COLORECTAL CANCER Quality Performance Indicators (QPI) Comparative Report

Transcription

1 SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT COLORECTAL CANCER Quality Performance Indicators (QPI) Comparative Report Mr S Yalamarthi, NHS Fife, Lead Colorectal Cancer Clinician, SCAN Group Chair Mr K Pal, NHS Borders Mr S Whitelaw, NHS Dumfries & Galloway Mr N Manimaran, NHS Fife Mr D Speake, NHS Lothian 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 Martin Keith, Cancer Improvement, NHS Dumfries & Galloway Maureen Lamb, Cancer Audit Facilitator, NHS Fife SA C01/18_W SCAN Audit Office, c/o Department of 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 2017 Contents DOCUMENT HISTORY... 3 Comment by Chair of the SCAN Colorectal Group... 4 ACTION POINTS... 6 Key... 9 Introduction and Methods Data Quality Estimate for 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: Neo-adjuvant Therapy 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 QPI 10 (i): 30 Day Mortality Following Surgical Resection QPI 10 (ii): 90 Day Mortality Following Surgical Resection QPI 10 (ii): 90 Day Mortality Following Surgical Resection ONCOLOGICAL TREATMENT OUTCOMES QPI 11: Adjuvant chemotherapy in Patients with High Risk Dukes B QPI 11: Adjuvant chemotherapy in Patients with Dukes C colorectal cancer QPI 12 (i): 30 Day Mortality Following Chemotherapy or Radiotherapy QPI 12 (i): 90 Day Mortality Following Chemotherapy or Radiotherapy QPI 12 (ii): 30 Day Mortality Following Chemotherapy or Radiotherapy Clinical Trials Key Categories Summary of Quality Performance Indicators: Glossary

3 DOCUMENT HISTORY Version Circulation Date Comments Version 1 Version 1.2 Lead Clinicians Sign off Group Lead Clinicians Sign off Group 02/11/ /11/2017 Circulated in advance of the Leads meeting D&G figures updated. Minor changes to Fife figures. Low case ascertainment investigated and 7 additional patients added following update of Cancer Registry queries. Version 2.4 SCAN Lead Clinician for commentary 08/12/2017 Commentary received 15/01/2018 and added to Version 4 of the report. Version 3 SCAN Colorectal Group Members 18/12/2017 Final comments from SCAN Group requested None received. Final Report SA C01/18 Clinical Governance Groups 16/01/2018 SA C01/18 Final report added to the SCAN website Report assessed for disclosure and prepared for website 3

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 The SCAN Audit Team have worked extremely hard to produce data of consistently high quality. This has been facilitated by the local data collection teams, who have again delivered with high quality data in a timely manner. This year some changes were made to the CRC QPI Attainment Summary sheet, with inclusion of Numerator and Denominator numbers. This is a useful and helpful amendment. SCAN data holds up extremely well in comparison to other UK areas in terms of Colorectal Cancer outcomes. During across SCAN, 891 patients were diagnosed with colorectal cancer and the numbers are relatively similar for the last 2 years. Since the introduction of the bowel screening programme 7 years ago, there has been a reduction of nearly 15% in cancers. Radiological staging investigations have consistently improved over the years and this is the first time we achieved the required target for rectal cancers. Pre-operative colonic imaging still requires some work and has been a difficult target to meet over the years. Reasons for the failure to meet this target need further analysis.. Nearly 80% (711 patients) of patients underwent surgical treatment with a high curative resection rate of 90%, this figure being higher for rectal cancers (92%). Nearly 22% of patients underwent emergency surgery, which has been consistent over the years. Surgical outcomes in terms of low positive resection margins (2.4%), anastomotic leak rates (2.7% for colonic; 4.2% for rectal surgery) and re-operations (2.4% for elective surgery; 4.2% for emergency surgery) are excellent outcomes, demonstrating the high degree of surgical care offered across the network. The target for lymph node yield of >12 nodes was increased from 80% to 90% this year and we have fallen short of this target. Over the last 4 years we have consistently been between 85-90%. Further analysis of the node numbers in those with negative nodes were analysed and 83.7% had >12 nodes, reassuring us about the quality of resections and adequate sampling by pathologists. Despite the busy workload, exceptional standard of surgical care across the region has been maintained, demonstrated by low 30-day day mortality rates after elective and emergency surgery of 1.5% and 5.3% respectively. 90-day mortality rates for all patients undergoing elective surgery were 1.9% and 8.3% for emergency patients which compares favourably with UK wide averages of 2.2% and 10.5% (National Large Bowel Cancer Audit 2015). Over the last few years we have seen a steady and increasing use of laparoscopic surgery for colorectal cancers. This year nearly 60% of all the resections were done by laparoscopic means. Transanal Endoscopic Microsurgery (TEMS) continued to be used for a small select group of patients. Adjuvant chemotherapy, as in previous years, has been delivered by a highly professional team of oncologists to High Risk Dukes B and C patients, achieving the targets with very low mortality figures. Though we have recruited adequate numbers into translational research, there is room for improvement to recruit more patients into interventional studies. As a SCAN wide target, there are plans to look at this more closely and have a wider strategy for entry into clinical trials 4

5 The introduction of QPIs has progressively improved the outcomes in some areas, but there are still some areas to work on, which will be challenging. I believe that through continued effort by the entire team, these should be achievable, thereby delivering patient care to the best possible standards. Mr S Yalamarthi Chair SCAN Colorectal Group January 18 5

6 ACTION POINTS Colorectal QPI Action Plans QPI Action Required Lead Date for update 1 (i) Monitor D&G results Mr Whitelaw Dec D&G, Fife and Lothian to ensure appropriate pre-operative imaging of colon is performed and ensure CT of the colon is performed if endoscopic imaging is incomplete. Mr Whitelaw Mr Manimaran Mr Speake Next SCAN Group Meeting 2/2/ Action is required to ensure patients are seen and marked appropriately by Stoma Nurses in Lothian. Mr Speake 5 7 (i) Clinical Trial QPI Performance has remained at 85-89% over the past 4 years, continued monitoring is required. Ensure local pathology leads know that the target has increased to 90%. This QPI was met but SCAN will carry out a separate audit of cases with positive margins from the cohort, which will be documented in the report As Surgical Services require infrastructure to recruit to clinical trials, a strategic plan is required in order to meet this QPI. Mr Whitelaw Mr Manimaran Mr Speake Dr Fineron Next SCAN Group Meeting 2/2/2018 Next SCAN Group Meeting 2/2/2018 Mr Yalamarthi Dec 2018 Mr Speak Mr Cruickshank Dr Philips Next SCAN Group Meeting 2/2/2018 General The TNM staging system is moving to TNM 8 from January This will create some difficulties with data collection as Dukes staging is now technically obsolete. Our audit team are already addressing this issue and for a period of time all pathology results will be reported both with TNM 5 and TNM 8 to ensure that the data capture is not affected. This will also allow the new system to embed into the clinical practice. Mr Whitelaw Mr Pal Mr Manimaran Mr Speake Dec 2018 Action Points from No. Action Required Progress/Action Status Status QPI 2 Dumfries, Fife and Lothian to disseminate requirement for appropriate preoperative imaging of colon and need for CT Colon if endoscopic imaging is D&G: Following discussion NHS D&G does not have the CT capacity to increase the number of CT Colons beyond current level. Therefore all patients diagnosed by flexible sigmoidoscopy will receive completion colonoscopy and patients with incomplete colonoscopies will receive CT Colon. The newly appointed MDT Co-ordinator will highlight patients who have not had complete bowel visualisation and has made changes to the MDT database to identify patients who require further bowel visualisation. Colonoscopies are now being done in Stranraer although reporting capacity has not increased Fife: Following the last 2 years, this QPI was reviewed and steps were taken to ensure that CT colon is appropriately requested in situations of incomplete colonoscopies. This has enabled better checks under these circumstances and increased the number of CT colons requested, guided by the clinical picture of the patients 2 1 6

7 No. Action Required Progress/Action Status Status incomplete. Lothian: Cancer MDM Co-Coordinator has been asked to remind all endoscopists to order CT colon not plain CT in all patients where colonoscopy incomplete Discussion at the SCAN group on 5/7/17 suggests that this is happening now. 1 QPI 3 Dumfries to look at their practice to determine if changes need to be made D&G: MDT Co-ordinator appointed who will work with the Cancer Tracking team to ensure all new cancers known to the tracking team are listed for MDT. Those patients who are for palliative treatment should also be included for discussion at the MDT. This will hopefully improve performance in this QPI and will need continued monitoring. Non-surgical colleagues will be advised to refer patients to the colorectal services even if their cancers are picked up incidentally and do not require any intervention. 2 QPI 5 QPI 7 Lothian to feedback information to Pathology regarding reduction in lymph node yield year on year All Boards to review all positive resection margins at MDM as a learning opportunity Complete 1 Borders: Complete D&G: Discussion will be held within the MDT and a documented action if required stored within MDT system. Fife: All positive resection margins are discussed at Colorectal MDT and this will continue in the future Lothian: Ongoing, Michael Duff will progress this now. There are plans to look at the Positive margins across SCAN to identify learning points and find ways forward. Each individual unit will collect specific data (to be finalised) and this will be collectively looked at QPI 9 (i) Dumfries to look at their practice to determine if there are any available learning or changes in practice that need to be made D&G: Case reviewed during QPI analysis with S Whitelaw. 2/3 patients were treated as emergencies by non colorectal surgeons and 1/3 by a colorectal surgeon. No obvious learning was identified however it is apparent that this will only be of clinical benefit if reviewed at time of surgery/ anastomotic leak. This will be managed going forward as per QPI 7This Action is now complete 1 7

8 CRC QPI Attainment Summary Target% Borders D&G Fife Lothian SCAN 1. Radiological Staging & Diagnosis Colon 95 N 32 N 36 N 88 N % 92.3% 100% 99.0% N 352 D 32 D 39 D 88 D 197 D % Rectum 95 N 15 N 14 N 38 N % 87.5% 100% 96.1% N 165 D 15 D 16 D 38 D 102 D % 2. Pre-operative imaging of the Colon 95 N 46 N 47 N 113 N % 85.5% 93.4% 92.5% N 441 D 48 D 55 D 121 D 254 D % 3. MDT before definitive treatment 95 N 71 N 78 N 169 N % 96.3% 95.5% 95.1% N 587 D 77 D 81 D 177 D 283 D % 4. Stoma Care: stoma site marked pre-operatively 95 N 14 N 23 N 27 N % 85.2% 100% 93.8% N 139 D 14 D 27 D 27 D 80 D % 5. Lymph Node Yield: surgical resection where 12 lymph N 41 N 60 N 108 N % 100% 83.1% 86.2% N 427 nodes D 47 D 60 D 130 D 252 D % 6. Neo-adjuvant Radiotherapy (rectal) 90 N 2 N 3 N 10 N 20 N % 100% 83.3% 100% D 2 D 3 D 12 D 20 D % 7. Surgical Margins 8. Re-operation Rates Primary surgery or surgery after short course XRT After neo-adjuvant chemo, long course chemoradiotherapy, long course radiotherapy or short course radiotherapy with long course intent 9. Anastomotic Dehiscence 10i). 30 day mortality following surgical resection Elective <10 Emergency <15 Colon <5 Rectum incl. TME <10 TME <20 Elective <3 Emergency <15 N 13 N 13 N 31 N % 100% 96.9% 97.1% N 123 D 13 D 13 D 32 D 68 D 126 N 2 N 3 N 10 N 24 N 39 D 2 100% D 3 100% D % D % D 40 N 1 N 1 N 3 N 7 2.1% 1.6% 2.4% 2.7% N 12 D 47 D 62 D 127 D 258 D 494 N 0 N 1 N 1 N 4 N 6 0% 5.9% 3.6% 4.5% D 10 D 17 D 28 D 88 D 143 N 0 N 2 N 2 N 3 N 7 0% 6.1% 3.0% 2.3% D 26 D 33 D 66 D 130 D 255 N 0 N 0 N 1 N 8 N 9 0% 0.0% 2.0% 6.3% D 21 D 14 D 51 D 128 D 214 N N N N N D D D D D N 0 N 1 N 4 N 2 N 7 0% 1.7% 3.1% 0.8% D 44 D 58 D 127 D 253 D 482 N 2 N 1 N 2 N 2 N % 8.3% 7.1% 2.5% D 12 D 12 D 28 D 81 D % 97.5% 2.4% 4.2% 2.7% 4.2% - 1.5% 5.3% 8

9 CRC QPI Attainment Summary Target% Borders D&G Fife Lothian SCAN N 0 N 1 N 5 N 3 N 9 Elective <4 0.0% 1.7% 4.0% 1.2% 10ii) 90 day mortality following surgical D 44 D 58 D 127 D 253 D % resection N 3 N 1 N 2 N 5 N 11 Emergency < % 8.3% 7.4% 6.2% D 12 D 12 D 27 D 81 D % 11. Adjuvant Chemotherapy HR Dukes B 50 N 2 N 1 N 3 N 14 N % 50.0% 50% 51.9% D 3 D 2 D 6 D 27 D % Dukes C 70 N 8 N 10 N 26 N 48 N % 71.4% 86.7% 82.8% D 11 D 14 D 30 D 58 D % All oncology treatment <1 N N N N N D D D D D - N 0 N 0 N 0 N 0 N 0 Neo-adjuvant <1 0% 0% 0% 0% 12i) 30 day Mortality after D 1 D 2 D 9 D 24 D 36 0% Curative Oncological Treatment N 0 N 0 N 0 N 1 N 1 Radiotherapy <1 0% 0% 0% 3.4% D 4 D 8 D 12 D 29 D % Adjuvant Chemotherapy <1 N 0 N 0 N 0 N 0 N 0 0% 0% 0% 0% D 17 D 14 D 44 D 87 D 162 0% All oncology treatment <1 N N N N N D D D D D - N 0 N 0 N 0 N 0 N 0 Neo-adjuvant <1 0% 0% 0% 0% 0% D 1 D 2 D 8 D 24 D 35 12i) 90 day Mortality after N 0 N 0 N 0 N 1 N 1 Curative Oncological Treatment Radiotherapy <1 0% 0% 0% 3.4% 2.0% D 4 D 5 D 12 D 29 D 50 Adjuvant Chemotherapy <1 12ii). 30 day Mortality after Palliative Chemotherapy <10 QPI Clinical Trials NB: N: patients enrolled in Trials and held on SCRN database D: 5 year average Cancer Registry patients Key Numerator (N) % Denominator (D) Performance Interventional 7.5 Translational 15 N 0 N 0 N 0 N 0 N 0 0% 0% 0% 0% D 14 D 11 D 45 D 87 D 157 N 0 N 1 N 1 N 6 0% 8.3% 5.9% 14.0% N 8 D 5 D 12 D 17 D 43 D 77 N 1 N 1 N 5 N 17 N % 0.8% 2.3% 3.0% D 95 D 130 D 220 D 576 D 1021 N 31 N 42 N 60 N 46 N % 32.3% 27.3% 8.0% D 95 D 130 D 220 D 576 D % 10.4% 2.6% 18.0% 9

10 Introduction and Methods Cohort and Personnel This report is the twelfth 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), and Western General Hospital, Edinburgh (NHS Lothian). The report covers data on patients newly-diagnosed in the twelve months from 1 April 2016 to 31 March Lead Clinicians and staff involved in audit were as follows SCAN Region Hospital Lead Clinician Audit Support NHS Borders Borders General Hospital Mr Karol Pal Lynn Smith NHS Dumfries & Galloway Dumfries & Galloway Royal Infirmary Mr Stuart Whitelaw Laura Halliday Martin Keith NHS Fife Victoria Hospital Mr Natarajan Manimaran Maureen Lamb SCAN & NHS Lothian Western General Hospital Mr Doug Speake Sarah Buchan Audit Processes and data recording Data was analysed by the audit facilitators in each NHS Board according to the measurability document provided by ISD. SCAN data was collated by Sarah Buchan, SCAN Audit Facilitator for Colorectal cancer. 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). Each of the 5 hospitals provides surgery and chemotherapy but radiotherapy is provided centrally in Edinburgh Cancer Centre. Patients living closer to either Carlisle or Dundee may opt to have treatment outwith the SCAN region. All QPIs will be analysed and presented by Hospital of Diagnosis for data verification/sign off purposes with additional reports by Hospital of Surgery as appropriate. The process remains dependent on audit staff for capture and entry of data, and for data quality checking In Borders, Fife and Dumfries & Galloway data was collected using E-case. Data was recorded on TRAK in Lothian. 10

11 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. Following year 3 results the Colorectal QPIs were subject to a formal review and revised documents for data collection were published in August This is the fourth publication of QPI results for colorectal cancer within SCAN and some of the revisions will not be implemented till year 5, depending on whether new data items were required or not. 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

12 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 2015 and overall accuracy percentage results are shown below: Borders D&G Fife Lothian Scotland Accuracy of data recording (%) 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 additional patients: 1. Pathology records 2. GRO Death lists 3. Dept of Clinical Oncology retrospective database 4. Clinical Nurse Specialist database 5. ACaDMe (Acute, Cancer, Deaths and Mental Health); a data mart part of NHS National Services Scotland. 12

13 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 2011 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 Borders D&G Fife Lothian SCAN Colon cancer Rectal cancer Total Estimate of case ascertainment: calculated using the average of the most recent available five years of Cancer Registry Data Borders D&G Fife Lothian SCAN Cases from Audit Cancer Registry 5 Year Average Case Ascertainment % 101.1% 79.2% 98.2% 82.6% 87.3% 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 on 13/11/2017. 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

14 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 surgery (c) Patients undergoing supportive care only (d) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (e) Patients who die before first treatment Target 95% Borders D&G Fife Lothian SCAN Cohort Ineligible for this QPI Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusion Not Recorded for Denominator % Performance 100.0% 92.3% 100.0% 99.0% 98.6% Comments where the QPI was not met: D&G: The target was not met showing a shortfall of 2.7% (3 cases). All 3 were diagnosed by CT colon and did not have full chest imaging completed. Changes to the MDM process were made in February 2017 to highlight patients who have not had CT chest pre-operatively, so this figure should improve for the next round of reporting. Action: Monitor D&G results next year, no further action identified 14

15 Following formal review after year 3, QPI 1 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset and additional exclusions were added; (d) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (e) Patients who die before first treatment. Below are QPI 1 (i) figures from the first 3 years of QPI collection. 15

16 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 surgery 3 (c) Patients with a contraindication to MRI (d) Patients who undergo Transanal Endoscopic Microsurgery (TEM) (e) Patients who undergo Transanal Resection of Tumour (TART) (f) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (g) Patients who died before first treatment Target 95% Borders D&G Fife Lothian SCAN Cohort Ineligible for this QPI Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 87.5% 100.0% 96.1% 96.5% Comments where the QPI was not met D&G: The target was not met showing a shortfall of 7.5% (2 cases). 1 was felt to be endoscopically sigmoid, but resectional pathology confirmed rectal. 1 patient declined investigation then subsequently agreed and no documented reason was found as to why an MRI was not performed. Action: No action identified. Following formal review after year 3, QPI 1 (ii) was updated. Additional exclusions were added; (d) Patients who undergo Transanal Endoscopic Microsurgery (TEM) (e) Patients who undergo Transanal Resection of Tumour (TART) (f) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (g) Patients who died before first treatment. Below are the QPI 1 (ii) figures comparing the four years of data collected. 3 Emergency surgical resection is defined by the Consultant in Charge of the patient s care 16

17 17

18 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 Target 95% Borders D&G Fife Lothian SCAN Cohort Ineligible for this QPI Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for the Denominator % Percentage 95.8% 85.5% 93.4% 92.5% 92.3% Comments where the QPI was not met D&G: The target was not met showing a shortfall of 9.5% (8 cases). 5 had flexible sigmoidoscopy only; 2 had incomplete colonoscopies; 1 had a large tumour visualised on CT chest, abdomen and pelvis and proceeded to surgery post MDT. Fife: The target was not met showing a shortfall of 1.6% (8 cases). 6 had flexible sigmoidoscopy only; 1 scope was limited by pain and 1 scope was limited by looping. All patients discussed at MDT. Lothian: The target was not met showing a shortfall of 2.5% (19 cases). 10 were limited by tumour. 8 colonoscopies were not performed due to various different reasons. 1 declined investigation. Action: Again, action is required in D&G, Fife and Lothian. 18

19 Following formal review after year 3 QPI 2 was updated: The inclusion of appendiceal cancers was removed from the dataset. A new value was added to the field Large Bowel Imaging in the Colorectal Data Definitions, Incomplete due to obstructing tumour. This value has been added for patients diagnosed from year 5 (01/04/2017 to 31/03/2018). Below are QPI 2 figures from the first 3 years of QPI collection. 19

20 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. Target 95% Borders D&G Fife Lothian SCAN Cohort Ineligible for this QPI Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 92.2% 96.3% 95.5% 95.0% 94.9% Comments where the QPI was not met Borders: The target was not met showing a shortfall of 3.8% (6 cases). 2 were not referred to the Colorectal Team. 2 died but were not discussed at MDM at all. 1 was given palliative treatment before the MDM discussion, it was agreed the outcome would not have changed. 1 was diagnosed incidentally and not for further treatment. Action: No action is identified. 20

21 Following formal review after year 3 QPI 3 was updated: The inclusion of appendiceal cancers was removed from the dataset. Multi-Disciplinary Team (MDT) Meeting information was not collected in year 1 of the QPI implementation. Figures for years 2 and 3 are below. 21

22 QPI 4: Stoma Care Hospital of Surgery 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. Lothian Target 95% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 85.2% 100.0% n/a 93.8% 93.9% Cases operated on outwith Board of Diagnosis: Lothian: operated on 1 case each from BGH, D&G, Fife & 3 cases from WoSCAN region. Fife also sent 1 case to Tayside & 1 to Forth Valley. Comments where the QPI was not met: D&G: The target was not met showing a shortfall of 9.8% (4 cases) 2 were not listed for stoma creation on theatre lists as anastomosis was planned at time of surgery therefore not known to Stoma Nurses. 1 listed as +/- ileostomy was not sited. Patient very nervous about Stoma and although risk explained it was decided not to site this patient. 1 not sited, no documented reason why this was not done but was not known to Stoma Nurse preoperatively. Lothian: The target was not met with a shortfall of 1.2% (5 cases). 2 were seen the day after surgery, 2 were seen before discharge, 1 was not reviewed by the Stoma Service. Action: The volume of patients makes this QPI difficult to achieve. Action is required to ensure patients are seen and marked appropriately by Stoma Nurses. 22

23 Following formal review after year 3 QPI 3 was updated: The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 4 figures from the first 3 years of QPI collection. 23

24 SURGICAL OUTCOMES QPI 5: Lymph Node Yield Hospital of Surgery Target = 90% 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. Lothian Target 90% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 87.2% 100.0% 83.1% 100.0% 86.2% 87.3% Cases operated on outwith Board of Diagnosis: Borders sent 1 case to Lothian and 1 to Tayside; Fife sent 1 to Forth Valley; Lothian operated on 1 case from Borders and 3 from WoSCAN region. Comments where this QPI was not met: Borders: There was a shortfall of 2.8% (6 cases). Fife: There was a shortfall of 6.9% (22 cases). Lothian: There was a shortfall of 3.5% (34 cases). Action: Performance has remained at 85-89% over the last 4 years, continued monitoring is required. 24

25 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 Patients LN BGH D&G Fife Lothian SCAN < to to > Total It is noted that the QPI target has increased from 80% to 90% following the 3-year formal review. The target was continuously met in previous years by all Boards, but each Board is aware of the new target and will strive to meet this. It is noted in the HIS Colorectal QPI paper ( 48f6-999a-1e248d5ab6aa&version=-1) that varying evidence exists regarding the most appropriate target level therefore this may need redefined in the future, to take account of new evidence or as further data becomes available. Below are QPI 5 figures from the first 3 years of QPI collection. 25

26 QPI 6: Neo-adjuvant Therapy Target= 90% Numerator = Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive long course neo-adjuvant therapy. Denominator = All patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery. Exclusions = Patients who refuse neo-adjuvant. Patients in whom neo-adjuvant therapy is contraindicated. Patients who presented as an emergency for surgery Target 90% Borders D&G Fife Lothian SCAN Cohort Ineligible for the QPI Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 100.0% 100.0% 83.3% 100.0% 94.6% Comments where the QPI was not met Fife: The target was not met showing a shortfall of 16.3% (2 cases). One had short course radiotherapy and one didn't have any pre-op treatment, due to liver metastases being found the decision was made to go straight to surgery. Action: All patients were treated appropriately and no action is required. Following formal review after year 3, QPI 6 was updated. The inclusion of appendiceal cancers was removed from the dataset. The next page has QPI 6 figures comparing the four years of data collected. 26

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28 QPI 7: Surgical Margins (i) Hospital of Surgery Target = 95% 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. Lothian Target 95% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 100.0% 100.0% 96.9% 0.0% 97.1% 97.6% Cases operated on outwith Board of Diagnosis: Borders sent 1 case to Tayside; Fife sent 1 case to Forth Valley. All Boards met this QPI Action: This is a good result, however we strive to avoid positive margins, so SCAN will carry out a separate audit of cases with positive margins in data which will be included in next years report. Following formal review after year 3, QPI 7 (i) was not updated. The next page has QPI 7 (i) figures comparing the four years of data collected 28

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30 QPI 7: Surgical Margins (ii) Hospital of Surgery Target = 85% Numerator = Number of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy in which tumour is not 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. Lothian Target 85% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 100.0% 100.0% 90.9% 0.0% 100.0% 97.5% Cases operated on outwith Board of Diagnosis: D&G sent 1 case to Lothian, Fife sent 1 case to Lothian and 1 to Tayside; Lothian operated on 1 case from D&G, 1 case from Fife and 1 case from WoSCAN All Boards met this QPI Action: No action required. Following formal review after year 3, QPI 7 (ii) was not updated. The next page has QPI 7 (ii) figures comparing the four years of data collected. 30

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32 QPI 8: Re-operation Rates - Hospital of Surgery 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. Lothian Elective - Target <10% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 1.8% 1.6% 2.4% 0.0% 4.3% 2.4% Cases operated on outwith Board of Diagnosis: Lothian operated on 1 case from BGH and 1 case from Fife. 32

33 Lothian Emergency - Target <15% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 5.9% 3.6% 0.0% 4.8% 4.2% Following formal review it has been agreed that ISD will no longer provide the figures for QPI 8 from SMR01 returns. It will now be collected locally by audit staff in each Board. It should be noted however, that in Borders, Fife and Lothian we have been collecting and reporting on this QPI from information collected locally since

34 QPI 9: Anastomotic Dehiscence (i) Hospital of Surgery 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. Lothian Target <5% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 6.1% 3.0% 0.0% 2.3% 2.7% Cases that were operated on outwith Board of Diagnosis: 3 cases from Borders were operated on in Lothian Comments where QPI not met D&G: The target was not met showing a shortfall of 1.1% (2 cases). Both were reviewed by the MDT (different surgeons) and no specific learning was identified. Action: These figures are very good. Small number variation in regional boards induces large percentage changes. No action is identified. 34

35 Following formal review after year 3, QPI 9 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 9 (i) figures from the first 3 years of QPI collection. 35

36 QPI 9: Anastomotic Dehiscence (ii) Hospital of Surgery 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 = None. Lothian Target <10% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 0.0% 2.0% 0.0% 6.3% 4.2% Cases that were operated on outwith Board of Diagnosis: 1 case from Borders was operated on in Tayside; 1 case from WoSCAN was operated on in Lothian This QPI was met by all Boards. Action: No action required. 36

37 Following formal review after year 3, QPI 9 (ii) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 9 (ii) figures from the first 3 years of QPI collection. 37

38 QPI 10 (i): 30 Day Mortality Following Surgical Resection Hospital of Surgery Target = Elective surgical resection <3% 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 Lothian Target <3% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 1.7% 3.1% 0.0% 0.8% 1.5% Cases operated on outwith Board of Diagnosis: Borders sent 2 cases to Lothian, 1 case to Tayside; D&G sent 1 case to Lothian, Fife sent 1 case to Tayside, 1 case to Forth Valley; Lothian operated on 2 cases from Borders, 1 case from D&G, 1 case from Fife and 3 cases from WoSCAN. Comments where the QPI was not met: Fife: The target was not met with a shortfall of 0.1% (4 cases) 25 days - multi-organ failure; 10 days - pulmonary oedema/heart failure; 5 days - aspiration pneumonia; 11 days - pulmonary embolism. Action: No action identified. 38

39 Following formal review after year 3, QPI 10 (i) was updated. The target was changed from <5% to <3%. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (i) figures from the first 3 years of QPI collection. 39

40 QPI 10 (i): 30 Day Mortality Following Surgical Resection Hospital of Surgery Emergency Surgery Lothian Target <15% BGH DGRI VHK RIE WGH SCAN Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 16.7% 8.3% 7.1% 0.0% 2.6% 5.3% Cases operated on outwith Board of Diagnosis: 1 case from Borders operated on in Lothian. Comments where the QPI was not met: Borders: The target was not met with a shortfall of 1.7% (2 cases). 1 died 1 day post operative from intractable hypotension, 1 died 3 days post operatively from sepsis and multiorgan failure which did not respond to treatment. Action: Small numbers produce large percentage changes and no action has been identified. 40

41 Following formal review after year 3, QPI 10 (ii) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (ii) figures from the first 3 years of QPI collection. 41

42 QPI 10 (ii): 90 Day Mortality Following Surgical Resection Target = Elective surgical resection <4% 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 Lothian Target <4% BGH DGRI VHK RIE WGH SCAN Numerator (elective surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 1.7% 3.9% 0.0% 1.2% 1.9% Cases operated on outwith Board of Diagnosis: Borders sent 2 cases to Lothian, 1 case to Tayside; D&G sent 1 case to Lothian, Fife sent 1 case to Tayside, 1 case to Forth Valley; Lothian operated on 2 cases from Borders, 1 case from D&G, 1 case from Fife and 3 cases from WoSCAN. This QPI was met in all Boards. 42

43 Following formal review after year 3, QPI 10 (ii) was updated. The target was changed from <5% to <4%. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (ii) figures from the first 3 years of QPI collection. 43

44 QPI 10 (ii): 90 Day Mortality Following Surgical Resection Hospital of Surgery Emergency Surgery Lothian Target <20% BGH DGRI VHK RIE WGH SCAN Numerator (emergency surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 25.0% 8.3% 7.4% 0.0% 6.6% 8.3% Cases operated on outwith Board of Diagnosis: 1 case from Borders operated on in Lothian. Comments where this QPI was not met: Borders: The target was not met showing a shortfall of 5% (3 cases). 1 patient under the care of the palliative team with extensive distant metastases died from progression. 1 elderly patient did not improve postoperatively and the decision was made to limit further therapeutic interventions. 1 patient presented with perforated cancer and stercoral peritonitis and progressed to multiorgan failure. The high postoperative death rate is rather unfortunate as we are dealing with very small numbers. Action: Small numbers produce large percentage changes and no action has been identified. 44

45 Following formal review after year 3, QPI 10 (ii) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (ii) figures from the first 3 years of QPI collection. 45

46 ONCOLOGICAL TREATMENT OUTCOMES QPI 11: Adjuvant chemotherapy in Patients with High Risk Dukes B Target = 50% Numerator = Number of patients between 50 and 74 years of age at diagnosis with 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 high risk Dukes B colorectal cancer who undergo surgical resection. Exclusions = No exclusions. Target 50% Borders D&G Fife Lothian SCAN Cohort Ineligible for the QPI Numerator - High Risk Dukes B Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 66.7% 50.0% 50.0% 51.9% 52.6% High risk Dukes B colorectal cancer is defined as patients with (pt4a or pt4b disease) with/ without extramural venous invasion, or pt3 pn0 M0 with extramural venous invasion This QPI was met by all Boards 46

47 Following formal review after year 3, QPI 11 was updated. The inclusion of appendiceal cancers was removed from the dataset. In addition the definition of high risk Dukes B was changed to all patients with (pt4a or pt4b disease) with/without extramural vascular invasion or pt3 N0 M0 with extramural vascular invasion. Below are the QPI 11 figures from the first 3 years of QPI collection. Action: No action identified. 47

48 QPI 11: Adjuvant chemotherapy in Patients with Dukes C colorectal cancer Target = 70% Numerator = Number of patients between 50 and 74 years of age at diagnosis with Dukes C, 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, colorectal cancer who undergo surgical resection. Exclusions = No exclusions. Target: 70% Borders D&G Fife Lothian SCAN Cohort Ineligible for the QPI Numerator - Dukes C Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 72.7% 71.4% 86.7% 82.8% 81.4% All Boards met this QPI 48

49 Following formal review after year 3, QPI 11 was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 11 figures from the first 3 years of QPI collection. Action: No action identified. 49