minimal access code were considered in the laparoscopic group for further
analysis.
The Charlson score was considered in three categories 0, 1-4 and 5. The postoperative
mortality within each of these groups was similar.
222

Table 9.2: OPCS codes used to classify colorectal resection.
Type of resection Procedure OPCS code
Right sided resections Right hemicolectomy H07
Extended right hemicolectomy and transverse H06, H08
colectomy
Left sided resections left hemicolectomy sigmoid colectomy H09
Hartmanns procedure (if not associated with H10
rectal cancer diagnosis) H33.5
Rectal resection anterior resection H33.2, H33.3, H33.4, H33.6, H33.7,
H33.8, H33.9
abdominoperineal resection (APE) H33.1
Hartmanns procedure (if associated with H33.5
rectal cancer diagnosis)
total colectomy panproctocolectomy H04.1, H04.3, H04.8, H04.9
total colectomy H05
colectomy of unspecified site H11
223

Restorative Proctocolectomy
Database inclusions and variable coding: all primary elective RPCs were included from 1st
April 1996 to 31st March 2008. They were denoted by the following OPCS codes:
qualified
Individual diagnoses were recoded into major diagnostic categories according to ICD 10 code
as follows: K51- Ulcerative colitis (UC), K50 - Crohns disease, C18 C19 C20 C21
C26 D37- Malignant disease, D010 D12-Benign colorectal tumours. The remaining
codes were classified as other diagnosis (the latter are described below). Patients were
grouped into four age cohorts: <17, 17-39, 40-59 and >59 years according to age at time of
surgery. We considered that a Charlson score of greater than three would include the more
comorbid patient and those patients with a score of less than or equal to two would represent
those patients with few or no comorbidities Mortality at 30 days increased significantly in
those patients with a Charlson score of 3 and small numbers of patients with high Charlson
scores, Charlson score was grouped into two clinically relevant categories: 2 and >2.
Ethnicity was coded according to the HES dataset classification: white, black, Indian
subcontinent, unknown and other.
224

Volume considerations
Colorectal Resection volume
In order to examine the role of volume, colorectal caseload is considered in several ways.
The first approach divides caseload into three tertiles according to the volume of elective
colorectal cancer resection performed by the consultant team or Trust per year giving three
groups of approximately equal numbers of consultant teams or Trusts. The volume per year
was found by averaging the total volume over the study period by the number of years in
which the relevant consultant code or Trust code was present. The second approach explores
the proposed threshold suggested by the Association of Coloproctology of Great Britain and
Ireland (ACPGBI) of twenty colorectal cancer resections per year (ACPGBI, 2007) As this
guideline refers to both elective and emergency cases, both were included to determine
volume thresholds. When analysing abdominoperineal resection rates, consultant teams and
Trusts were divided into tertiles according to their rectal cancer caseload per year. The
volume per year was found by averaging the total elective rectal cancer volume over the
study period by the number of years in which the relevant consultant code or Trust code was
present. Due to mergers, Trust codes were unified to reflect their status as of April 2008. A
hospital Trust may comprise several sites. The tertile approach was chosen as when
compared with a continuous or quintile approach, this model for reoperation and 30-day
mortality had the lowest Deviance Information Criterion statistic (Spiegelhalter et al., 2002).
Table 9.3 shows the volume thresholds for each means of exploring colorectal resection
volume.
To minimise the effects of erroneous coding, only those Trusts that performed ten or more
procedures and those consultant teams that performed greater than 4 procedures over the
225

study period were included. In addition, those patients with unquantified deprivation scoring
were excluded. In total this excluded 1762 patients.
226

Table 9.3: Volume thresholds for elective colorectal resection.

Number of
Volume Thresholds Procedures per year %
patients
Consultant Team
Volume
LV 1.0-7.4 procedures 5693 5.2
MV 7.5-20.7 procedures 27295 25.1
HV >20.7 procedures 76273 69.8
Total 109261 100.0
Guideline surgeon
<20 procedures 21164 19.4
volume
20 procedures 88097 80.6
Total 109261 100.0
Consultant Team Rectal surgery volume
rLV 1-3.4 procedures 1774 4.8
rMV 3.5-7.8 procedures 9710 26.4
rHV >7.8 procedures 25230 68.7
Total 36714 100.0
Institutional volume
LV 1-68.9 procedures 19478 17.8
69.0-103.5
MV 34243 31.3
procedures
HV >103.5 procedures 55540 50.8
Total 109261 100.0
Institutional Rectal surgery volume
rLV 1-21.6 procedures 6140 16.7
rMV 21.7-37.8 procedures 14328 39.0
rHV >37.8 procedures 16246 44.3
Total 36714 100.0
227

Pouch Case Volume
In an attempt to investigate comprehensively the role between outcome and volume in pouch
surgery three separate methodological approaches to categorical handling of surgical volume
were utilised. First, hospital and surgeon volume was categorised into three groups following
ranking of institutions and surgeons according to volume and then dividing the ranking into
three equal groups, A, B and C. This technique yielded a similar number of institutions (or
surgeons) in each group but inequality in the number of patients in each group. Secondly, we
determined volume tertiles by ranking patients according to aggregated surgeon or
institutional caseload to give three volume categories including: low volume (LV), medium
volume (MV) and high volume (HV). Each volume tertile contained equal numbers of
patients and tertile ranges were calculated separately for both surgeon and institution. The
caseloads resulting from the latter two approaches are shown in Table 9.4.
The consultant code was only available from April 2000 to March 2008. Therefore the
surgeon volume category spans eight study years and the institutional provider volume spans
twelve study years. To evaluate further the role of extreme volumes on outcome, a third
pragmatic approach was used. In this method centres where fewer than twelve procedures
were performed over the study period (i.e. less than one a year, ExtLV) were compared with
centres with a higher caseload (equal to or more than one procedure a month, ExtHV). The
remaining patients were designated in the ExtMV category. Lastly, institutional pouch
volume was investigated graphically as a continuous variable by charting it against
unadjusted failure rates in a funnel plot.
228

Table 9.4: Volume categories and number of patients in each category for restorative
proctocolectomy.
Number of Number of Percentage Number of
Volume category procedures per year patients of patients providers
Institutional A 1-14 procedures 0.1-1.2 402/5771 7.0 55 trusts

B 15-31 procedures 1.3-2.6 1068/5771 18.5 48 trusts
C 32 procedures 2.7 4301/5771 74.5 51 trusts
Low volume 1-39 procedures 0.1-3.3 1964/5771 34.0 117 trusts

Medium volume 40-100 procedures 3.3-8.3 1816/5771 33.2 28 Trusts
High volume 101 procedures 8.4 1891/5771 33.8 9 trusts
Surgeon A 1-2 procedures 0.1-0.3 266/3878 6.9 209 surgeons

B 3-6 procedures 0.4-0.8 554/3878 14.3 126 surgeons
C 7 procedures 0.9 3058/3878 78.9 164 surgeons
Low volume 1-10 procedures 0.1-1.3 1331/3878 34.3 397 surgeons

Medium volume 11-28 procedures 1.4-3.5 1329/3878 34.3 78 surgeons
High volume 29 procedures 3.6 1218/3878 31.4 24 surgeons
229

Outcome variables
30-day in-hospital mortality was ascertained. Length of stay (LOS) is the time (in days) spent
in hospital during the primary admission for colorectal resection; a patient admitted and
discharged on the same day would have a LOS of zero. Readmission refers to emergency
(unplanned) readmission to hospital within 28 days for any reason. Reoperation was defined
as any return to theatre for an intra abdominal procedure or wound complication on the index
admission or on a subsequent admission to hospital within 28 days of the initial resection.
30 day medical morbidity and 365 day medical morbidity were defined as the presence of
relevant acute postoperative diagnosis code or as a primary code on a subsequent admission
within 30 and 365 days respectively (Mamidanna et al., 2011). The relevant ICD10 codes
were as follows: angina (I20), myocardial infarction (I21, I22), ischaemic heart disease (I24,
I25), congestive cardiac failure (I50), atrial fibrillation / flutter when not present
preoperatively (AF) (I48), pneumonia (J12-J16, J18, J22, J69, J95, J98), pleural effusion
(J90-J91, J948), respiratory failure (J80, J96) and other respiratory complications (J41-J46,
J81), deep vein thrombosis (I80), pulmonary embolism (I26), acute ischaemic stroke (I63,
I64), sequelae of stroke (I69), renal failure (N17, N18, N19, N990). 28 day readmission
refers to any unplanned readmission within 28 days. Length of stay (LOS) is the time (in
days) spent in hospital during the primary admission; a patient admitted and discharged on
the same day would have an LOS of zero.
Pouch failure was defined as excision of the ileal reservoir or formation of ileostomy with no
subsequent reversal. If a patient had undergone both ileostomy formation and a subsequent
excision, the first date was selected as the pouch failure date. Failure rates are presented for
230

all patients and for a subgroup of patients who underwent definite initial ileostomy reversal
(i.e. those patients who regained intestinal continuity). Not all patients are actively coded as
having a stoma alongside RPC. It is unclear whether the coding for ileostomy reversal is
accurate, and therefore all pouch failures were considered for the statistical analyses.
Excision of pouch was defined by the following codes following advice from professional
coders: H661 Excision of ileoanal pouch, H468 Other specified operation on rectum,
H331 Excision of rectum, Abdominoperineal excision of rectum and end colostomy,
H335 Excision of rectum, Rectosigmoidectomy and closure of rectal stump and
exteriorisation of bowel, H338 Excision of rectum, Other specified, H339 Excision of
rectum, Unspecified. The following code was used to denote pouch revision: H662
Revision of ileo-anal pouch. Of note both the H661 and H662 codes were first introduced
in 2006.
The following codes were used to define reversal of ileostomy: G753 Attention to
artificial opening into ileum, Closure of ileostomy G732 Attention to connection of ileum,
Closure of anastomosis of ileum, H154 Other exteriorisation of colon, Closure of
colostomy, G733 Attention to connection of ileum, Resection of ileostomy. Ileostomy
formation was defined by the following codes: G741 Continent ileostomy, G742
Temporary ileostomy, G743 Defunctioning ileostomy, G748 Other specified, G749
Other unspecified, G751 Refashioning of ileostomy.
To assess the point at which the addition of cases no longer led to improved outcome or
reduced APE rate, 5 and 2.5 cases were added to the total caseload until there was no
231

reduction in mortality or APE rate. If such a transition point was found, this was termed the
tipping point.
Statistical methodology
Categorical variables were investigated using the Chi-squared test. Correlation analysis was
performed using the Pearson correlation test or Spearmans Rho test for parametric or non-
parametric respectively. Logistic regression analysis was used to investigate the independent
role of age, gender, primary diagnosis, Charlson comorbidity score, Carstairs index of social
deprivation, provider volume, consultant volume and discharge year on postoperative
mortality and 28 day readmission rates. Linear regression was used to investigate the
independent role of age, gender, primary diagnosis, Charlson score, Carstairs index of social
deprivation, provider volume, consultant volume and discharge year on LOS. Cox regression
analysis was used to explore the independent role of age, gender, primary diagnosis, Charlson
score, Carstairs index of social deprivation, provider volume, consultant volume and
discharge year and time to failure. Hospital volume was considered in the Cox regression
model with consultant status considered separately for examining the impact of volume on
pouch failure. For those patients who experienced failure, the pouch survival time was
calculated as either the time in months from the date of RPC to the date of the procedure that
denoted pouch failure. The patients who did not experience failure were considered to have
an intact pouch until the end of the study period (31st March 2008) unless they died within
365 days of RPC. Patients known to have died within 365 days of RPC were considered to
have an intact pouch until 365 days after RPC. Factors with a significance level of 0.1 on
univariate analysis were included in the regression analyses.
232

Multilevel logistic regression analysis was used to investigate postoperative mortality,
readmission and reoperation rate for colorectal resection taking account clustering of patients
within consultant teams and teams within hospitals. Multilevel modelling was carried out
using MLWin Version 2.21 (Rabash et al., 2010).
Statistical analyses were carried out using SPSS Version 16.0 (Statistical Package for Social
Sciences, SPSS, Chicago, Illinois, USA). For tests of significance, a p value of <0.05 was
considered significant. For non-parametric variables the median and interquartile range (IQR)
are given. Funnel plots were respectively constructed using the web tool:
http://www.erpho.org.uk/topics/tools/funnel.aspx
Results
Does a relationship exist between consultant team or Trust volume and outcome
following colorectal cancer surgery?
Demographics
The numbers of patients in each volume category are shown in Table 9.3.
Patient characteristics and volume
Of the elective colorectal cancer resections, 6.1% (6634/109261) were selected to have their
procedure laparoscopically. Table 9.5 shows the characteristics of patients operated on by
consultant teams and institutions with varying caseload. Higher volume consultant teams
performed more rectal procedures and demonstrated greater use of laparoscopy. Higher
volume consultant teams managed fewer patients from areas of increased social deprivation.
233

Table 9.5: Patient characteristics and type of surgery by approach for patients undergoing an
elective colorectal resection.
Consultant Team Volume Guideline surgeon volume Institution volume
LV MV HV P value <20 20 P value LV MV HV P value
Resection 2335 7963 22080 6912 25466 5626 10048 16704

right sided <0.001 <0.001 <0.001
type (41.0) (29.2) (28.9) (32.7) (28.9) (28.9) (29.3) (30.1)
1300 4603 11326 3948 13281 3178 5393 8658

left sided
(22.8) (16.9) (14.8) (18.7) (15.1) (16.3) (15.7) (15.6)
1850 13740 40517 9534 46573 10024 17608 28475

rectal
(32.5) (50.3) (53.1) (45.0) (52.9) (51.5) (51.4) (51.3)
subtotal/ 208 989 2350 770 2777 650 1194 1703

total (3.7) (3.6) (3.1) (3.6) (3.2) (3.3) (3.5) (3.1)
Surgical Laparoscopic 118 1803 4713 1057 5577 1475 1863 3296
<0.001 <0.001 <0.001
Approach approach (2.1) (6.6) (6.2) (5.0) (6.3) (7.6) (5.4) (5.9)
70.1 69.4 69.7 69.6 69.7 69.3 69.6 69.8

Age Mean (SD) <0.001 0.013 <0.001
(11.3) (11.2) (11.1) (11.3) (11.4) (11.4) (11.1) (11.0)
Charlson 3311 16531 45562 12734 52670 11552 20095 33757

0 <0.001 0.224 <0.001
score (58.2) (60.6) (59.7) (60.2) (59.8) (59.3) (58.7) (60.8)
445 2632 6873 1961 7989 1903 3245 4802

1-4
(7.8) (9.6) (9.0) (9.3) (9.1) (9.8) (9.5) (8.6)
1937 8132 23838 6469 27438 6023 10903 16981

5
(34.0) (29.8) (31.3) (30.6) (31.1) (30.9) (31.8) (30.6)
Carstairs 1 (least 1044 4542 16257 3826 18017 3641 6972 11230
<0.001 <0.001 <0.001
deprivation deprived) (18.3) (16.6) (21.3) (18.1) (20.5) (18.7) (20.4) (20.2)
1304 5732 18808 4530 21314 4018 8231 13595

2
(22.9) (21.0) (24.7) (21.4) (24.2) (20.6) (24.0) (24.5)
1195 6061 16963 4543 19676 4040 7630 12549

3
(21.0) (22.2) (22.3) (21.5) (22.3) (20.7) (22.3) (22.6)
1086 5687 14067 4205 16635 3902 6516 10422

4
(19.1) (20.8) (18.4) (19.9) (18.9) (20.0) (19.0) (18.8)
5 (most 1064 5273 10178 4060 12455 3877 4894 7744

deprived) (18.7) (19.3) (13.3) (19.2) (14.1) (19.9) (14.3) (13.9)
2540 11552 32368 12084 50717 8374 14484 23602

Gender Male 0.004 0.212 0.289
(44.6) (42.3) (42.4) (57.1) (57.6) (43.0) (42.3) (42.5)
234

Outcome and volume
Of the elective patients, 3.3% (3602/109261) died in hospital within 30 days of admission.
8.6% (9450/109261) had an unplanned readmission within 28 days of discharge from
hospital. 5.9% (6469/109261) had a surgical complication requiring a re-intervention in the
postoperative period. The mean length of stay for elective colorectal cancer resections was
12.7 days (SD 1.76). Volume is considered as a continuous and a categorical variable.
Continuous
In unadjusted analysis, higher consultant team volume was correlated with reduced mean
postoperative mortality [Correlation coefficient=-0.013, p<0.001 (Spearmans Rho test)],
increasing mean readmission rate [Correlation coefficient=0.018, p<0.001 (Spearmans Rho
test)] but reduced LOS [Correlation coefficient=-0.037 p<0.001 (Pearson correlation
following logarithmic transformation)]. Correlation of consultant team volume and mean
reoperation rate [Correlation coefficient=-0.005, p=0.072 (Spearmans Rho test)] did not
meet significance.
Following adjustment in multilevel hierarchical analysis, hospital or consultant team cancer
resection volume was not a significant predictor of postoperative mortality (p=0.160 and
p=0.595 respectively, DIC=28091), reoperation (p=0.419 and p=0.464 respectively,
DIC=48149), readmission (p=0.366 and p=0.322 respectively, DIC=63630) or LOS (Trust
p=0.484 and consultant team p=0.448, DIC= 4267).
235

Categorical
When considered as a categorical variable, we divided caseload into three tertiles according
to the volume of elective colorectal cancer resection performed by the consultant team or
Trust per year giving three groups of approximately equal numbers of consultant teams or
Trusts.
We also assessed the impact of consultant teams performing greater than or equal than twenty
elective and emergency cancer procedures on outcome.
As described in Table 9.6, in unadjusted analysis consultant teams who perform greater than
twenty procedures per year had slightly higher readmission rates but a marginally shorter
LOS. Table 9.6 shows unadjusted postoperative outcome according to volume categories. As
shown in Table 9.6, in unadjusted analysis higher volume consultant teams had a lower 30-
day mortality and shorter LOS but a higher 28-day readmission rate. Higher volume Trusts
had slightly lower reoperation rates and shorter LOS. However, in regression analysis, higher
volume consultant teams and institutions have a shorter LOS as shown in Table 9.7.
236

Table 9.6: Unadjusted outcome of elective colorectal cancer resection according to volume
categories.
Length of in hospital
30 day mortality 28 day Readmission Reoperation stay
N (%) P value N (%) P value N (%) P value Mean (SD) P value
LV 223 (3.9) 0.012 436 (7.7) 0.023 306 (5.4) 0.113 13.47 (1.73) <0.001
Consultant
Team MV 859 (3.1) 2384 (8.7) 1660 (6.1) 13.06 (1.77)
Volume
HV 2520 (3.3) 6630 (8.7) 4503 (5.9) 12.54 (1.75)
0.744 13.33 (1.75) <0.001
Guideline <20 721 (3.4) 0.318 1735 (8.2) 0.009 1243 (5.9)
surgeon
2881 (3.3) 12.57 (1.76)
volume 20 7715 (8.8) 5226 (5.9)
LV 656 (3.4) 0.399 1710 (8.8) 0.725 1229 (6.3) 0.008 13.47 (1.73) <0.001
Institutional
MV 1155 (3.4) 2937 (8.6) 1936 (5.7) 13.06 (1.77)
volume
HV 1791 (3.2) 4803 (8.6) 3304 (5.9) 12.55 (1.75)
237

Table 9.7: Multiple regression of 30-day postoperative mortality, 28-day unplanned readmission, reoperation and length of stay for elective
colorectal cancer resection.
30-day mortality 28-day Readmission Reoperation Length of in hospital stay APE for rectal cancer*
Odds Confidence Odds Confidence Odds Confidence Odds Confidence Odds Confidence
P value P value P value P value P value
Ratio intervals Ratio intervals Ratio intervals Ratio intervals Ratio intervals
Resection right sided* 1.00 1.00 1.00 1.00
type left sided 0.95 0.85 1.06 0.338 1.06 0.99 1.14 0.104 1.19 1.09 1.31 <0.001 1.09 1.08 1.10 <0.001
rectal 1.13 1.04 1.22 0.003 1.45 1.38 1.53 <0.001 1.95 1.83 2.09 <0.001 1.28 1.27 1.29 <0.001
total 1.69 1.43 2.01 <0.001 1.55 1.38 1.74 <0.001 2.03 1.77 2.33 <0.001 1.34 1.32 1.37 <0.001
Surgical Lap vs open
0.66 0.55 0.79 <0.001 1.04 0.95 1.13 0.423 1.27 1.15 1.41 <0.001 0.72 0.71 0.73 <0.001 0.96 0.85 1.09 0.539
Approach approach
Age 1.09 1.09 1.10 <0.001 0.99 0.99 0.99 <0.001 1.00 0.99 1.00 0.001 1.01 1.01 1.01 <0.001 1.00 0.99 1.00 0.002
Charlson 0* 1.00 1.00 1.00 1.00 1.00
score 1-4 1.85 1.63 2.09 <0.001 1.21 1.13 1.30 <0.001 1.16 1.06 1.27 0.001 1.06 1.05 1.08 <0.001 1.04 0.96 1.13 0.379
5 3.32 3.08 3.58 <0.001 1.10 1.05 1.15 <0.001 1.31 1.24 1.38 <0.001 1.09 1.09 1.09 <0.001 0.89 0.85 0.94 <0.001
Carstairs 1* 1.00 1.00 1.00 1.00 1.00
deprivation 2 1.02 0.91 1.14 0.705 0.99 0.92 1.05 0.679 1.01 0.94 1.10 0.378 1.02 1.02 1.03 <0.001 1.12 1.04 1.21 0.002
3 1.14 1.02 1.27 0.022 1.00 0.94 1.07 0.901 1.05 0.97 1.14 0.113 1.06 1.05 1.07 <0.001 1.16 1.08 1.25 <0.001
4 1.21 1.08 1.36 0.001 1.09 1.02 1.17 0.011 1.08 1.00 1.17 0.032 1.09 1.08 1.10 <0.001 1.29 1.20 1.48 <0.001
5 1.35 1.21 1.52 <0.001 1.19 1.11 1.28 <0.001 1.11 1.01 1.20 0.012 1.15 1.14 1.16 <0.001 1.34 1.22 1.48 <0.001
Female vs
Gender 0.61 0.57 0.66 <0.001 0.84 0.80 0.88 <0.001 0.66 0.63 0.70 <0.001 1.00 0.99 1.01 0.976 0.89 0.85 0.94 <0.001
Male
Consultant LV* 1.00 1.00 1.00 1.00 1.00
Team MV 0.90 0.77 1.05 0.194 1.00 0.90 1.12 0.955 0.98 0.86 1.11 0.385 0.99 0.98 1.00 0.187 0.93 0.83 1.04 0.204
Volume HV 0.94 0.81 1.09 0.423 1.01 0.91 1.12 0.827 0.95 0.84 1.07 0.210 0.95 0.94 0.97 <0.001 0.78 0.70 0.87 <0.001
Institution LV* 1.00 1.00 1.00 1.00 1.00
volume MV 0.98 0.89 1.08 0.686 0.99 0.93 1.06 0.790 0.90 0.83 0.97 0.002 0.98 0.97 0.99 <0.001 1.05 0.98 1.13 0.134
HV 0.96 0.87 1.05 0.377 1.01 0.95 1.07 0.795 0.96 0.90 1.03 0.127 0.96 0.95 0.97 <0.001 0.96 0.90 1.03 0.248
* Caseload of rectal surgeon volume refers to volume of procedures for rectal cancer only.
238

Figure 9.1 and figure 9.2 show the variation in mortality and reoperation rates with institution
caseload. Four and ten NHS Trusts are above the upper control limit (corresponding to 3
standard deviations) for mortality and reoperation respectively. For consultant teams, there
are two and six outliers for mortality and return to theatre rates respectively (Figure 9.3 and
figure 9.4). 0.3 Trusts and 2.3 Consultant teams would be expected through chance alone.
239

Figure 9.1: Funnel plot of adjusted 30-day mortality and Trust elective colorectal cancer
caseload.
240

Figure 9.2: Funnel plot of Trust postoperative return to theatre rates and elective colorectal
cancer caseload.
241

Figure 9.3: Funnel plot of consultant team elective colorectal cancer caseload and 30-day
postoperative mortality
242

Figure 9.4: Funnel plot of adjusted consultant team return to theatre rates and elective
colorectal cancer caseload.
243

Is there a relationship between operative volume and rectal cancer surgery?
Rectal procedures
36,714 patients who underwent an elective resection coded to a primary diagnosis of rectal
cancer were included. Of these, 26.1% (9574/36714) had an APE resection. 63.3%
(23224/36714) of rectal cancer patients were coded to an anterior resection. 7.4%
(2722/36714) of patients were coded to a Hartmanns procedure. More patients who
underwent APE were from areas of higher social deprivation [Carstairs score 5 (most
deprived) APE 17.3% (1655/9574), Other procedure 14.8% (4021/27140), p<0.001]. Patients
selected for APE had a lower 30-day mortality and 28-day unplanned readmission rate [30-
day mortality - APE 2.7% (256/9574), Other procedure 3.3% (896/27140), p=0.002, 28 day
readmission - APE 9.9% (948/9574), Other procedure 11.6% (3152/27140), p<0.001].
Patients undergoing APE had a higher return to theatre rate in the postoperative period [APE
10.0% (957/9574), Other procedure 7.8% (2130/27140), p<0.001].
When considered as a continuous variable, increasing consultant team caseload of rectal
surgery and of all elective surgery were associated with reduced APE rate [0.97 per
additional patient caseload (0.95-0.98), p=0.002 and 0.98 per addition 5 total elective patients
(0.97-0.99), p=0.003 respectively]. There was no relationship between total Trust caseload or
Trust rectal surgery volume and APE rate (p=0.421 and p=0.401 respectively).
Table 9.3 shows the number of rectal procedures in each volume category for consultant
teams and Trust when volume is categorised using the tertile approach to both volume.
Lower volume rectal consultant teams and Trusts performed higher volume of APE in the
unadjusted analysis [rLV consultant teams 30.4% (540/1774), rMV consultant teams 28.5%
244

(2768/9710), rHV consultant teams 24.8% (6266/18964), p<0.001, rLV Trusts 27.0%
(1659/6140), rMV Trusts 26.8% (3836/14328), rHV Trusts 25.1% (4079/16246), p=0.001].
Given the likely relationship between consultant team caseload and APE rate, the critical
threshold over which outcome improved was explored. To this end, the impact of the
addition of 5 and 2.5 extra procedures to a given surgeons caseload was compared. Figure
9.5 and figure 9.6 show these comparisons. These figures suggest that 7.5 procedures per
year is the point at which there is a significant difference in APE rate.
In multiple regression analysis of APE versus other surgery for elective rectal cancer patients,
in addition to increased co morbidity, social deprivation, increasing age and male gender,
patients treated by lower volume rectal consultant teams were more likely to undergo APE
than higher volume consultant teams as shown in Table 9.7.
245

volume of surgery (increments of 5).
1.4
1.2
1
Odds Ratio
0.8
0.6
0.4
0.2
0
0-5 vs 5-10 5-10 vs 10-15 10-15 vs 15-20 15-20 vs >20
Volume categories
246

volume of surgery (increments of 2.5).
1.4
1.2
1
Odds ratio
0.8
0.6
0.4
0.2
0
0-2.5 vs 2.5-5.0 vs 5.0-7.5 vs 7.50-10.0 vs 10.0-12.5 vs 12.5-15.0 vs 15.0-17.5 vs 17.5-20.0 vs
2.5-5.0 5.0-7.5 7.5-10 10.0-12.5 12.5-15.0 15.0-17.5 17.5-20.0 >20.0
Volume categories
247

Is there a relationship between total resection workload (i.e. benign and

malignant) and outcome?
Although the cancer resection volume does not appear to be a significant impact on outcome,
does total resection volume a significant impact on outcome? Does a high volume IBD
surgeon who, in consequence, does lower volume of cancer work, have similar outcome to a
high volume cancer surgeon?
In total, 155,169 patients who underwent elective colorectal resection were included. Of these
3.1% (4861/155169) died in hospital within 30 days. 6.1% (9505/155169) experienced a
complication requiring reoperation. Of these patients, 9.3% (14372/155169) required
readmission. The median LOS was 12 days (9-16 days).
Following multiple regression analysis, consultant team volume (for each increase in 5
procedures per year) was an independent predictor [OR 0.96 (0.95-0.98), p=0.001] for lower
postoperative death but Trust volume (for each increase in 10 procedures per year) failed to
predict postoperative death [OR 1.00 (1.00-1.01), p=0.309].
Consultant team and Trust volume were not predictors of reoperation [OR 0.99 (0.98-1.00),
p=0.236 and OR 1.00 (1.00-1.01), p=0.319, respectively] or readmission [OR 1.00 (1.00-
1.01), p=0.257 and OR 1.00 (1.00-1.00), p=0.350, respectively].
Given the relationship between total resection volume and consultant team elective cancer
mortality, figures 9.7 and 9.8 demonstrate the likely cut off threshold for consultant team
248

total resection volume. The cut-off threshold appears to be between 5 and 10 procedures per
year.
To assess whether total caseload is important in determining cancer resection outcome, we
performed a multiple regression model with total resection caseload as a binary variable (less
than or equal to 7.5 or greater than 7.5. A total elective consultant team caseload of greater
than 7.5 procedures per year was associated with reduced postoperative death following
elective colorectal cancer resections [OR 0.80 (0.68-0.94), p=0.002].
249

Figure 9.7: Confidence intervals of odds ratios of 30 day mortality following cancer resection
at incremental increases in total surgical caseload to demonstrate critical volume of surgery
(increments of 10).
1.8
1.6
1.4
1.2
Odds ratio
0.8
0.6
0.4
0.2
0
0.1-10.0 vs 10.1-20.0 vs 20.1-30.0 vs 30.1-40.0 vs 40.1-50.0 vs 50.1-60.0 vs 60.1-70.0 vs
10.1-20.0 20.1-30.0 30.1-40.0 40.1-50.0 50.1 - 60.0 60.1-70.0 70.1-80.0
Volume categories
250

Figure 9.8: Confidence intervals of odds ratios of 30 day mortality following cancer resection
at incremental increases in total surgical caseload to demonstrate critical volume of surgery
(increments of 5).
1.4
1.2
1
Odds Ratio
0.8
0.6
0.4
0.2
0
0.1-5.0 vs 5.1-10.0 10.1-15.0 15.1-20.0 20.1-25.0 25.1-30.0 30.1-35.0 35.1-40.0 40.1-45.0
5.1-10.0 vs vs vs vs vs vs vs vs
10.1-15.0 15.1-20.0 20.1-25.0 25.1-30.0 30.1-35.0 35.1-40.0 40.1-45.0 45.1-50.0
Volume Categories
251

Is volume relationship mitigated in part by structural factors?

Those consultant teams performing less than 7.5 cases per year work in hospitals with a
lower median number of inpatient beds per Trust [873 beds (IQR 571-1138) vs 915 beds
(IQR 662-1196), p=0.036], with a slightly reduced median number of theatres per inpatient
bed [2.16 (IQR 1.76-2.41) vs 2.21 (IQR 1.86-2.51), p=0.024], and slightly lower median
number of critical care beds per inpatient beds [1.90 (IQR 1.59-2.64) vs 1.97 (IQR 1.60-
3.18), p=0.026]. There were no differences in terms of median CT, MRI, USS or fluoroscopy
use (p=0.605, p=0.127, p=0.491 and p=0.156 respectively).
Is there a relationship between surgeon laparoscopic caseload and outcome?

Between 2002 and 2008, 84620 patients underwent an elective colorectal cancer resection.
Of these 7.7% (6554/84620) were selected for the laparoscopic approach. These procedures
were performed by 495 consultant teams who performed between 1 and 29 elective
laparoscopic cancer cases per year with a median of 10 cases per year (IQR 6-15 cases,
n=6554). There was an increase in number of surgeons selecting patients for the laparoscopic
approach from 2002 to 2008. In 2002, 41 consultant teams performed laparoscopic
resections whereas in 2007 there were 398 consultant teams (Figure 9.9).
252

Figure 9.9: Increase in number of consultant teams using the minimal access approach from
2002 to 2008 with dates of publication of randomised control trials and guidelines.
450
400
Number of consultant teams
NICE
350 guidelines
300
250
200 COST study
150
Braga et al
100 Lacy et al
50
0
2002 2003 2004 2005 2006 2007
Year of Surgery
253

Table 9.8 shows the characteristics of the elective colorectal cancer patients (2002-2008)
included in this analysis. As shown in Table 9.9, high volume surgeons operated on more
patients from affluent areas than other surgeon teams. Higher and medium volume surgeons
operated on more patients with rectal disease. The patients were similar in other
characteristics across surgeon volume categories.
254

Table 9.8: Patient characteristics of all patients undergoing an elective colorectal cancer
resection between 2000 and 2002.
Characteristic
Resection type right sided 44527 (28.7)

left sided 29564 (19.1)
rectal 70269 (45.3)
total 10809 (7.0)
Laparoscopic
Surgical Approach 10046 (6.5)
approach
Age Mean (SD) 66.5 (14.0)
Charlson score 0 101353 (65.3)
1-4 14530 (9.4)
5 39286 (25.3)
Carstairs deprivation 1 (least deprived) 30745 (19.8)
2 36319 (23.4)
3 34197 (22.0)
4 29942 (19.3)
5 (most deprived) 23966 (15.4)
Gender Male 82443 (53.1)
255

Table 9.9: Patient characteristic of cancer patients undergoing a laparoscopic elective

colorectal cancer resection between 2002 and 2008 in each volume category.
Low Medium High volume

volume volume
1-8 9-16 >16
procedures procedures per procedures per
per year year year p
n (%) n (%) n(%)
Resection type right sided 843 (38.1) 730 (33.8) 744 (34.1) <0.001
left sided 438 (19.8) 322 (14.9) 323 (14.8)
rectal 884 (40.0) 1067 (49.4) 1093 (50.0)
total 45 (2.0) 41 (1.9) 24 (1.1)
Age 17-54 192 (8.7) 201 (9.3) 199 (9.1) 0.849

55-69 753 (34.1) 741 (34.3) 723 (33.1)
70-79 813 (36.8) 780 (36.1) 786 (36.0)
>79 452 (20.5) 438 (20.3) 476 (21.8)
Charlson score 0 1393 (63.0) 1299 (60.1) 1374 (62.9) 0.143

1-4 251 (11.4) 240 (11.1) 245 (11.2)
5 566 (25.6) 621 (28.7) 565 (25.9)
Carstairs 1 (least deprived) 449 (20.3) 491 (22.7) 527 (24.1) <0.001
deprivation index 2 533 (24.1) 528 (24.4) 542 (24.8)
3 482 (21.8) 465 (21.5) 519 (23.8)
4 376 (17.0) 396 (18.3) 370 (16.9)
5 (most deprived) 370 (16.7) 279 (12.9) 224 (10.3)
Gender Male 1149 (52.0) 1172 (54.3) 1172 (53.7) 0.296

Female 1061 (48.0) 988 (45.7) 1012 (46.3)
256

Of these patients, 2.0% (133/6554) patients died in hospital within 30 days. 7.2% (472/6554)
had a surgical complication necessitating reoperation. 14.2% (930/6487) experienced a
medical complication within 30 days of the procedure and 15.6% (1020/6487) within one
year of the procedure. 9.7% (639/6554) required an unplanned readmission within 28 days.
The median LOS was 8 days (IQR 5-12 days, n=6554). Table 9.10 shows the unadjusted
outcome across volume categories. In unadjusted analyses, lower volume consultant teams
have lower reoperation rates. High volume consultant teams had the lowest medical
morbidity rates with the shortest LOS. Medium volumes teams have the highest medical
morbidity rates. Table 9.11 shows the multiple regression analysis for reoperation, 30 day
medical morbidity, 365 day medical morbidity and LOS. Medium volume consultant teams
had higher medical morbidity rates with high volume consultant teams having shorter LOS
than other providers. There were no statistically significant differences following regression
in reoperation rates across volume providers.
257

Table 9.10: Outcome following elective laparoscopic colorectal cancer resection in each
volume category.
Medium
Low volume High volume
volume
1-8 9-16 >16
procedures procedures procedures P value
per year per year per year
30 day in
2.1% 1.8% 2.2%
hospital 0.515
(46/2210) (38/2160) (49/2184)
mortality
6.1% 7.5% 8.0%
Reoperation 0.044
(135/2210) (163/2160) (174/2184)
30 day medical 13.6% 16.1% 13.3%
0.018
morbidity (296/2175) (344/2138) (290/2174)
365 day medical 14.9% 17.7% 14.6%
0.008
morbidity (324/2175) (379/2138) (317/2174)
9.2% 10.3% 9.8%
Readmission 0.506
(204/2210) (222/2160) (213/2184)
8 days 8 days 7 days
LOS <0.001
(6-12 days) (5-11 days) (5-11 days)
258

Table 9.11: Multiple logistic regression for reoperation, 30 day medical morbidity, 365 day medical morbidity and LOS for patients undergoing
an elective laparoscopic colorectal cancer resection.
Reoperation 30 day medical morbidity 365 day medical morbidity LOS
Odds Odds Odds Relative
95% C.I. p 95% C.I. p 95% C.I. p 95% C.I. p
Ratio Ratio Ratio Risk
0.209 0.057 0.032
Surgeon volume
LV 1.00 1.00 1.00 1.00
MV 0.83 0.66 1.05 0.121 1.16 0.97 1.38 0.109 1.15 0.98 1.37 0.101 0.94 0.90 0.97 <0.001
HV 1.00 0.80 1.26 0.975 0.94 0.78 1.13 0.520 0.93 0.78 1.11 0.394 0.90 0.87 0.93 <0.001
Age <0.001 <0.001
17-54 1.00 1.00 1.00
55-69 2.58 1.64 4.05 <0.001 2.42 1.61 3.63 <0.001 1.11 1.05 1.17 <0.001
70-79 4.70 3.01 7.33 <0.001 4.09 2.75 6.09 <0.001 1.28 1.21 1.35 <0.001
>79 6.81 4.34 10.69 <0.001 5.52 3.67 8.28 <0.001 1.54 1.45 1.64 <0.001
Charlson score <0.001 <0.001 <0.001
0 1.00 1.00 1.00 1.00
1-4 1.13 0.83 1.54 0.424 1.54 1.23 1.93 <0.001 1.55 1.26 1.93 <0.001 1.09 1.04 1.14 0.001
5 1.40 1.14 1.74 0.002 2.34 2.01 2.74 <0.001 2.28 1.96 2.65 <0.001 1.13 1.09 1.17 <0.001
0.009 0.002
Carstairs
1 1.00 1.00 1.00
deprivation index
2 0.96 0.77 1.19 0.695 0.97 0.78 1.20 0.765 1.06 1.01 1.10 0.011
3 1.11 0.90 1.39 0.334 1.17 0.95 1.44 0.146 1.06 1.02 1.11 0.005
4 1.21 0.96 1.51 0.109 1.33 1.07 1.66 0.010 1.11 1.06 1.16 <0.001
5 1.46 1.15 1.85 0.002 1.46 1.15 1.84 0.002 1.19 1.14 1.26 <0.001
Type of <0.001 0.003 0.003
resection right sided 1.00 1.00 1.00 1.00
left sided 1.45 1.07 1.97 0.017 0.75 0.61 0.94 0.011 0.76 0.61 0.93 0.009 1.11 1.06 1.16 <0.001
rectal 2.03 1.61 2.54 <0.001 0.84 0.72 0.99 0.032 0.85 0.73 0.99 0.031 1.25 1.21 1.30 <0.001
total 2.20 1.15 4.22 0.018 2.07 1.03 4.15 0.042 2.01 1.02 3.95 0.044 1.35 1.20 1.51 <0.001
Gender Female vs male 0.75 0.65 0.87 <0.001 0.76 0.66 0.88 <0.001 0.97 0.94 1.00 0.069
Year of surgery 1.07 1.00 1.14 0.038 1.09 1.03 1.17 0.006 0.95 0.94 0.96 <0.001
259

Is there a relationship between caseload and outcome in subspecialist care?

To investigate the impact of surgeon and hospital caseload on outcome following RPC,
patients were categorised according to the volume of primary procedures carried out by their
named consultant team or institution during the study period. In the first instance these
categories were apportioned in two ways as described in the methodology section: categories
A to C and into low volume (LV), medium volume (MV) and high volume (HV). The latter
were assigned to tertiles derived from ranking individual patients.
Table 9.4 shows the number of patients in categories A to C and LV, MV and HV. Table
9.12 shows the unadjusted outcome amongst these volume categories. On multiple Cox
regression analysis, patient age and institutional volume were independent predictors of
failure (Table 8.9 for univariate and Cox regression of failure). The study year in which was
surgery undertaken was not significantly associated with failure on univariate Cox regression
(p=0.220). Table 9.13 shows the multiple linear regression analysis for LOS of patients
undergoing pouch procedures. Higher volume consultant team and hospital volume was a
predictor of shortened length of stay. Figure 9.10 shows a Kaplan-Meier curve
demonstrating differences in adjusted failure over time between provider volume categories
(HV, MV, LV). Figure 9.11 is a funnel plot illustrating the unadjusted failure rates
according to hospital provider volume. There is one institution outside two standard
deviations on the funnel plot.
260
Investigating*the*use*of*Hospital*Episode*Statistics*data*to*measure*variation*in*Performance*and*Quality*in*Colorectal*Surgery*
*
Table 9.12: Outcome of RPC according to institutional volume and surgeon volume
Institutions Surgeons
Low Medium High Low Medium High
volume volume volume A B C volume volume volume A B C
Frequency Frequency Frequency P Frequency Frequency Frequency P Frequency Frequency Frequency P Frequency Frequency Frequency P
(%) (%) (%) value (%) (%) (%) value (%) (%) (%) value (%) (%) (%) value
30 day 10/1964 11/1916 7/1891 2/402 3/1068 23/4301 5/1331 3/1329 3/1218 3/266 2/554 6/3058
mortality (0.5) (0.6) (0.4) 0.684 (0.5) (0.3%) (0.5%) 0.627 (0.4) (0.2) (0.2) 0.806 (1.1) (0.4) (0.2) 0.032
365 day 10/793 15/796 10/806 5/144 3/446 27/1805 17/712 12/836 6/847 5/133 8/298 22/1964
mortality (1.3) (1.9) (1.2) 0.514 (3.5) (0.7) (1.5) 0.050 (2.4) (1.4) (0.7) 0.022 (3.8) (2.7) (1.1) 0.008
Readmission 459/1964 404/1916 406/1891 90/402 247/1068 932/4301 319/1331 335/1329 264/1218 62/266 146/554 710/3058
rate (23.4) (21.1) (21.5) 0.183 (22.4) (23.1) (21.7) 0.577 (24.0) (25.2) (21.7) 0.106 (23.3) (26.4) (23.2) 0.276
Pouch 133/1964 140/1916 99/1891 30/402 70/1068 272/4301 74/1331 78/1329 63/1218 19/266 25/554 171/3058
Failure (6.8) (7.3) (5.2) 0.026 (7.5) (6.6) (6.3) 0.665 (5.6) (5.9) (5.2) 0.745 (7.1) (4.5) (5.6) 0.296
Median Median Median Median Median Median Median Median Median Median Median Median
stay in stay in days stay in days stay in days stay in days stay in days stay in days stay in days stay in days stay in days stay in days stay in days
days (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR) (IQR)
Length of
stay 12 (9-16) 12 (9-15) 11 (9-15) <0.001 12 (9-16) 12 (9-16) 12 (9-15) 0.026 11 (9-16) 11 (8-15) 11 (9-15) 0.004 13 (9-19) 11 (9-15) 11 (9-15) <0.001
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Table 9.13: Linear regression analysis for the logarithmic transformation of length of stay
(LOS) with institutional and surgeon volume considered separately for pouch surgery
Institution volume Surgeon volume
95% Confidence
OR p value OR 95% Confidence interval p value
interval
Gender
Female (compared with male) 0.99 0.97 1.02 0.605 0.99 0.96 1.02 0.543
Diagnosis
UC (reference)*
Malignant disease 1.00 0.95 1.05 0.868 0.99 0.93 1.05 0.687
Crohns disease 1.01 0.92 1.10 0.899 0.97 0.87 1.08 0.582
Benign disease 0.98 0.93 1.03 0.426 0.99 0.92 1.05 0.656
Other diseases 0.96 0.92 1.00 0.039 0.97 0.93 1.02 0.305
Age cohort
Age <17 (reference)*
Age 17- 39 years 1.06 0.99 1.14 0.078 1.10 1.00 1.20 0.040
Age 40-59 years 1.19 1.11 1.28 <0.001 1.23 1.13 1.35 <0.001
Age >59 years 1.30 1.20 1.34 <0.001 1.33 1.21 1.48 <0.001

Charlson 2 (reference)*
Charlson 3 1.23 1.12 1.34 <0.001 1.36 1.22 1.53 <0.001
Quintile of deprivation
(Carstairs index)
1 (reference) least deprived*
2 1.02 0.98 1.06 0.380 1.01 0.97 1.06 0.559
3 1.10 1.06 1.14 <0.001 1.08 1.03 1.13 0.002
4 1.09 1.04 1.13 <0.001 1.09 1.04 1.15 0.001
5 Most deprived 1.13 1.08 1.17 <0.001 1.14 1.07 1.20 <0.001
6 Unclassified 1.06 0.85 1.31 0.623 1.01 0.68 1.52 0.951
Discharge Year 0.98 0.98 0.98 <0.001 0.97 0.96 0.98 <0.001
Provider Volume/Consultant
team volume
LV (reference)*
MV 0.96 0.93 0.99 0.006 0.92 0.88 0.95 <0.001
HV 0.93 0.90 0.96 <0.001 0.93 0.90 0.97 0.001
*odds ratios and confidence intervals have been exponentiated after regression analysis.
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Figure 9.10: Kaplan Meier curve showing variation in failure rates according to institutional
volume groups
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Figure 9.11: Funnel plot showing provider volume and failure rates following RPC
100
90
80
70
Percentage pouch failure rate
Data
60
Upper 3SD
50 limit
Upper 2SD
limit
40
30
20
10
0
0 100 200 300 400 500 600
Provider volume
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The impact of very high and low volume groups
To examine further the role of volume on outcome, we studied the differences in hospitals
with very low ( 1 /year) and very high ( 12/year) volumes (ExtLV and ExtHV). The
failure rate was significantly higher amongst patients treated in very low (7.8%) compared
with very high (5.3%) volume centres on both univariate [ExtLV centres (reference) p=0.032
ExtMV centres odds ratio 0.81 (CI 0.53-1.24, p=0.333) ExtHV odds ratio 0.61 (CI 0.38-0.96,
p=0.034)] and multiple Cox analyses [p=0.039]. On univariate analysis, however, low
volume centres were not associated with higher 30-day mortality, 365 day mortality, LOS or
the readmission rate (p=0.618, p=0.490, p=0.757, p=0.546 respectively).
Summary
This chapter explores the role of surgeon and institution volume in determining postoperative
outcome in colorectal surgery in the England. Chapter 6 demonstrated marked variation in
activity amongst surgeons. This chapter aimed to explore whether these differences in
activity translate into differences in outcome. In addition, it aims to differentiate whether it is
the total caseload that is important or whether only the cancer caseload needs to be accounted
for. Caseload has been examined previously using many different methodologies. This
chapter seeks to establish which of these methodologies is the most useful means of
examining volume. If caseload is significant, is it significant at the surgeon or the hospital
level and what is the tipping point underpinning the volume outcome relationship? Finally
we aimed to assess whether the volume outcome relationship is present in more specialised
surgery such as rectal surgery, restorative proctocolectomy and laparoscopy.
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Following adjustment in multiple regression analysis, there were no differences in outcome
across consultant team or institution cancer resection caseload in terms of postoperative
mortality, reoperation rate or readmission rate when colorectal cancer resection volume was
considered. The absence of such a relationship held true irrespective of the methodology
used to examine caseload. Higher volume consultant teams had a shorter LOS. Though
higher volume Trusts in unadjusted analysis had a shorter LOS, this was not significant
following adjustment.
Higher consultant team total resection volume is associated with improved postoperative
mortality and reduced LOS following cancer resection but not with other measures such as
reoperation and readmission. The tipping point or cutoff appears to be low an approximately
7.5 elective resections per year (Figure 9.8). Pouch and rectal surgery appear to have a
relationship with caseload with higher volume pouch centres having lower pouch failure rates
and consultant teams performing less than 7.5 rectal cancer resections per year having lower
APE rates. No relationship was evident between laparoscopic cancer outcome and
laparoscopic caseload.
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Chapter 10- Discussion
Main findings
This thesis has described variation in colorectal surgery across patients and providers at
structure, process and outcome levels and demonstrated that it is feasible to measure new
perioperative outcome measures such as reoperation, and longer term measures such as
adhesion and pouch failure rates. The aim of describing such variation and defining potential
quality measures is to identify ways of quality improvement and the extent to which the HES
dataset can be used for such purposes. Increasing individual surgeon and institutions
caseload is one possible way of improving quality. This thesis explores the role of volume in
determining postoperative outcome and variation in process factors to identify areas in which
this may or may not be an effective strategy. Volume appears to play a role in determining
outcome in more specialised surgery such as pouch surgery. When examining short-term
postoperative outcome such as reoperation and mortality following colorectal cancer
resection, the relationship is less clear. It is likely that beyond a small number of resections,
the addition of extra cases confers no further short term benefits. This thesis has
corroborated previous research suggesting that higher volume centres perform fewer APE
with the threshold being approximately 7.5 elective rectal resections per year per consultant
team. Though centralising services has other benefits, indiscriminately increasing caseload
may not translate into tangible improvements in surgical quality. Finally, alongside other
established measures, such as mortality, reoperation is a possible measure of quality
following colorectal resectional surgery.
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Role of caseload in determining outcome
We have seen significant variation across providers in terms of process measures such as
APE rates and use of laparoscopy and outcome including reoperation rates and pouch failure.
Such variation in an equitable healthcare system such as the NHS is undesirable and steps
should be focused on improving quality and reducing this variation. One suggested means of
improving patient outcome is to increase a providers caseload, either at an institutional or
surgeon level, and therefore through increased experience improve outcome. However, this
may involve not only considerable restructuring of the way we deliver surgical care but also
increased inconvenience to patients such as longer distances to travel, losing the association
and relationship with their local hospital and increasing numbers leading to a strain on
existing stretched infrastructure in tertiary hospitals functioning at maximum capacity. It is
important, therefore, to have evidence of the potential efficacy of such a change in policy
prior to increasing caseload. The value of centralization and increasing caseload has been
demonstrated in vascular surgery (Holt et al., 2009b, Holt et al., 2007a) and in other general
surgical specialties such as for oesophagectomy and hepatobiliary surgery (Finks et al., 2011)
but does such an association exist for colorectal surgery in the UK and for which procedures?
There is some evidence in the UK regarding the impact of volume on outcome in colorectal
suregry. As stated in Chapter 9, Borowski and colleagues in two papers explored the impact
of surgeon and hospital volume on outcome following colorectal cancer resection (Borowski
et al., 2010, Borowski et al., 2007). Both of these studies used data from the Northern Region
Colorectal Cancer Audit Group registry. In the earlier work published in 2007, the authors
designated a high volume surgeon as one performing greater than 18.5 emergency and
elective colorectal cancer procedures per year (Borowski et al., 2007). Higher volume
surgeons were more likely to perform potentially restorative surgery for rectal cancer [OR
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1.53 (1.10-2.12), p=0.012]. Hartmanns procedure was considered as nonrestorative.
Following elective resection, higher volume surgeons had a significantly lower mortality [OR
0.58 (1.06-1.90), p<0.001]. No such association was seen for emergency surgery. Though
there was no association with anastomotic leak when volume was considered as a categorical
variable, when volume was analysed as a continuous variable, increasing volume was
associated with reduced leaks [OR 0.91 per ten patients (0.83-1.00), p=0.049]. Higher
volume surgeons were also more likely to be colorectal specialist. In the more recent study
by Borowski and colleagues published in 2010, high volume surgeons were those that
performed more than 40 procedures per year (Borowski et al., 2010). High volume
institutions were categorised as those performing annually more than 109 procedures per year
(Borowski et al., 2010). In this second study, such very high volume surgeons were found to
have reduced anastomotic leak rate [OR 0.59 (0.37-0.93), p=0.024] and reduced perioperative
death [OR 0.66 (0.51-0.85), p=0.002] compared with low volume surgeons. There were no
differences in longer term outcome. Smith and colleagues examined data from the Wessex
registry over a three year study period. Specialisation, as defined by membership of the
ACPGBI, was highly correlated with volume of colorectal cancer surgery (Smith et al.,
2003). The authors concluded that specialisation played more of a role in determining
outcome than volume. Volume and specialisation were not included, however, in the same
model. It is therefore difficult to unpick from this study whether volume or specialisation is
the predominant factor. Morris and colleagues explored the use of APE following rectal
cancer excision and specialisation using the Northern and Yorkshire cancer registry dataset
from 1998 to 2005 (Morris et al., 2011a). They employed a cut-off of seven rectal cancer
cases per year to define a high volume surgeon. These high volume surgeons were
considered as specialists. In this study the annual median rectal cancer caseload was two
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cases per year with only 76 of the 276 included consultants meeting the threshold of seven
cases per year. There was a 5mm difference in tumour height in APEs operated on by
different groups with lower tumours being operated by the higher volume specialists. Little
has been done in the UK to explore the relationship between volume and more specialied
colorectal surgery such as pouch surgery.
This is the first study to examine nationally the role of volume in England in determining
outcome following elective colorectal resection for cancer and for all diagnoses. We
examined nationally the role of caseload in determining APE rate and sought to begin to
provide an evidence base for a minimum threshold of rectal surgery. Furthermore, we looked
at the role of volume in laparoscopic colorectal surgery. Finally we examined the impact of
caseload at an institutional and consultant team level on outcome following restorative
proctocolectomy. This is the first worldwide study to examine such a relationship.
Volume and colorectal resection
In previous international literature, the finding of an association between mortality and
surgeon volume has been mixed with some studies finding a similar correlation as
demonstrated in this study while other studies fail to find a volume outcome relationship
(Schrag et al., 2003, Hannan et al., 2002, Callahan et al., 2003, Rogers et al., 2006). A
systematic review suggested that there was evidence for colonic cancer but not in studies
examining rectal or colorectal outcome (Iversen et al., 2007). Given the ambiguity in the
literature, the current study offers an important addition to the volume outcome debate. The
definition of a high volume surgeon or institution in any branch of medicine is problematic
with no clear consensus across the literature as to what should constitute a high volume
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practitioner or institution. Guidance has been offered by the ACPGBI in relation to cancer
work but not for benign pathology (ACPGBI, 2007). Studies from the United States
examining caseload tend to have much lower numbers considered as high volume than
research from elsewhere. (Rogers et al., 2006, Boudourakis et al., 2009, Billingsley et al.,
2008, Schrag et al., 2003). Studies have wide variation in the thresholds chosen for each
volume category. For the purposes of this thesis, volume was interrogated using several
different statistical and clinically meaningful ways. The Deviance Information Criterion
(DIC) was used to compare multilevel logistic regression models for 30 day mortality and
reoperation. The model with the smaller statistic was chosen. The DIC statistic was
proposed by Spiegelhalter and colleagues to be the Bayesian equivalent of the Akaike
Information Criterion Statistic (AIC) (Spiegelhalter et al., 2002). The model with the lowest
DIC statistic included a tertile approach to volume. This gave three roughly equal groups of
providers (institutions and surgical teams). The upper limit of a high volume surgical team
was 20.7 cases per year. This included only elective cancer cases. Furthermore it only
included primary resections so further resections in a subsequent year within the dataset were
excluded. Though a level of 20.7 cases is seemingly low to be a high volume surgeon, overall
elective colorectal cancer cases constituted 111023 cases, less than half of the dataset so the
true overall volume of these consultant teams may be more in the region of at least 41 cases
when elective and emergency practice is considered or appoximately 28 cancer resection.
This level is in fact higher than the 18.5 elective and emergency cases threshold set by
Borowskis earlier work (Borowski et al., 2007). When colorectal cancer cases were looked
at in isolation, no relationship was found between surgeon volume and outcome even if
volume was considered as a continuous variable. However, when total elective caseload i.e.
for all diagnoses was considered as a continuous variable, higher volume surgeons did appear
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to have an improved 30 day mortality rate. The tipping point appears to be quite low at 7.5
procedures per year. Similar methodology to attempt to define a tipping point for thresholds
in the volume outcome debate has been employed previously by Ananthakrishnan and
colleagues and Ross and colleagues (Ananthakrishnan et al., 2008, Ross et al., 2010).
Ananthakrishnan examined outcome in patients admitted with IBD from the Nationwide
dataset in the US (Ananthakrishnan et al., 2008). They use the same methodology used in this
study as a sensitivity analysis in IBD. Ross and colleagues examined the role of caseload in
determining mortality following myocardial infarction, heart failure and pneumonia (Ross et
al., 2010). They sought to define a high volume institution through the addition of 25 cases
and assessing where additional cases made no further impact on outcome.
In England the lack of an apparent volume outcome relationship when cancer alone is
considered may reflect the working practices in this country such as elective colorectal cancer
surgery being increasingly provided by colorectal specialists (Morris et al., 2007b) or the
increasing influence of the multidisciplinary team in surgeon decision making (Augestad et
al., 2010). Chapter 6 demonstrated an increase in resection activity amongst colorectal
resection surgeons suggesting that there has been some organic centralisation of services.
Chapter 8 does demonstrate significant variation in outcome from elective colorectal cancer
surgery across NHS Trusts and surgeons in England as shown in the funnel plots, Figures 9.1
to 9.5. There are outliers at both low and high volumes suggesting that there are other
differences in providers not explained by volume alone. Centralisation of services may have
unwanted consequences such as impact on emergency services and training. It is also not
clear what the appropriate caseload is to maximise the benefits and reduce these possible
unwanted effects of centralisation. This thesis has attempted to answer this question by
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examining the total volume of surgery but this may be too simplistic an approach. It maybe
that there are added longer term oncological benefits of increasing caseload that have not
been assessed in this study. Indiscriminate centralisation of services may not, however,
produce improvements in quality. It may be more beneficial to increase caseload amongst
those high performing providers. Centralisation to those providers who already demonstrate
good outcome may combine the benefits of increasing caseload with technical and non
technical proficiency to improve quality and outcome. Though a relationship was not
apparent with colorectal cancer resection, the impact of caseload may be more apparent in
newer techniques or for more specialised procedures. Therefore, the role volume was
examined for laparoscopic colorectal surgery and restorative proctocolectomy as a more
specialised procedure.
Volume and Laparoscopy
High volume laparoscopic consultant teams were associated with a shorter length of stay [OR
0.88 (0.85-0.91), p<0.0001] when compared with lower volume consultant teams. In this
analysis, low volume was considered as those that performed less than 7 procedures per year
and high volume teams were those that performed more than 12 procedures per year. These
numbers reflect practice in England. Larson and colleagues using data from the COLOR
study used the cut-off points of five and ten procedures per year to define a low volume and
high volume surgeon respectively (Larson et al., 2008). The latter study only examined
outcome from colonic surgery and was limited to those patients that were enrolled in the trial.
Therefore those surgeon thresholds were probably artificially lower than the true caseload of
the included surgeons. Even assuming the thresholds used by Larson and colleagues were
higher than those used in this study, they still did not demonstrate an impact of volume on
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outcome following laparoscopic surgery. Yasunaga and colleagues examined volume in
terms of the total number of laparoscopic colectomies performed throughout the career of the
surgeon (Yasunaga et al., 2009). Therefore, it is difficult to draw comparisons with the
current study. In Yasunagas study even surgeons performing greater than 200 procedures
during their career did not have lower postoperative complications.
The current study has, however, demonstrated differences in the case mix of differing volume
surgeons. Low volume consultant teams performed more right sided and left sided resections
than other volume surgeons. Laparoscopic rectal resections are technically more challenging
than colonic resections with a higher postoperative complication rate. The preference for left
and right sided resection may be due to low volume surgeons selecting the technically easier
cases for the laparoscopic approach. This may explain why medium volume surgeons
demonstrated the highest medical morbidity following surgery. In effect, medium volume
surgeons may not be as selective as the lower volume surgeons. As the data for this study are
derived from an administrative database, scoring of the complexity of surgery is not available
or feasible. The analysis has been risk adjusted for type of resection and to an extent for
patient comorbidity, but cancer stage is not available on this dataset.
Volume and restorative proctocolectomy
The median volume of pouch procedures carried out in England per year by individual
surgeons was extremely small. Approximately half of all procedures were performed at
centres that had carried out 22 or fewer operations during the twelve-year period of the study.
Moreover, ninety percent of the surgeons performing these complex operations had carried
out approximately two procedures per year (20 procedures over eight years).
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These findings are in line with the results of the recent IBD audit in England reported by the
UK IBD Audit steering group (IBD Audit, 2007). This body had suggested that hospitals
with a low volume of pouch surgery should consider referring to hospitals with a larger
volume. The present study has, in addition, demonstrated an increase throughout the study
period in the number of low volume hospitals performing pouch surgery (Figure 6.4). It has
also highlighted differences in case selection amongst surgeons with varying caseload in
terms of age and diagnosis. Most importantly a high hospital caseload is associated with a
lower adjusted failure rate. This finding supports the work by Kennedy and colleagues who
using Canadian administrative datasets, found that large surgical caseloads (defined as low
volume 10 procedures, medium volume 11-100, high volume>100 over approximately 6.5
years in this study) were associated with reduced reoperation and failure rates (Kennedy et
al., 2006).
In this study we used three different approaches for categorising the caseload of an institution
or surgeon. The first two were based on statistical techniques to create three groups of
providers or patients respectively. The procedure thresholds obtained using these statistical
approaches were small and may not have adequately discriminated between higher volume
more specialised and lower volume centres.
For these reasons we also used a more pragmatic approach to examining volume. From a
clinical standpoint this was a much more intuitive way of analysing the apparent benefits of
higher volume more specialised centres and surgeons. However, there was no a priori
evidence for the chosen cut off points but it resulted in the observation that failure was
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associated with lower volume centres irrespective of whether statistical or clinical thresholds
were used to define institutional volume.
Significant differences in case selection amongst high and low volume providers were
observed. Low volume providers (those in Category A) operate on more patients with
malignancy and Crohns disease than other providers. Importantly, these differences may not
only reflect surgeon experience but also the experience of others such as histopathologists in
establishing the correct preoperative diagnosis and multidisciplinary decision-making.
The study has found clear differences in outcome between different volume providers
following pouch surgery in terms of failure at an institutional level and one year mortality at
a surgeon level. The relative risk reduction of pouch failure between LV and HV providers
was 27% on adjusted analysis. When extremes of volume are considered, this increases to
39%. The absolute reduction in the failure rates between the LV and HV categories (6.8%
and 5.2% respectively) is small. In such a procedure as RPC, function is extremely important
with failure being the extreme endpoint of poor function. Thus small differences in failure
rates may reflect large differences in function in patients operated by institutions with varying
caseloads.
Given the complexity of case selection for pouch surgery, the procedure itself and subsequent
care, it might seem reasonable that these patients receive subspecialist expertise. Various
studies have suggested that patients undergoing colorectal surgery for both inflammatory
bowel disease and colorectal cancer at high-volume centres demonstrate better outcomes
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(Birkmeyer et al., 1999, Hannan et al., 2002, Melville et al., 1994, Porter et al., 1998).
Although centralization has not formally occurred in colorectal surgery, the UK IBD audit
group recommended that low-volume centres should refer complex procedures, such as
pouch surgery, to high volume centres (IBD Audit, 2007). The increasing reliance on the
volume-outcome relationship is being used to drive quality improvement via
subspecialisation. Given the relatively small numbers of RPCs performed annually in
England and the small number of very high volume centres combined with the proposed
establishment of recognised inflammatory bowel disease units, adequate training will become
increasingly difficult for surgical trainees. This aspect will need to be allowed for and
integrated into any proposals for centralising surgical services. It may be that centralisation
may be a more effective means of improving quality for more specialised procedures such as
restorative proctoclectomy. However, further work is needed to examine the relationship
between caseload and elective cancer oncological outcome.
The role of caseload in determining postoperative outcome and process factors appears to be
more magnified for subspecialist surgery. Increasing volume per se may not have the desired
effect on improving outcome across colorectal surgery. Prior to indiscriminate centralisation
further evidence is needed to support such a change in general colorectal services. There may
be other global ways to use data such as HES to improve the quality of care.
Quality improvement
Increasing volume is one possible way of improving quality but may not be effective across
the breadth of colorectal surgery. Other possible approaches include national and
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institutional performance benchmarking. A system similar to NSQIP would be feasible if data
accuracy can be assured. Some argue that as the data begin to be used to benchmark quality,
it will consequently improve as institutions submit more accurate data to meet the need to
demonstrate quality. Methodology such as that proposed by this research could be used as
part of this benchmarking. Caution should be exercised in public reporting of data pending
further ratification of risk adjustment methods and data accuracy.
Centralisation to centres of excellence may be an alternative means of improving quality
rather than indiscriminate centralising to all higher caseload units. Funders of healthcare
will need to establish criteria for defining a centre of excellence and then concentrate
referrals to these institutions (Birkmeyer and Birkmeyer, 2006). This may be possible under
the proposed changes to the NHS. HES data may be used to form one part of the assessment
if data accuracy can be assured. Alternatively, pay for performance initiatives reward high-
performing institutions and potentially penalise those where service quality is substandard
(Birkmeyer and Birkmeyer, 2006). These systems have been already suggested in England
with the proposal to withhold payment for unplanned readmissions. Through monetary
incentives, these initiatives may provide a stimulus for rapid quality improvement. It should
be noted however that there is, as yet, limited evidence to show that this method leads
directly to improved quality. There is some overlap between pay for performance and the
centre of excellence model. The Leapfrog programme, discussed previously, uses a
combination of the centre of excellence and pay for performance strategies (Leapfrog
Group, 2007). As stated, this type of programme utilises evidence-based hospital referral to
enhance service quality. In addition, it uses a range of other process and outcome measures
such as thromboembolic prophylaxis, safety culture and pressure ulcer rates to determine
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reward payments. Hospitals opt to participate in this type of programme to attain referrals and
rewards. These programmes require clear definition and universal consensus regarding the
criteria used to denote high performance.
Another strategy is the pay for participation model. It provides a monetary incentive for
providers to enrol in a quality improvement programme. A successful example of this type of
initiative was the Michigan Surgical Quality Collaborative (Englesbe et al., 2007), that
instituted a data-based quality improvement programme. The costs to the funder of this
incentive based programme are projected to be recouped through a modest reduction in
complications. Englesbe and colleagues made a successful business case for the pay for
participation programme, estimating that only a 1.8% reduction in complication rates was
sufficient to offset the programme costs (Englesbe et al., 2007). Providers opt to participate in
the data based quality improvement programmes, the costs of which are met by funders. The
provider benefits through improving quality and patient care in their organisation and the
funder reaps long-term benefits through reduced costs from lower complications rates. This
model does, however, have disadvantages. Certainly, it is difficult to organise and often
requires one funder to possess a dominant market share for the business case to be viable
(Birkmeyer and Birkmeyer, 2006). Of note, in these initiatives, individual provider data are
not made available for either payer or public consumption (Englesbe et al., 2007). In
addition, this model would require a complete overhaul in the way in which NHS services are
delivered.
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The proposed revalidation of clinicians through the General Medical Council may offer
benefits to patients. A need to demonstrate satisfactory outcome may actually improve
outcome through audit.
All these strategies require data and defined measures of quality. This thesis, therefore,
sought to explore methodologies that could be used to derive new measures from HES data
and assess HES data utility and versatility.
New outcome measures
Reoperation as a potential quality marker
The reoperation rates of 6.5% (7.0% following an emergency resection and 6.2% following
an elective resection) described in this thesis are consistent with those found by previous
studies from the American SEER and the National Surgical Quality Improvement Programme
data (Morris et al., 2007a, Billingsley et al., 2008, Bilimoria et al., 2008b). Morris and
colleagues, in a study of SEER-Medicare linked data, found that 5.7% of colon cancer
resections and 6.5% of rectal resections required a postoperative procedure (Morris et al.,
2007a). Male gender also conferred an increased risk of reoperation in the study by Morris
and colleagues. Cancer stage in this study was not a significant predictor of reoperation
following adjustment. Merkow and colleagues examined 23098 elective patients undergoing
a colorectal procedure recorded on the ACS NSQIP database. 5.7% of patients required a
reoperation (Merkow et al., 2009). In this study the range of reoperation rates amongst
hospitals varied from 0% to 38.1%. Using a similar ACS NSQIP dataset, Bilimoria and
colleagues examined reoperation rates following elective laparoscopic and open colonic
280

cancer resections (Bilimoria et al., 2008b). Reoperation rates (5.5% for a laparoscopic and
5.8% for an open resection, p=0.79) were similar in the laparoscopic and open groups.
Bilimorias study, however, only included elective colonic cancer resection and excluded
other indications for surgery and emergency presentations. Delaney and colleagues
examining NSQIP data found a similar small but statistically significant increase in
reoperation rates following laparoscopy (Delaney et al., 2008).
The methodology to derive reoperation rates from the UK administrative dataset employed in
this study reflects a valid way of investigating postoperative outcome. Data from individual
hospitals are submitted centrally from local institution administrative computer systems.
Thus these systems could be potentially used for real time monitoring of postoperative
outcome in a reproducible and feasible way through existing institution databases. As
clinical coders enter the data and not the clinical team caring for the patient, the data have a
degree of objectivity. Moreover, the data represent an opportunity to report the outcome of
all resections performed by all surgeons in the entire country.
Increasing socioeconomic deprivation is associated with higher reoperation rates and has
shown to be a factor in determining the type of surgery that patients undergo. As shown in
table 9.7 and corroborated by work by Tilney and colleagues and Morris and colleagues,
patients from areas of increased social deprivation are more likely to undergo an
abdominoperineal resection than other patients (Tilney et al., 2009, Morris et al., 2008).
Tilney and colleagues, from HES data, demonstrated that though the APE rates were
reducing over time, patients from more socially deprived areas were 50% more likely to
undergo an APE than those from the least socially deprived areas (Tilney et al., 2008).
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Furthermore, using NBOCAP clinical registry data, Tilney and colleagues showed that
patients from the most socially deprived areas had an excess of APEs (Tilney et al., 2009). In
the study by Tilney et al, there were no differences in APE rates between patients with Dukes
C tumours and those with Dukes A and B. Social deprivation has also been correlated with
poorer survival after treatment of colorectal cancer especially following surgical resection
(Wrigley et al., 2003, Faiz et al., 2009). These disparities in outcome may reflect severity of
disease at presentation or other unquantified characteristics but some of this variation will
reflect inequalities in access to care according to socioeconomic background. The observed
increase in reoperation rates with increasing socioeconomic deprivation suggests that further
work is required to redress this inequality through quality improvement and early detection of
disease.
Although older patients have been shown to have poorer postoperative mortality (Faiz et al.,
2011a) and increased morbidity such as postoperative medical complications, older patients
have not been found to have higher reoperation rates (Bentrem et al., 2009). Bentrem and
colleague found that, despite increased medical morbidity and mortality in those over 75
years of age, reoperation rates did not increase in the older age group (Bentrem et al., 2009).
This may reflect increased rates of stoma formation to avoid the disasterous consequences of
an anastomotic leak, more conservative surgery or a reluctance of surgeons to take older
patients back to theatre following surgery. Older patients may not be fit for a further
procedure or may die before returning to theatre following a complication. Further research is
required to target decision-making amongst surgeons treating patients in this age group.
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Reoperation is associated with other markers of poor postoperative outcome such as mortality
and prolonged LOS. Patients with a complication necessitating a reoperation are three times
more likely to die in the postoperative period than other patients. Furthermore, reoperation is
associated with poorer long term outcome including higher risk of local recurrence and lower
overall survival (Mirnezami et al., 2011). An anastomotic leak following rectal resection
increased the risk of local recurrence by 100% [OR 2.05 (1.51-2.8), p=0.0001](Mirnezami et
al., 2011). One study found that surgical complications had long-term effect on quality of life
(measured at one year postoperatively) following colorectal cancer resection (Anthony et al.,
2003). This study however included medical and surgical morbidity in the definition of a
complication. Further work is needed to establish whether a reoperation in itself leads to
poorer postoperative quality of life. We have demonstrated that patients requiring a return to
theatre for complication have increased risks of adhesions and incisional hernia. Patients
experiencing such a complication are twice as likely to require adhesionolysis and have a
50% increased risk of having an incisional hernia repair. This correlation has been
demonstrated previously (Hesselink et al., 1993, Parker et al., 2001, Rotholtz et al., 2008).
From this work it is suggested that reoperation is a possible measure of surgical quality and is
feasible to measure from HES data. The incidence is in line with published literature. In
addition, chapter 8 demonstrates variation at NHS Trust and Consultant team level. Using
funnel plots, significant outliers (for both high and low rates) were identified for reoperation.
At a patient level, reoperation correlates with other markers of poor outcome including
mortality. Certainly a reoperation rate of zero is not desirable. If reoperation was used in
isolation to measure performance of Trusts and Surgeons then it may be tempting to not
reoperate where clinically indicated. Reoperation should therefore be taken as one of a
283

toolkit of measures alongside other measures such as mortality. Prior to its use as an
individual measure of performance, further understanding of what range of reoperation is
acceptable is required. In addition, data quality must be assured. This may be performed
through an iterative process where Trusts and surgeons are given the opportunity to correct
their individual data prior to any publication. Finally, the risk adjustment afforded by clinical
registries and administrative datasets is inadequate. Therefore, a high outlier status should
serve as a prompt for further scrutiny rather than a definitive label of poor performance.
The methodology underpinning this measure is widely applicable to other surgical
specialities. If coding accuracy can be assured reoperation rates, along with existing quality
measures such as mortality, could offer a powerful means of benchmarking the quality of
surgical care.
As demonstrated by reoperation, it is possible to measure short term complications. Chapter
8 also explored the feasibility of measure medium term outcome measures. This is the first
population-based epidemiological survey to examine the national rates of incisional hernia
and adhesions following colorectal resection in England. This study suggests that use of the
minimally invasive approach in colorectal surgery results in fewer adhesion-related
admissions and reoperations with comparable rates of incisional hernia following colorectal
surgery between these approaches. At an institutional level, there was less variation in these
medium measures than in short term outcome measures such as reoperation.
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The occurrence of adhesions and incisional hernia in this study are similar to the findings
from other studies. The overall incisional hernia rates of 4.7% are in keeping with data from a
recent Cochrane review (Kuhry et al., 2008). The rate following laparoscopic surgery of 4.2%
is in the centre of the range in published series (0.55-7%) (Duepree et al., 2003, Lumley et
al., 2002, Regadas et al., 1998, Skipworth et al., 2010). The high admission rate for adhesions
(8.1%) and adhesiolysis rate (3.5%) reiterate the importance of this issue as recognised by
other authors (Bhardwaj and Parker, 2007, Parker et al., 2004, Parker et al., 2007). The rate
of post-operative adhesions requiring admission or operation rate in our population-based
study was higher than the 2.7% reported by the CLASICC group (Taylor et al., 2010). The
CLASICC study was underpowered to analyse these outcomes. One advantage of using HES
data is that it includes all patients admitted to NHS hospitals and thus it allows analysis of a
large number of patients. Furthermore, it includes all surgeons, not just those enthusiasts that
submit data to clinical trials. Those patients undergoing emergency surgery, unsurprisingly,
have increased risks of adhesions and incisional hernia (Hesselink et al., 1993, Parker et al.,
2001, Rotholtz et al., 2008).
Rectal procedures may be at increased risk of developing incisional herniae. Desouza and
colleagues (Desouza et al.) compared the occurrence of incisional hernia following
laparoscopic colorectal surgery with differing types of specimen removal. They found that
Pfannensteil incisions significantly reduced the risk of incisional hernia when compared to
midline extraction wounds and conventional open laparotomy. They undertook, however, all
their minimally invasive surgery using the hand-assisted approach, which theoretically may
obviate the reduced tissue handling benefits of the laparoscopic approach. In addition, they
excluded port-site and parastomal hernias, which may significantly have biased their
285

outcomes. As opposed to an intention to treat basis, they coded all their converted cases to
the conventional midline laparotomy approach.
The increasing risk of incisional herniae and adhesions over the period of this study merits
further investigation. The increased adhesion rate may be due to more accurate clinical
coding but the problem of adhesions following colorectal surgery has been increasingly noted
in the surgical literature (Menzies and Ellis, 1990, Parker et al., 2007). Parker and colleagues
issued a call for action on adhesions to the colorectal community and advocated adhesion
reduction strategies including the use of anti-adhesion agents (Parker et al., 2007). Whilst this
study could not make an assessment of the anti-adhesion strategies used, the evidence
surrounding the impact of the anti-adhesion meshes and solutions requires further
elucidation. A systematic review has suggested that some solutions may reduce the
development of adhesions postoperatively (Kumar et al., 2009). Little work has however
investigated the long term development of clinically relevant adhesions or necessity for
admission with adhesional bowel obstruction. Further work is necessary to evaluate the
longer term clinical benefits of such anti-adhesion strategies.
Pouch failure
Individual procedures may have more pertinent outcome measures than those that are
applicable to general colorectal surgery. Pouch failure is an important end point for patients
undergoing such surgery. Derivation of such a measure demonstrates the feasibility of
examining more long term outcome measures as well as tailoring the measures to individual
procedures on HES.
286

The failure rate observed compares favourably with the rates of 3-12 percent reported from
large single centre case series (Fazio et al., 1995, Tulchinsky et al., 2003, Delaney et al.,
2003, Chapman et al., 2005, Gemlo et al., 1992, Setti Carraro et al., 1994). Despite
refinement in surgical technique over time, failure did not significantly decrease during the
study period. The period of follow up may have been too short to capture any such trend, as
improvement of technique and experience in the more recent years may not be reflected in
reduced failure for some years to come. In an analysis of patients entered on the UK
National Pouch Registry, Tekkis and colleagues found that failure increased from 5.3% at
five years to 16.1% at ten years follow up (Tekkis et al., 2009).
The diagnosis was not found to be a predictor of pouch failure, although it should be stated
that there is not a code in the ICD-10 classification for indeterminate colitis. This may be
coded to either UC or Crohns disease or it may be included in the non-infective colitis
category. The lack of an apparent relationship between pouch failure and diagnosis may
reflect discrepancies in the coding of inflammatory bowel disease. Failure rates do vary
significantly across NHS Trusts and amongst consultant teams. The rates varied from over
20% in some small volume centres to less than 3% in higher volume centres. Such variation
in rates is unlikely to be solely attributable to variation in case mix or aberrant coding. It is
therefore important to assess what steps can be taken to reduce such undesirable variation.
Laparoscopic versus open approaches
One focus of this thesis has been the interplay between process factors i.e. use of laparoscopy
and outcome. The patient reported benefits of laparoscopic colorectal surgery have been
287

documented (Braga et al., 2002, Lacy et al., 2002, Veldkamp et al., 2005, Jayne et al., 2007,
Braga et al., 2005). There have been several randomised control trials (RCT) that have
explored the efficacy and safety of laparoscopic colorectal surgery. Lacy and colleagues
reported the first RCT (the Barcelona trial) of 219 patients investigating laparoscopic surgery
for colonic cancer.(Lacy et al., 2002). They found reduced morbidity following laparoscopic
surgery than open (12% vs 31%, p=0.001) and equivalent postoperative mortality rates,
although the reoperation rates were not recorded in this study. Cancer related survival was
higher in the laparoscopic group. The Clinical Outcomes of Surgical Therapy Study Group
(COST) study published its findings in 2004 (2004a). In a study of 872 colonic cancer
patients, the postoperative complication rates (21% vs 20%, p=0.64), mortality (<1% and 1%,
p=0.40) and cancer recurrence rates were similar in the open and laparoscopically assisted
groups (16% vs 18%, p=0.32). The colon cancer laparoscopic or open resection (COLOR), a
North American and European RCT, in 2005 reported comparable morbidity and mortality in
the laparoscopic and open surgical groups (2004a). However in this study the reintervention
rate was not significantly higher in the laparoscopic group than in the open group (7% vs 5%,
p=013). The conventional versus laparoscopic assisted surgery in patients with colorectal
cancer (MRC CLASICC trial) reported the short term outcome in 2005 (Guillou et al., 2005).
In this study of 794 patients, 268 patients were allocated to open surgery and 526 to
laparoscopic surgery. The laparoscopic group and open groups had similar overall
complication rates (32% versus 33%). The three year and five year results reported no
difference in overall survival (Jayne et al., 2007, Jayne et al., 2010).
288

These studies report different outcome measures and include a total of 3133 patients. It is
possible that these trials are underpowered to examine more subtle variation in outcome
following laparoscopic surgery.
We have shown that elective patients selected for a laparoscopic approach experienced higher
reoperation rates. 7.1% of elective laparoscopic patients underwent a reoperation following
the primary resection. Though Bilmoria and colleagues did not demonstrate a difference in
reoperation rates following colonic cancer resections (lap 5.5% and open 5.8%, p=0.79)
(Bilimoria et al., 2008b), a later study by Delaney and colleagues also using NSQIP data
examined outcome following colectomy for all diagnoses (Delaney et al., 2008). This study
found a similar small increase in the adjusted reoperation rate following laparoscopic
resection when compared with the open approach (OR=1.78, p=0.002). When examining
reoperation rates following laparoscopic colorectal cancer surgery, the reoperation rates
demonstrated in this study are higher than those previously published from the American
College of Surgeons National Surgical Quality Improvement Program (NSQIP) data or trial
data (Bilimoria et al., 2008b, Hewett et al., 2008, Schwenk et al., 2005). The latter studies,
however, mostly included only colonic procedures. Laparoscopic rectal procedures were
twice as likely to experience a reoperation following surgery (table 9.11) than right sided
resections. The increased reoperation rates may also reflect the learning curve by English
surgeons taking up laparoscopic surgery or the impact of widening practice from dedicated
enthusiasts to the more general colorectal surgeons. Importantly, surgeon caseload did not
impact on postoperative reoperation rates. Broadly, this implies that low volume laparoscopic
surgeons are not associated with higher serious surgical morbidity rates than colleagues
exposed to greater activity. It is unclear whether this increase in reoperation represents a
289

truly higher incidence of surgical complications requiring reoperation or whether a surgeons
propensity for reoperation is increased following the laparoscopic approach.
We have demonstrated a reduction in clinically important adhesions following the
laparoscopic approach. This confirms the findings from single-centre observational
studies.(Dowson et al., 2008, Lumley et al., 2002, Duepree et al., 2003). However, the
laparoscopic approach is not without risk for adhesion development. The SCAR-2 study
examining pelvic gynaecological surgery documented similar adhesion-related risk regardless
of the surgical approach (Lower et al., 2004).
From 2002 to 2008, the number of consultant teams practising minimal access colorectal
surgery increased. This increase corresponded with the publication of several randomised
control trials in 2002 and 2004 ratifying the safety of the laparoscopic approach for cancer
surgery (Braga et al., 2002, Lacy et al., 2002, 2004a). The National Institute of Clinical
Excellence (NICE) introduced its guidelines on laparoscopic colorectal cancer surgery in
2006 (NICE, 2006), by which point there had already been a significant expansion in the
number of surgeons offering the minimal access approach. In England, the National Training
Programme for Laparoscopic Colorectal Surgery began in 2008 with the aim to increase the
number of colorectal surgeons trained to independently perform laparoscopic colorectal
surgery. This program in conjunction with the NICE guidelines is likely to increase further
the number of surgeons performing laparoscopic colorectal surgery.
290

Study limitations
Reoperation
The advantage of this administrative dataset is that it provides a comprehensive overview of
current colorectal practice in England. By including all patients admitted to NHS hospitals in
England, any submission bias is avoided. There are several limitations, common to all
included studies that merit discussion.
HES dataset
The dataset, although prospectively collected, includes all patients undergoing surgery
without standardisation of treatment and selection bias of procedure or management by
individual surgeons or trusts cannot be excluded. HES data lack clinical information such as
disease severity that would allow a more refined risk adjustment for comparison of
institutions or surgeons.
Data accuracy has been frequently questioned. Extensive comparisons between the HES
dataset and other data sources have suggested the reliability of HES data for clinical outcome
analysis (Aylin et al., 2001, Poloniecki et al., 2004, Aylin et al., 2007a, Aylin et al., 2007b,
Garout et al., 2008). The systematic review sought to quantify the data accuracy published in
this thesis. This demonstrated an overall accuracy of 83.2% with a diagnostic accuracy of
80.3% and a procedure accuracy of 84.2%. Accuracy, however, is likely to be improving. A
recent Audit Commission assessment of coding accuracy suggested recent improvement in
coding accuracy with a procedure accuracy of 90% and diagnostic accuracy of 87% (Audit
Commission, 2010). Derivation of the reoperation rates in this study relies on the secondary
procedure codes. The accuracy of secondary codes may be less than that of the primary
291

codes but this is difficult to ascertain from the published literature. The Charlson score is
based on secondary diagnosis coding and was used to adjust for comorbidity in the included
studies. It has been used previously for colorectal cancer patients and shown to be valid
(Ouellette et al., 2004). The Charlson score has also been used to adjust for comorbidity in
predicting surgical complications in the United States (Kemp and Finlayson, 2008). A more
comprehensive explanation of the Charlson scoring system is given in Chapter 4. Trusts may
vary in the accuracy to which they record secondary procedures or diagnosis codes. Some of
the inter trust variability seen in these studies may reflect differences in local coding
practices.
Coding
The OPCS code for conversion of a minimal access to an open procedure was introduced in
2006. Cases converted prior to the introduction of this code will not have been captured as
conversions and may have been included in the open group of patients prior to 2006. The
current study used the OPCS codes Y75 (introduced in 2006) and Y50.8 to designate a
laparoscopic procedure. From these codes, it is not possible to know how much of the
procedure was performed laparoscopically and how many procedures were converted to the
open approach. In addition, it is not possible to ascertain if they were hand assisted or how
much of the operation was completed laparoscopically. Therefore, analysis was performed
on an intention to treat basis.
For this analysis where emergency patients were included, patients coded to a Hartmanns
procedure (H33.5) were included in the left sided group. The majority of these cases had a
diagnosis of diverticular disease. It was therefore felt that these resections were more likely
292

to be sigmoid resections rather than true rectal resections. However, when elective
procedures were considered, Hartmanns procedures were included in the rectal group.
Up to April 2006 specific codes for pouch revision did not exist and the reliability with which
pouch revisional procedures can be identified is unclear. However, the coding used prior to
2006 was similar to the coding for pouch excision with the addition of the Y71.3 revisional
operation code. Thus revisional procedures prior to 2006 will be captured in the pouch
excision group.
The anonymised consultant codes refer to the consultant in charge of the patients care. It is
not possible to determine who the operating surgeon is or their level of experience. It is
difficult therefore to assess the learning curve of the operating surgeon rather than the
consultant team.
The dataset is not able to code for parastomal hernia, which may be coded with other ventral
hernia, which will artificially increase the incisional hernia incidence. As operative codes are
more likely to be accurate than diagnosis codes, the study may not be as specific in
identifying incisional hernias or adhesions that did not require admission or operation.
The ICD10 code for rectal cancer excluded cancers coded to a rectosigmoid diagnosis (C19).
It is not possible to ascertain height from the anal verge for rectal cancers.
293

Reoperation
Surgical complications that do not require reoperation such as wound infection treated by
antibiotics are not included in this study. Interventional radiological procedures such as
image-guided drain insertion are also not included. Thus the total surgical morbidity that
may have an impact on outcome including length of stay and mortality will be
underestimated in this study. Surgeons may differ in their threshold for taking patients back
to theatre reflecting differences in surgeon level reoperation rates. Furthermore, surgeons
may have a lower threshold for performing a diagnostic laparoscopy in patients who
underwent a minimal access procedure, elevating the apparent reoperation rate.
Each patient will undergo different preoperative decision-making and differ in their
postoperative management according to the clinician in charge of their care. Different
surgeons will have different selection criteria for the laparoscopic approach.
The clinical severity of a hernia is not conveyed within this administrative database. The
clinical impact of a limited port-site hernia is likely to differ from that of a large midline
laparotomy herniation. This is important as at the consultant level one surgeon may operate
on the more difficult cases. Moreover, data such as length of incision or previous surgery are
not included in this dataset. We cannot, therefore, say with absolute certainty that any
herniae or adhesions are secondary to the colorectal resection admission included in this
study. Though patients undergoing a resection in at least the six years prior to the study
period have been excluded, other operations such as gynaecological procedures may have
been undertaken. Furthermore, our dataset only examines inpatient admissions so any
294

patient who has an incisional hernia conservatively treated on an outpatient basis will not be
included in this dataset.
Cancer stage or disease severity are not included in the dataset so have not been included in
the risk adjustment models. This would be pertinent as cases for more advanced disease are
more likely to have been converted from laparoscopic to open with the inherent risks of
incisional hernia development. The dataset has no coding for the use of anti-adhesion
strategies as discussed earlier.
The dataset does not contain long-term mortality data. Therefore, patients in both groups are
assumed to be alive at three years or the end of the study period. It is therefore not possible
to assess the competing risk in each group. This may account in part for the reduced
reoperation for adhesions and hernia rates seen in the elderly population. Long term survival
is likely to be similar following laparoscopic and open colorectal cancer resections (Buunen
et al., 2009, Kuhry et al., 2008). Therefore the impact of an excess mortality in the
laparoscopic or open group is likely to be limited.
Overall pouch failure rates are consistent with those described in other studies suggesting that
the current data are valid (Gemlo et al., 1992, Setti Carraro et al., 1994). It was not feasible to
ascertain type of actual RPC that was performed (whether handsewn or stapled) nor other
potentially important variables such as severity of disease and steroid usage at the time of
surgery. Furthermore, it was not possible to evaluate clinical outcomes such as poor
functional outcome or other complications such as pouchitis or late-presenting pelvic sepsis.
295

Volume
Hospital provider volume in this study refers to the volume of surgery carried out in a
particular NHS Trust during the study period. An NHS Trust may contain multiple sites on
which colorectal surgery is performed. These are, however, overseen by the same surgical
team and patients should therefore have access to the same services across sites.
Furthermore, the consultant code used to differentiate between surgeons denotes an
individual consultant team under whose care a patient is operated upon. The consultant may
not carry out every single procedure but maintains responsibility for patient care. The grade
of surgeon performing the procedure is not known. Given the complexity of the surgery it is
likely that the vast majority of operations would be carried out by or under the direct
supervision of the responsible consultant. This is more likely in the elective setting.
Therefore, at a consultant team level only elective patients were included. The patients
named consultant surgeon is responsible for the care of the patient, and therefore must ensure
that clinicians of an appropriate level and competency undertake a patients management. If
the level of trainee supervision varied between different volume centres or teams then this
may impact on the providers outcome. However, it is not possible to investigate this from
this dataset.
The resection volume only includes a patients primary resection so may underestimate
slightly the consultant teams volume. Furthermore, only elective resections were included.
Consultant teams may have a variable emergency workload.
In the analysis of APE rate, only the primary operation was examined. We did not assess
how many patients who underwent an anterior resection were defunctioned or how many had
296

intestinal continuity restored on a subsequent admission. It is important to recognise that for
some patients an APE is the most appropriate management strategy. Without more detailed
data on tumour stage and height, it is difficult to draw meaningful conclusions. However,
such wide variation in practice would not be expected through patient factors alone.
Conclusion
This thesis provides a comprehensive overview of general and subspecialist colorectal
surgery in England. We have demonstrated considerable variation in colorectal surgery and
defined new outcome measures from routinely collected datasets. Routinely collected data
offer an exciting potential data source for measuring performance and quality, as they are
cost effective and comprehensive. If data accuracy can be assured, measures such as
reoperation may be used alongside established measures of quality in a meaningful way to
benchmarking performance of providers. The methods described in this thesis can be applied
to a broad range of surgical specialties. Furthermore, the variation described in this thesis is
a starting point to develop quality improvement initiatives to reduce unwanted variation in
healthcare. Though volume has a role in determining outcome and reducing this variation in
some aspects of subspecialist colorectal surgery, it is by no means the panacea to improve
quality across all providers. Thought must be given to centralising services to the optimum
providers rather than indiscriminately increasing volume. Further work is required to
examine other outcome measures such as oncological factors and also to unpick the features
that make an excellent provider irrespective of whether they have a high or low volume
caseload. These positive aspects of an institution may then be replicated elsewhere to
improve quality of care for the majority of colorectal surgical patients.
297

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Investigating

the use of Hospital Episode

Statistics data to measure variation in

Performance and Quality in Colorectal Surgery

DIVISION OF SURGERY, DEPARTMENT OF SURGERY AND CANCER,

IMPERIAL COLLEGE LONDON

Doctor of Philosophy (PhD) 2012

Publications and presentations resulting from this thesis ............................................ 17

Statement of Contribution and Declaration of Originality ............................................. 23

Chapter 1- Introduction ............................................................................................................. 24

Chapter 2- What is surgical quality and how do we measure it? ................................. 30

The demand for high-quality healthcare ......................................................................... 30

The definition of surgical quality ....................................................................................... 31

Reporting of surgical performance and quality ............................................................ 32

Measuring quality in surgery ............................................................................................... 36

Risk-adjustment and statistical considerations in quality measurement ............ 47

Measurement of quality in colorectal surgery ............................................................... 51

Chapter 3- Data sources for quality measurement. .......................................................... 59

Routinely collected datasets ................................................................................................ 59

Clinical databases .................................................................................................................... 62

National Surgical Quality Improvement Program ........................................................ 63

Advantages and disadvantages of routinely collected data ...................................... 64

Systematic review of accuracy of routinely collected data ........................................ 69

Variation from HES data ........................................................................................................ 91

HES data and Colorectal surgery ......................................................................................... 96

Chapter 4- Materials and Methods ...................................................................................... 100

Hospital Episode Statistics (HES) .................................................................................... 100

HES Coding ............................................................................................................................... 101

Risk adjustment ..................................................................................................................... 103

Outcome measures ............................................................................................................... 108

Ethical considerations ......................................................................................................... 109

Statistical considerations ................................................................................................... 109

Volume ...................................................................................................................................... 110

Chapter 5- Variation in patient factors .............................................................................. 111

Introduction ............................................................................................................................ 111

Aim ............................................................................................................................................. 112

Methods .................................................................................................................................... 112

Results ...................................................................................................................................... 113

Summary .................................................................................................................................. 123

Chapter 6- Variation in Structural factors ........................................................................ 124

Introduction ............................................................................................................................ 124

Aim ............................................................................................................................................. 125

Methods .................................................................................................................................... 126

Results ...................................................................................................................................... 127

Summary .................................................................................................................................. 142

Chapter 7- Variation in process factors ............................................................................. 144

Introduction ............................................................................................................................ 144

Aim ............................................................................................................................................. 147

Methods .................................................................................................................................... 147

Results ...................................................................................................................................... 149

Summary .................................................................................................................................. 160

Chapter 8- Variation in outcome factors ........................................................................... 161

Introduction ............................................................................................................................ 161

Aim ............................................................................................................................................. 162

Methods .................................................................................................................................... 163

Results ...................................................................................................................................... 172

Variation in established colorectal outcome measures 197

The impact of process factors on outcome 209

Summary .................................................................................................................................. 210

Chapter 9- Reducing variation in outcome following colorectal surgery in

England- the role of volume in determining outcome .................................................. 212

Introduction ............................................................................................................................ 212

Aims ........................................................................................................................................... 221