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Assessing the Effect of Clinical Guidelines on Cancer Services for Colorectal Cancer UKACR Annual Conference, London 29th September 2004 Lou Gonsalves, Colin Brooks, Carly Mellors, Gill Lawrence West Midlands Cancer Intelligence Unit [email protected] tel: 0121 414 7711 fax: 0121 414 7712 West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Acknowledgements WMCIU Registration and Data Quality teams Henry Gowen Lillian Somervaille - WMPHO Richard Wilson - South Birmingham PCT Gavin Rudge - University of Birmingham West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Colorectal cancer in the UK 3rd most commonly-diagnosed cancer • over 35,000 cases per year • increasing 2nd most common cause of cancer death • over 16,000 deaths per year (>10% of all cancer deaths) 5 year survival just under 50% • prognostic factors • stage at diagnosis • admission method into hospital • quality of surgery West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Improving Outcomes in Colorectal Cancer cancer service guidance published by DH/NICE • initially published in 1997 • updated June 2004 West Midlands Cancer Intelligence Unit recommendations on appropriate treatment and care of people with colorectal cancer evidence-based www.wmpho.org.uk/wmciu Improving Outcomes in Colorectal Cancer Patient-centred care Access to appropriate services Multi-disciplinary teams Diagnosis Surgery and histopathology Radiotherapy in primary disease Adjuvant chemotherapy Anal cancer Follow-up Recurrent and advanced disease Palliative care West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Key Questions Has clinical practice changed in the West Midlands since the introduction of the clinical guidelines? Have outcomes improved between 1998 and 2002? West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Hospital Episode Statistics (HES) data What are HES data? information on admitted patient care delivered by NHS hospitals in England sub-set of the data submitted by NHS Trusts to the NHS-Wide Clearing Service (NWCS) ‘episode’ defined as a period of admitted patient care under a particular consultant within a single hospital provider (several episodes spell) do not include out-patient treatments West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Hospital Episode Statistics (HES) data What is recorded? patient demographics • postcode, date of birth, sex, NHS number episode details • diagnosis (7)(14 from 2002/3), OPCS4 codes (4)(12 from 2002/3), admission date, admission method, procedure date, discharge date, discharge destination, episode start and end dates, hospital code West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Linking data sets Cancer registration database at WMCIU HES database at West Midlands Public Health Observatory (WMPHO) Match cohort of cancer registry patients against episodes on HES database Issues of confidentiality • identifiable patient information • Data Protection Act 1998, Health and Social Care Act 2001, Caldicott Principles • NWCS Security and Confidentiality Advisory Group protocols • UKACR and WMCIU Confidentiality Guidelines West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Linkage Methodology Step 1 - match WMCIU patients to HES episodes • on NHS number, postcode, date of birth, sex • partial matches - corroborate with treatment data Step 2 - data quality checks • group HES episodes into spells and compare to WMCIU treatment dates Step 3 - compare treatments between HES and WMCIU • OPCS4 codes • some treatments not expected to match – diagnostic procedures, non-cancer related procedures (HES) – treatments in private/voluntary organisations, out-patient treatments (WMCIU) West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Linkage Methodology Step 4 - produce composite database of combined information • demographic details • tumour characteristics • treatment details – validated OPCS4 codes – admission method – length of stay in hospital West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Data Tumours registered at WMCIU : with colorectal cancer diagnosis (ICD10 codes C18-C20) diagnosed in the periods: • 1st January - 31st December 1998 • 1st January - 31st December 2002 Resections: OPCS4 codes H04 - H11 and H33 West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Diagnosis and surgery 1998 2002 Tumours diagnosed 3382 3192 Surgical interventions 2619 2294 81.52% 91.54% Surgical interventions ‘matched’ to HES episodes recording of NHS numbers in HES data has improved not all interventions are expected to match • day surgery on out-patient basis, private hospitals West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Admission method (matched cases) 1998 2002 4% 26% 27% 69% 74% elective West Midlands Cancer Intelligence Unit emergency not known www.wmpho.org.uk/wmciu Histopathology reporting IOG: “The histopathologist should search for as many lymph nodes as possible in the excised specimen ...and the number found should be audited.” Measure: “The proportion of histopathology reports which give the degree of involvement of surgical margins...the number of lymph nodes examined and the number involved.” West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Histopathology reporting (matched cases) % with margins reported Elective % with margins reported Emergency West Midlands Cancer Intelligence Unit 1998 2002 82.34% 87.95% 84.52% 89.69% 76.28% 83.92% www.wmpho.org.uk/wmciu Excision margins (matched cases, resections only) IOG: Measure: “Proportion of “curative” resections...with involved surgical margins.” % with involved margins 1998 2002 Elective 10.52% 7.81% Emergency 11.95% 9.49% West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Surgical caseload IOG: “Surgery should be undertaken by specialist colorectal cancer surgeons” • 1997: “An average figure of one or two radical colorectal resections per month has been suggested as a minimum number.” • 2004: “Each surgeon in the MDT should carry out a minimum of 20 colorectal resections with curative intent per annum.” West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Surgical caseload 100% 100% 90% 90% 80% 80% <5 70% 5-9 60% 50% 10-19 40% >20 30% % treated by surgeon % treated by surgeon (matched cases, resections only) 1998 2002 70% 60% 50% 40% 30% 20% 20% 10% 10% 0% 0% elective emergency Admission method West Midlands Cancer Intelligence Unit elective emergency Admission method www.wmpho.org.uk/wmciu Conclusions Linking cancer registration and hospital episode statistics data facilitates the monitoring of cancer services in the West Midlands The introduction of clinical guidelines for the management of colorectal cancer patients has resulted in some changes in clinical practice • better reporting of excision margins • lower rates of margin involvement at first surgery but • little change in surgical specialisation West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu Any questions? West Midlands Cancer Intelligence Unit www.wmpho.org.uk/wmciu