Colorectal Cancer Comparative Audit Report

Transcription

1 SOUTH EAST SCOTLAND CANCER NETWORK (SCAN) PROSPECTIVE CANCER AUDIT Colorectal Cancer Comparative Audit Report Mr B.J. Mander, NHS Lothian, Lead Colorectal Cancer Clinician, SCAN Group Chair Mr K Pal, NHS Borders Mr S Whitelaw, NHS Dumfries & Galloway Mr S Yalamarthi, NHS Fife Mr R G Wilson, NHS Lothian Dr H Philips, Clinical Oncologist, NHS Lothian Sarah Buchan SCAN Colorectal Cancer Audit Facilitator Lynn Smith, Cancer Audit Facilitator, NHS Borders Laura Halliday, Cancer Audit Facilitator, NHS Dumfries & Galloway Maureen Lamb, Cancer Audit Facilitator, NHS Fife Report No: SA CO1/16 SCAN Audit Office, Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU T: W: lorna.bruce@luht.scot.nhs.uk

2 COLORECTAL CANCER COMPARATIVE AUDIT REPORT Patients diagnosed 1 April March 2015 Table of Contents Document History... 4 Comment by Chair of the SCAN Colorectal Group... 5 Action Points... 6 Summary of Quality Performance Indicators:... 7 Introduction and Methods Data Quality Estimated Case Ascertainment Actions for Improvement Diagnosis and Staging QPI 1: Radiological Diagnosis and Staging (i) QPI 1: Radiological Diagnosis and Staging (ii) QPI 2: Pre-Operative Imaging of the Colon QPI 3: Multi-Disciplinary Team (MDT) Meeting QPI 4: Stoma Care Surgical Outcomes QPI 5: Lymph Node Yield QPI 6: Neoadjuvant Radiotherapy QPI 7: Surgical Margins (i) QPI 7: Surgical Margins (ii) QPI 8: Re-operation Rates QPI 9: Anastomotic Dehiscence (ii) QPI 10 (i): 30 Day Mortality Following Surgical Resection Elective Surgery QPI 10 (i): 30 Day Mortality Following Surgical Resection Emergency Surgery QPI 10 (ii): 90 Day Mortality Following Surgical Resection Elective Surgery QPI 10 (ii): 90 Day Mortality Following Surgical Resection Emergency Surgery Oncological Treatment Outcomes QPI 11: Adjuvant Chemotherapy QPI 11: Adjuvant Chemotherapy Dukes C QPI 12 (i): 30 Day Mortality Following Chemotherapy or Radiotherapy QPI 12 (ii): 90 Day Mortality Following Chemotherapy or Radiotherapy Clinical Trials Clinical Trials Access Interventional Clinical Trials Clinical Trials Access Translational Research Key Categories Glossary

3 DOCUMENT HISTORY Version Circulation Date Comments D&G comments Lead Clinicians Sign Version 1 05/11/2015 required. BGH off Meeting corrections Version 2.1 SCAN Colorectal Group Members 12/01/2016 D&G comments added. BGH corrections made. Version 3 Health Board Clinical Governance Groups and to the RCPG. Also numbered and lodged on the audit report index 01/02/2016 Consideration by Lead Clinicians of any comments received from Clinical Governance Groups or RCPG. Audit staff assess report for risk of disclosing any sensitive personal information. Amendments made as required. Version 3W (for website) prepared. Version 3W Version 3W lodged on website after elapse of suitable length of time 4

4 Comment by Chair of the SCAN Colorectal Group This report provides comprehensive data on the management of colorectal cancer in the South East of Scotland from 1 st April st March Once again the SCAN Audit Team and Sarah Buchan in particular, have worked extremely hard to produce data of consistently high quality. This has been facilitated by local data collection teams. SCAN Colorectal Data has been submitted to the UK and Ireland Large Bowel Cancer Audit allowing for direct comparisons with the whole of the British Isles ( SCAN data holds up extremely well in comparison to other UK areas in terms of surgical outcomes. During 2014 in SCAN 932 patients were diagnosed with colorectal cancer. This represents an almost identical number of cancers as treated the previous year an approximately a 6% decrease on 2010 which may represent the plateau of increased incidence predicted by the introduction of bowel screening. Nonetheless we are managing over 20% more colorectal cancers in the region than we were in Of the 932 patients 649 (70%) underwent surgery, which was performed with curative intent in 90% of cases. Nearly 20% of the patients who had surgery were treated as emergencies. Despite the substantial increase in workload the exceptional standard of surgical care across the region has been maintained. Perioperative mortality for all patients undergoing elective surgery was 0.6% (which compares favourably with the UK audit average 30 day mortality rate of 3.7%. Complications caused by anastomotic dehiscence (leakage at the site of the surgical join) are very low (1.3% for colonic anastomosis, 2.2% for rectal anastomosis,). They fall well within the required national NHSQIS standards of 5% and 10% respectively and are the lowest level we have ever recorded in the region. We have seen a steady rise in the percentage of cases treated laparoscopically within SCAN and within a relatively brief period of time we have got the percentage of patients within the region whose operation is intended to be completed laparoscopically up to over 40% which is the UK average. 60 patients were treated with minimally invasive endoluminal techniques involving either endoscopic resection or Transanal Endoscopic Microsurgery (TEMS). This is the second year we have submitted data to the Colorectal Quality Performance Indicator Programme. In the vast majority of areas the targets have been met across the entire SCAN area. In a few cases where performance has not met the targets substantial progress has been made. Specific issues apposite to individual targets are discussed in the relevant sections and the strive for continuous quality improvement remains at the forefront of all the groups activities. Mr B.J. Mander Chair SCAN Colorectal Group Jan 16 5

5 ACTION POINTS Action Points from QPI QPI 1 (i) QPI 1 (ii) Action required Change in practice at Radiology for emergency patients who are not undergoing CT chest preoperatively. Ensure all patients upper rectal or rectosigmoid tumours undergo a pre-operative MRI, along with CT scan of chest, abdomen and pelvis. Person Responsible SCAN Colorectal Lead Clinicians SCAN Colorectal Lead Clinicians Progress at Board Level Fully implemented in Lothian and Fife. No requirement for change in D&G. Action agreed in Borders. Fully implemented in Borders Fife and Lothian. Discussions to be held in D&G QPI 2 QPI 4 QPI 5 Recommend all elective patients, who are unable to have colonoscopy, should have CT colonoscopy preoperatively. Ensure all patients at risk of a stoma meet a Stoma Nurse pre-operatively. The CRM (circumferential resection margin) should be recorded in all pre-operative imaging. SCAN Colorectal Lead Clinicians Colorectal Lead Clinicians in Lothian and Dumfries & Galloway SCAN Colorectal Lead Clinicians Fully implemented in Borders, Fife and Lothian. Discussions to be held in D&G Fully implemented in Borders and Fife. D&G: MDT system development in progress with expected completion date of 31/03/2015. Lothian: Active discussion initiated to consider preoperative marking of all anterior resections Fully implemented in Borders, Fife and Lothian. Discussions to be held in D&G. Action Points from QPI Action required Person Responsible Date for update QPI 1 (ii) Liaise with D&G regarding the policy of this QPI. Mr B J Mander, Lead Clinician SCAN March 2016 QPI 2 All Boards to disseminate requirement for appropriate pre-operative imaging of colon and need for CT Colon if endoscopic imaging is incomplete. All Lead Clinicians, SCAN March 2016 QPI 4 D&G and Lothian to continue to work with their respective Stoma Service to facilitate improvements Mr B J Mander, Lead Clinician, Lothian. Mr Whitelaw, Lead Clinician, D&G March 2016 QPI 7 (ii) D&G to review clinical management of patients with positive margins Mr Whitelaw, Lead Clinician, D&G March

6 Summary of Quality Performance Indicators: Target % % % % % % QPI 1 Radiological Diagnosis and Staging i) Patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment ii) Patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment QPI 2 Pre-Operative Imaging of the Colon Patients with colorectal cancer undergoing surgical resection should have the whole colon visualised pre-operatively QPI 3 - Multi-Disciplinary Team (MDT) MDT Meeting Patients with newly diagnosed colorectal cancer should be discussed by a MDT prior to definitive treatment NOT MEASURED QPI 4 Stoma Care Patients with colorectal cancer who require a stoma are assessed and have their stoma site marked pre-operatively by a nurse with expertise in stoma care QPI 5 Lymph Node Yield In patients undergoing resection for colorectal cancer the number of lymph nodes examined should be maximised QPI 6 Neoadjuvant Radiotherapy Patients with locally advanced rectal cancer should receive neo-adjuvant chemoradiotherapy designed to facilitate a margin-negative resection

7 QPI 7 Surgical Margins Target % % % % % % Rectal cancers undergoing surgical resection should be adequately excised (i) Primary surgery, or surgery following neo-adjuvant short course radiotherapy < < (ii) Surgery following neo-adjuvant long course radiotherapy or chemoradiotherapy < < QPI 8 Re-operation Rates For patients undergoing surgery for colorectal cancer re-operation should be minimised Elective Index Procedure < < Emergency Index Procedure < < QPI 9 Anastomotic Dehiscence For patients undergoing surgical resection for colorectal cancer anastomotic dehiscence should be minimised. (i) Colonic anastomosis < < (ii) Rectal anastomosis < (iii) Anterior resection with total mesorectal excision (TME) (ii) Rectal anastomosis inc anterior resection with total mesorectal excision (TME) < < QPI and 90 Day Mortality following Surgical Resection Mortality after surgical resection for colorectal cancer Elective Procedure < days < days < Emergency Procedure < days < days <

8 Target % % % % % % QPI 11 Adjuvant Chemotherapy Patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy. High Risk Dukes B n/a Dukes C QPI and 90 day Mortality following Chemotherapy or Radiotherapy Mortality after chemotherapy or radiotherapy with curative intent for colorectal cancer < day mortality < day mortality <

9 Introduction and Methods Cohort and Personnel This report is the eleventh to present comparative data on patients newly diagnosed with colorectal cancer in South East Scotland Cancer Network (SCAN) at the following hospitals: Borders General Hospital (NHS Borders), Dumfries and Galloway Royal Infirmary (NHS Dumfries & Galloway), Victoria Hospital, Kirkcaldy (NHS Fife), St John's Hospital at Howden, Livingston, and Western General Hospital, Edinburgh (NHS Lothian). The report covers data on patients newly-diagnosed in the twelve months from 1 April 2014 to 31 March Lead Clinicians and staff involved in audit were as follows Borders General Hospital (BGH) Mr K Pal Lynn Smith Dumfries & Galloway Royal Infirmary (DGRI) Mr S Whitelaw Laura Halliday Victoria Hospital (Fife) Mr S Yalamarthi Maureen Lamb Western General Hospital, Edinburgh (WGH) Mr BJ Mander Sarah Buchan SCAN Mr BJ Mander Sarah Buchan Audit Processes and data recording Collection of the nationally-agreed core minimum dataset continues in all hospitals in South East Scotland. Data capture is focused round the process for the weekly multidisciplinary meetings i.e. ensuring that data covering patient referral, investigation, and diagnosis is being picked up through the routine process. Surgical and Oncology data is obtained either from the clinical records (electronic systems and case notes) or by download from the Department of Clinical Oncology database within the Edinburgh Cancer Centre (ECC) The process remains dependent on audit staff for capture and entry of data, and for data quality checking 3.4 Data was recorded on TRAK in Lothian. In Borders, Fife and Dumfries & Galloway data was collected using E-case. 10

10 Dataset and Definitions The QPIs have been developed collaboratively with the three Regional Cancer Networks, Information Services Division (ISD), and Healthcare Improvement Scotland. QPIs will be kept under regular review and be responsive to changes in clinical practice and emerging evidence. The overarching aim of the cancer quality work programme is to ensure that activity at NHS board level is focussed on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland 1. Accompanying datasets and measurability criteria for QPIs are published on the ISD website 2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level. The QPI dataset for Colorectal was implemented from 01/04/2013, and this is the second publication of QPI results for colorectal cancer within SCAN. The standard QPI format is shown below: QPI Title: Description: Rationale and Evidence: Specifications: Target: Short title of Quality Performance Indicator (for use in reports etc.) Full and clear description of the Quality Performance Indicator. Description of the evidence base and rationale which underpins this indicator. Numerator: Denominator: Of all the patients included in the denominator those who meet the criteria set out in the indicator. All patients to be included in the measurement of this indicator. Patients who should be excluded from measurement of this Exclusions: indicator. Include in the denominator for measurement against the target. Not recorded for Present as not recorded only if the patient cannot otherwise be numerator: identified as having met/not met the target. Include in the denominator for measurement against the target unless there is other definitive evidence that the record should Not recorded for be excluded. Present as not recorded only where the record exclusion: cannot otherwise be definitively identified as an inclusion/exclusion for this standard. Exclude from the denominator for measurement against the Not recorded for target. Present as not recorded only where the patient cannot denominator: otherwise be definitively identified as an inclusion/exclusion for this standard. Statement of the level of performance to be achieved. 1 QPI documents are available at 2 Datasets and measurability documents are available at 11

11 Data Quality Clinical Sign-Off: This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. Additionally, the collated SCAN results are reviewed jointly by the lead clinicians, including the lead Oncologist, to assess variances and provide comments on results. External QA: SCAN Audit participates in external quality assurance (QA) of data by ISD Scotland, (i.e. when a sample of data is compared with the data definitions). A QA of the QPI colorectal dataset took place in February Estimated Case Ascertainment: Case ascertainment has been estimated using Scottish Cancer Registration data for comparison purposes. Tables on case ascertainment and five year averages are contained in the next section. Most patients are identified through weekly multidisciplinary meetings. The following sources are used to check for missing patients: 1. Pathology records 2. GRO Death lists 3. Dept of Clinical Oncology retrospective database 4. Clinical Nurse Specialist database 12

12 ESTIMATE OF CASE ASCERTAINMENT Estimated Case Ascertainment An estimate of case ascertainment (the percentage of the population with colorectal cancer recorded in the audit) is made by comparison with the Scottish Cancer Registry five year average data from 2010 to High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance. Number of cases recorded in audit: patients diagnosed to Colon cancer Rectal cancer Total Estimate of case ascertainment: calculated using the average of the most recent available five years of Cancer Registry Data Cases from Audit Cancer Registry 5 Year Average Case Ascertainment % Actions for Improvement After final sign off, the process is for the report to be sent to the Clinical Governance groups within the four health boards and to the Regional Cancer Planning Group. Action plans and progress with plans will be highlighted to the groups. The report will be placed on the SCAN website once it has been fully signed-off and checked for any disclosive material. Sarah Buchan SCAN Audit Facilitator Source: Scottish Cancer Registry, ISD. Data extracted from ACaDMe Note: Case ascertainment is reported by board of diagnosis and has been estimated using a denominator based on the latest ( ) five-year annual average available from the Scottish Cancer Registry. Death certificate only cases have been excluded. Cases that have been diagnosed in the private sector but received any treatment in NHS hospitals have been included. 13

13 DIAGNOSIS AND STAGING QPI 1: Radiological Diagnosis and Staging (i) Target = 95% Numerator = Number of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment. Denominator = All patients with colon cancer Exclusions = (a) Patients who refuse investigations (b) Patients who undergo emergency surgeryª (c) Patients undergoing supportive care. Patients with colon cancer who undergo staging investigations before definitive treatment Borders N D&G N Fife N Lothian N SCAN N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusion Not Recorded for Denominator % Performance 100.0% 97.1% 95.3% 98.4% 97.6% This QPI was met in all Boards 14

14 QPI 1 (i) Colon Cancer - Pre-op Staging 100 % Patients Patients undergoing pre-op staging investigations QPI Target 20 0 Borders D&G Fife Lothian Scan Health Board Comments: These results show the high standard of pre-operative imaging in all Boards. 15

15 QPI 1: Radiological Diagnosis and Staging (ii) Target = 95% Numerator = All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment. Denominator = All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection). Exclusions = (a) Patients who refuse investigations (b) Patients who undergo emergency surgeryª (c) Patients with a contraindication to MRI. Patients with rectal cancer undergoing staging investigations before definitive treatment N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 94.7% 50.0% 90.0% 89.2% 85.7% Comments where QPI not met Borders: 1 Patient: an incompletely excised polyp then went on for resection. D&G: 9 Patients: 4 had recto-sigmoid tumours and MRI was not performed. 2 had no documented reasons as to why MRI was not performed. 2 had high grade dysplasia on biopsy (1 went on to have MRI post-treatment). 1 had a high rectal cancer and no MRI was performed. Fife: 5 patients: 4 were thought to be recto-sigmoid and found to be rectal at surgery and no MRI was performed. 1 was under review for ulcerative colitis and was an incidental Dukes A on surgery. Lothian: 8 patients: 4 thought to be distal sigmoid on CT. 2 had proven metastases so MRI wound not have changed management. 1 had a synchronous rectal tumour diagnosed at surgery for sigmoid cancer. 1 primary was difficult to see on CT?upper rectal. ª Emergency surgical resection is defined by the Consultant in Charge of the patient s care 16

16 QPI 2 Pre-op Visualisation of Colon % Patients Pre-op Staging of Colon QPI Target 20 0 Health Board Comment: This has been a challenging QPI because of the difficulties in localising upper rectal tumours confidently. The vast majority of patients not meeting the QPI had imaging discussed at the Multi-Disciplinary Meeting and MRI was not felt to be necessary. 17

17 QPI 2: Pre-Operative Imaging of the Colon Target = 95% Numerator = Number of patients who undergo elective surgical resection for colorectal cancer who have the whole colon visualised by colonoscopy or CT colonography before surgery, unless the non-visualised segment of colon has been removed. Denominator = All patients who undergo elective surgical resection for colorectal cancer Exclusions = No exclusions Elective Colorectal Patients undergoing Surgical Resection have the whole colon visualised by colonoscopy/ct colonography preoperatively, unless the non-visualised segment has been removed N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for the Denominator % Percentage 95.7% 80.0% 80.9% 92.5% 88.2% Comments where QPI not met Borders: 2 patients: both had flexible sigmoidoscopy as colonoscopy was limited by tumour and excess looping causing patient discomfort D&G: 15 patients: 7 had incomplete colonoscopies. 5 had flexible sigmoidoscopy. 2 had CT colons were requested, 1 did not attend and 1 was not completed (radiology vetting error) 1 had CT abdomen diagnosis but was at risk of obstruction so no scope was performed. Fife: 25 patients: 16 incomplete colonoscopies - all limited by tumour. 8 not performed - 9 had flexible sigmoidoscopy and 3 went straight to surgery. Lothian: 21 patients: 16 had incomplete colonoscopies. 4 had no colonic imaging (one of whom had contraindications for CT colon). 1 had flexible sigmoidoscopy only. 18

18 QPI 2 Pre-op Visualisation of Colon % Patients Pre-op Staging of Colon QPI Target 20 0 Health Board Comment: There has been a small improvement across SCAN in this QPI. Nearly all patients were endoscoped to the tumour. Further discussions should be held locally to facilitate an increase in patients undergoing complete colonic imaging either by colonoscopy or CT colon. 19

19 QPI 3: Multi-Disciplinary Team (MDT) Meeting Target = 95% Numerator = Number of patients with colorectal cancer discussed at the MDT before definitive treatment. Denominator = All patients with colorectal cancer. Exclusions = Patients who died before first treatment, patients undergoing emergency surgery and patients undergoing treatment with endoscopic polypectomy only. All patients diagnosed with colorectal cancer (excluding patients who died before first treatment patients undergoing emergency surgery and patients undergoing treatment with endoscopic polypectomy only). N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 93.2% 97.2% 98.3% 97.5% Comments where QPI not met D&G: 6 patients: 4 had high grade dysplasia on biopsy. 1 was an unexpected cancer and 1 had palliative care and died within 6 days of emergency admission. 20

20 QPI 3: Multi-Disciplinary Team Meeting % Patients MDT Meeting QPI Target 20 0 Health Board Comment: This is the first year this QPI has been measured. Overall SCAN is meeting the target for this QPI. 21

21 QPI 4: Stoma Care Target = 95% Numerator = Number of patients with colorectal cancer who undergo elective surgical resection which involves stoma creation who are seen by and have their stoma site marked preoperatively by a nurse with expertise in stoma care. Denominator = All patients with colorectal cancer who undergo elective surgical resection which involves stoma creation. Exclusions = Patients who refuse to be seen by a nurse with expertise in stoma care. Number of patients with colorectal cancer undergoing elective surgical resection which involves stoma creation are seen by and have their stoma site marked pre-operatively by a Stoma Care Nurse Borders N D&G N Fife N Lothian N SCAN N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 76.5% 97.0% 89.2% 90.9% Comments where QPI not met D&G: 4 patients: 2 were not seen by stoma nurse and 2 were unplanned stomas at surgery Lothian: 7 patients: 6 had no stoma sited pre-surgery and 1 was unplanned stoma at surgery. 22

22 QPI 4: Stoma Care 100 % Patients Patients seen by Stoma Nurse Preoperatively QPI Target 20 0 Health Board Comment: There has been a slight improvement overall in SCAN in this QPI. Since these results stoma booking arrangements have been changed in Dumfries & Galloway, along with including stoma skill in the proposed ERAS nurses job description. In Lothian, there were some unexpected stomas but work will continue with the Stoma Nurses to improve the service. 23

23 SURGICAL OUTCOMES QPI 5: Lymph Node Yield Target = 80% Numerator = Number of patients with colorectal cancer who undergo curative surgical resection where > 12 lymph nodes are pathologically examined. Total number of lymph nodes examined microscopically after final surgery is more than or equal to 12. Denominator = All patients with colorectal cancer who undergo curative surgical resection (with or without neoadjuvant short course radiotherapy). Exclusions = Patient with rectal cancer who undergo long course neo-adjuvant chemoradiotherapy or radiotherapy. Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Colorectal Cancer Patients undergoing curative surgical resection have > 12 lymph nodes pathologically examined N N N N N Cohort Ineligible for this QPI Target 80% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 84.0% 96.2% 87.7% 87.4% 88.4% All Boards met this QPI. Following discussion at the Colorectal QPI National Meeting in February 2015, it was agreed it would be useful to consider looking at lymph node yield from node negative patients. This table shows the number of nodes examined for patients with Node negative (N0) disease. Lymph Node Yield in Node Negative BGH D&G Fife Lothian SCAN Patients N N N N N < to to > Total

24 QPI 5: Lymph Node Yield 100 % Patients Number of Patients having > 12 Lymph Nodes removed QPI Target 20 0 Health Board Comment: All boards are meeting the target for this QPI. This is a good marker of surgical quality in the SCAN region. As patient numbers are small, review after a 3 year cycle is recommended. 25

25 QPI 6: Neoadjuvant Radiotherapy Target= 90% Numerator = Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive long course neoadjuvant chemoradiotherapy¹. Denominator = All patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery. Exclusions = (a) Patients who refuse radiotherapy (b) Patients in whom radiotherapy is contraindicated (c) Patients who presented as an emergency for surgery Rectal Cancer Patients with threatened or involved CRM on preop MRI receive long course neoadjuvant chemoradiotherapy Borders N D&G N Fife N Lothian N SCAN N Cohort Ineligible for the QPI Target 90% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 100.0% 100.0% 71.4% 100.0% 91.3% Comments where QPI not met Fife: 2 patients: 1 had short course radiotherapy and one had no neo adjuvant treatment. 2 Not recorded for denominator - predicted CRM not recorded on MRI or MDT proforma. 26

26 QPI 6: Neoadjuvant Radiotherapy 100 % Patients Rectal Patients undergoing neoadjuvant chemoradiotherapy QPI Target 20 0 Health Board Comment: The CRM needs to be recorded in all pre-operative imaging. Changes at MDM level will assist with data collection. It is noted that there are very small numbers of patients being analysed in this QPI, giving rise to high percentage changes. Overall SCAN results are achieving the QPI. 27

27 QPI 7: Surgical Margins (i) Target = <5% Numerator = Number of patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy in which tumour is present at the circumferential margin. Denominator = All patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy. Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Rectal Cancer Patients who undergo elective primary surgical resection or surgical resection following short course neo-adjuvant therapy N N N N N Cohort Ineligible for the QPI Target <5% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 6.7% 0.0% 2.1% 1.7% Comments where QPI not met D&G: 1 patient had a palliative resection only. 28

28 QPI 7 (i) - Surgical Margins % Patients Primary surgery or surgery follow ing neoadjuvant short course XRT w ith +CRM QPI Target <5% 0 Health Board Comment: CRM needs to be recorded diligently pre-operatively. This QPI may require revision to exclude patient receiving palliative resections. Small numbers of patients being analysed are giving rise to high percentage changes. Overall SCAN is achieving this QPI. 29

29 QPI 7: Surgical Margins (ii) Target = <15% Numerator = Number of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy in which tumour is present at the circumferential margin. Denominator = All patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. All Rectal Cancer patients who undergo elective surgical resection following neoadjuvant long course radiotherapy or chemoradiotherapy N N N N N Cohort Ineligible for the QPI Target <15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 0.0% 16.7% 0.0% 4.5% Comments where QPI not met Fife: 1 patient: Treatment was long course radiotherapy and surgery with involvement of anterior CRM by 0.35 mm. 30

30 QPI 7 (ii) Surgical Margins % Patients Surgery follow ing neoadjuvant long course XRT or ChemoXRT QPI Target <15% 0 Health Board Comment: Again small numbers of patients being analysed are giving rise to high percentage changes. Overall SCAN is achieving this QPI. 31

31 QPI 8: Re-operation Rates Target = <10% (elective surgical resection) <15% (emergency surgical resection) Numerator = Number of patients with colorectal cancer who undergo surgical resection who return to theatre following initial surgical procedure (within 30 days of surgery) to deal with complications related to the index procedure. Denominator = All patients with colorectal cancer who undergo surgical resection. Exclusions = No exclusions. All colorectal cancer patients undergoing surgical resection who return to theatre within 30 days of their index procedure for complications - Index procedure Elective Borders N D&G N Fife N Lothian N SCAN N Cohort Ineligible for the QPI Target <10-15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 8.0% 2.3% 2.0% 2.6% All colorectal cancer patients undergoing surgical resection who return to theatre within 30 days of their index procedure for complications - Index procedure Emergency N N N N N Cohort Ineligible for the QPI Target <10-15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.7% 0.0% 8.0% 4.8% 5.1% This QPI was met by all Boards. Comment: The QPI figures above have been generated by each Board, not ISD. Figures supplied by ISD were not felt to be an accurate measurement for this QPI. This QPI indicates a high level of primary surgery outcomes in SCAN. 32

32 QPI 9: Anastomotic Dehiscence (i) Target = <5% Numerator = Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon; or rectum; or patients with rectal cancer who undergo anterior resection and TME; having anastomotic leak requiring intervention (radiological or surgical). Denominator =.All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon. Exclusions = No exclusions. All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon N N N N N Cohort Ineligible for the QPI Target <5% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 4.2% 1.4% 0.6% 1.3% This QPI was met by all Boards 33

33 QPI 9 (i): Colonic Anastomosis % Patients All patients undergoing anastomosis of the colon QPI Target <5% Health Board Comments: SCAN is achieving the target for this QPI. This is a very good result across all Boards reflecting the high standard of operating in the region. 34

34 QPI 9: Anastomotic Dehiscence (ii) Target = <10% Numerator = Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon; or rectum; or patients with rectal cancer who undergo anterior resection and TME; having anastomotic leak requiring intervention (radiological or surgical). Denominator = All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with TME) Exclusions = Nil. All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum N N N N N Cohort Ineligible for the QPI Target <10% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 4.0% 5.9% 2.0% 1.4% 2.2% This QPI was met by all Boards. 35

35 QPI 9 (ii): Rectal Anastomosis (including anterior resection with TME) % Patients Health Board All patients undergoing anastomosis of the rectum QPI Target <10% Comment: Overall, SCAN is achieving the target for this QPI. This is a very good result across all boards reflecting the high standard of operating in the region. 36

36 QPI 10 (i): 30 Day Mortality Following Surgical Resection Target = Elective surgical resection <5% Emergency surgical resection <15% Numerator = Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 30 days of surgery. Denominator = All patients with colorectal cancer who undergo emergency or elective surgical resection. Exclusions = No exclusions Elective Surgery All patients with colorectal cancer who undergo elective surgical resection who die within 30 days of surgery N N N N N Cohort Ineligible for this QPI Elective Surgery <5% Numerator (elective surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 2.2% 1.3% 0.0% 0.4% 0.6% This QPI was met in all Boards QPI 10(i): 30 Day Mortality (Elective) % Patients Health Board 30 Day mortality follow ing elective surgery QPI Target <5% 37

37 QPI 10 (i): 30 Day Mortality Following Surgical Resection Emergency Surgery All patients with colorectal cancer who undergo emergency surgical resection who die within 30 days of surgery N N N N N Cohort Ineligible for this QPI Emergency Surgery <15% Numerator (emergency surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.7% 0.0% 7.4% 4.1% 4.8% This QPI was met in all Boards. QPI 10(i): 30 Day Mortality (Emergency) % Patients Day Mortality follow ing emergency surgery QPI Target <15% Health Board Comments: These low results reflect the high standard of operating in the SCAN region. In comparison to England and Wales combined elective and emergency figure of 2.9%, SCAN has a combined figure of 1.4%. 38

38 QPI 10 (ii): 90 Day Mortality Following Surgical Resection Target = Elective surgical resection <5% Emergency surgical resection <15% Numerator = Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 90 days of surgery. Denominator = All patients with colorectal cancer who undergo emergency or elective surgical resection. Exclusions = No exclusions Elective Surgery All patients with colorectal cancer who undergo elective surgical resection who die within 90 days of surgery N N N N N Cohort Ineligible for this QPI Elective Surgery <5% Numerator (elective surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.5% 2.7% 0.0% 0.4% 1.1% Comments where QPI not met Borders: 3 patients: they have been reviewed by the Clinical Team. 39

39 QPI 10 (ii): 90 Day Mortality (Elective) % Patients Day mortality follow ing elective surgery QPI Target <5% 0 Health Board 40

40 QPI 10 (ii): 90 Day Mortality Following Surgical Resection Emergency Surgery All patients with colorectal cancer who undergo emergency surgical resection who die within 90 days of surgery N N N N N Cohort Ineligible for this QPI Emergency Surgery <15% Numerator (emergency surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.7% 11.1% 7.4% 9.5% 8.8% This QPI was met in all Boards. QPI 10 (ii): 90 Day Mortality (Emergency) % Patients Day Mortality follow ing emergency surgery QPI Target <15% Health Board Comment: These low results reflect the high standard of operating in the SCAN region. In comparison to England and Wales where the combined elective and emergency figure is 4.6%, SCAN has a combined figure of 2.6%. 41

41 ONCOLOGICAL TREATMENT OUTCOMES QPI 11: Adjuvant chemotherapy Target = Patients with Dukes C colorectal cancer 70% colorectal cancer 50% Patients with high risk Dukes B Numerator = Number of patients between 50 and 74 years of age at diagnosis with Dukes C, or high risk Dukes B, colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy. Denominator = All patients between 50 and 74 years of age at diagnosis with Dukes C, or high risk Dukes B, colorectal cancer who undergo surgical resection. Exclusions = No exclusions. High Risk Dukes B N N N N N Cohort Ineligible for the QPI High Risk Dukes B - 50% Numerator - High Risk Dukes B Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 50.0% 75.0% 64.3% 65.0% This QPI was met by all Boards 42

42 QPI 11: Adjuvant Chemotherapy (High Risk Dukes B) 100 % Patients Health Board High Risk Dukes B receiving adjuvant chemotherapy QPI Target <50% Comments: Borders did not have any High Risk Duke s B patients. Small figures being analysed result in big percentage changes. 43

43 QPI 11: Adjuvant chemotherapy Dukes C N N N N N Cohort Ineligible for the QPI Target: Dukes C - 70% Numerator - Dukes C Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 69.2% 100.0% 66.7% 68.1% 72.6% Comments where QPI not met Borders: 4 patients: 2 had palliative chemotherapy. 1 had cardiac issues. 1 had upper GI bleed and was not fit for treatment. Fife: 5 patients: 2 were considered unfit for chemotherapy; 1 had palliative chemo; 1 died post op; 1 had surgery for a synchronous cancer. Lothian: 23 patients: 11 had co-morbidities; 4 underwent palliative chemotherapy; 5 had ongoing post-operative problems; 1 patient died before treatment; 1 had a synchronous primary to be treated; in 1 the risks and toxicity of chemotherapy outweighed the benefits. 44

44 QPI 11: Adjuvant Chemotherapy (Dukes C) % Patients Health Board Dukes C receiving adjuvant chemotherapy QPI Target <70% Comment: All patients are considered in a MDM setting and clinical reasons for not achieving this QPI were sound. The SCAN Group queried the attainability of achieving the target level set. 45

45 QPI 12 (i): 30 Day Mortality Following Chemotherapy or Radiotherapy Target = <2% Numerator = Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 30 days of treatment. Denominator = All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent. Exclusions = No exclusions. All patients with colorectal cancer who undergo neoadjuvant chemotherapy, radiotherapy, or adjuvant chemotherapy with curative intent who die within 30 days of treatment N N N N N Cohort Ineligible for the QPI Target <2% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.3% 0.0% 0.0% 1.2% 1.1% Comments where QPI not met Borders: 1 patient died before commencement of treatment. 46

46 QPI 12(i): 30 Day Morality after Chemotherapy or Radiotherapy 20 % Patients Day Mortality follow ing Oncology treatment QPI Target <2% 0 Borders D&G Fife Lothian SCAN Health Board Comment: Small numbers are being analysed across the Boards. Overall, SCAN is meeting this QPI. 47

47 QPI 12 (ii): 90 Day Mortality Following Chemotherapy or Radiotherapy Target = <2% Numerator = Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 90 days of treatment. Denominator = All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent. Exclusions = No exclusions. All patients with colorectal cancer who undergo neoadjuvant chemotherapy, radiotherapy, or adjuvant chemotherapy with curative intent who die within 90 days of treatment N N N N N Cohort Ineligible for the QPI Target <2% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 6.3% 0.0% 2.1% 1.2% 1.7% Comments where QPI not met Borders: Same patient as 30 day mortality Fife: 1 patient died 70 days post treatment. 48

48 QPI 12 (ii): 90 Day Morality after Chemotherapy or Radiotherapy 20 % Patients Day Mortality follow ing Oncology treatment QPI Target <2% 0 Health Board Comment: Small numbers in individual boards being analysed give rise to higher percentage change. Overall SCAN are meeting the target set. 49

49 CLINICAL TRIALS Clinical Trials Access Interventional Clinical Trials Target = 7.5% Numerator = Number of patients with Colorectal cancer enrolled in an interventional clinical trial Denominator = All patients with Colorectal cancer Exclusions = No exclusions Note: The clinical trials QPI will be measured utilising SCRN data and Cancer Registry data (5 year average of case ascertainment ) SCAN Target 7.5% Numerator 6 Not recorded for numerator 0 Denominator 1044 Not recorded for exclusions 0 Not recorded for denominator 0 % Performance 0.6% 50

50 Clinical Trials Access Translational Research Target = 15% Numerator = Number of patients with Colorectal cancer enrolled in translational research Denominator = All patients with Colorectal cancer Exclusions = No exclusions Note: The clinical trials QPI will be measured utilising SCRN data and Cancer Registry data (5 year average of case ascertainment ) SCAN Target 15% Numerator 238 Not recorded for numerator 0 Denominator 1044 Not recorded for exclusions 0 Not recorded for denominator 0 % Performance 22.8% 51

51 KEY CATEGORIES Table 1: Rectal v Other Colorectal Patients, percentage of patients undergoing Surgery No of Patients Diagnosed Number of patients diagnosed with rectal cancer Number of patients diagnosed with rectal cancer who had surgery All patients who had surgery Borders % % % D&G % % % Fife % % % Lothian % % % SCAN % % % Table 2: Rectal v Other Colorectal Patients No of Patients Diagnosed All patients who had definitive surgery Number of patients diagnosed with rectal cancer Number of patients diagnosed with rectal cancer who had definitive surgery Borders % % % D&G % % % Fife % % % Lothian % % % SCAN % % % Table 3: Emergency v Elective Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients who had definitive surgery Emergency Elective Inapplicable Missing Data Borders % % 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % 0 0.0% 0 0.0% SCAN % % 0 0.0% 0 0.0% 52

52 Table 4: Rectal Cancer Patients Emergency V Elective Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients diagnosed with rectal cancer who had definitive surgery Emergency Elective Not Recorded Missing Data Borders % % 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % 0 0.0% 0 0.0% SCAN % % 0 0.0% 0 0.0% Table 5: Intent of Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All Patients who had Definitive Surgery Curative Palliative Not Recorded Missing Data Borders % % 0 0.0% 0 0.0% D&G % 4 4.9% 0 0.0% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % % 0 0.0% SCAN % % % 0 0.0% Table 6: Intent of Surgery Rectal Cancer N=All patients diagnosed with rectal cancer who had definitive surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients diagnosed with rectal cancer who had definitive surgery Curative Palliative Not Recorded Missing Data Borders % 0 0.0% 0 0.0% 0 0.0% D&G % 1 6.7% 0 0.0% 0 0.0% Fife % 4 8.5% 0 0.0% 0 0.0% Lothian % 4 5.0% 3 3.8% 0 0.0% SCAN % 9 5.6% 3 1.9% 0 0.0% 53