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  • Journal article
    Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Aylin Pet al., 2011,

    Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals

    , Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, Vol: 13, Pages: 816-822, ISSN: 1463-1318

    AIM: Reduced hospital stay confers clinical and economic benefits for patients and healthcare providers. This article examines the length of stay and consequent bed resource usage of patients undergoing elective excisional colorectal surgery in English NHS trusts. METHOD: All patients undergoing elective colorectal resections for malignancy between 1996 and 2006 in English NHS trusts were included from the Hospital Episode Statistics data set. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay and 28-day readmission. RESULTS: Over the 10-year period, 186,013 patients underwent elective colorectal procedures in 181 NHS trusts. About 2.893 b million bed days were utilized for elective colorectal surgery. Admission stay was shorter following colonic surgery than following rectal surgery (median 11 vs 13 days, P < 0.001). A 2-day decrease in median stay was observed over the 10-year period for both colonic and rectal procedures. Readmissions within 28 days of discharge were higher following rectal excision than following colonic surgery (9.4 vs 7.6%, P < 0.001). Multiple logistic regression analyses revealed the following independent predictors of prolonged hospital stay: distal (vs proximal) bowel resection, benign pathology, open technique, increasing age, comorbidity, social deprivation and low provider volume status. Independent predictors of 28-day readmission included distal bowel resection, benign diagnosis, young age, social deprivation and high provider volume status. CONCLUSION: Patients of advanced age, with associated comorbidities, and those living in areas of social deprivation are at increased risk of prolonged stay. Targeted pre-emptive discharge planning and enhanced use of laparoscopic surgery could improve bed resource utilization.

  • Journal article
    Faiz O, Haji A, Bottle A, Clark SK, Darzi AW, Aylin Pet al., 2011,

    Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007

    , Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, Vol: 13, Pages: 779-785, ISSN: 1463-1318

    BACKGROUND: This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated. METHODS: All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset. RESULTS: Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively). CONCLUSIONS: Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

  • Journal article
    Almoudaris AM, Burns EM, Bottle A, Aylin P, Darzi A, Faiz Oet al., 2011,

    A colorectal perspective on voluntary submission of outcome data to clinical registries

    , The British journal of surgery, Vol: 98, Pages: 132-139, ISSN: 1365-2168

    BACKGROUND: The aim of the study was to identify outcome differences amongst patients undergoing resection of colorectal cancer at English National Health Service trusts using Hospital Episode Statistics (HES). A comparison was undertaken of trusts that submitted and those that did not submit, or submitted only poorly, voluntarily to a colorectal clinical registry, the National Bowel Cancer Audit Programme (NBOCAP). METHODS: The NBOCAP data set was used to classify trusts according to submitter status. HES data were used for outcome analysis. Data for major resections of colorectal cancer performed between 1 August 2007 and 31 July 2008 were obtained from HES. Trusts not submitting data to NBOCAP and those submitting less than 10 per cent of their total workload were termed 'non-submitters'. HES data for 30-day mortality, length of stay and readmission rates were compared according to submitter and non-submitter status in multifactorial analyses. RESULTS: A total of 17,722 patients were identified from HES for inclusion. Unadjusted 30-day in-hospital mortality rates were higher in non-submitting than in submitting trusts (5.2 versus 4.0 per cent; P = 0.005). Submitter status was independently associated with reduced 30-day mortality (odds ratio 0.76, 95 per cent confidence interval 0.61 to 0.96; P = 0.021) in regression analysis. CONCLUSION: A higher postoperative mortality rate following resection of colorectal cancer was found in trusts that do not voluntarily report data to NBOCAP. Implications regarding the voluntary nature of submission to such registries should be reviewed if they are to be used for outcome benchmarking.

  • Journal article
    Calderón-Larrañaga A, Carney L, Soljak M, Bottle A, Partridge M, Bell D, Abi-Aad G, Aylin P, Majeed Aet al., 2011,

    Association of population and primary healthcare factors with hospital admission rates for chronic obstructive pulmonary disease in England: national cross-sectional study

    , Vol: 66, Pages: 191-196

    Background Hospital admission rates for chronic obstructive pulmonary disease (COPD) are known to be strongly associated with population factors. Primary care services may also affect admission rates, but there is little direct supporting evidence.Objectives To determine associations between population characteristics, diagnosed and undiagnosed COPD prevalence, primary healthcare factors, and COPD admission rates primary care trust (PCT) and general practice levels in England.Design, setting, and participants National cross-sectional study (53,676,051 patients in 8,064 practices in 152 English PCTs), combining data on hospital admissions, populations, primary healthcare staffing, clinical practice quality and access, and prevalence.Main outcome measures Directly and indirectly standardised hospital admission rates for COPD, for PCT and practice populations.Results Mean annual COPD admission rates per 100 000 population varied from 124.7 to 646.5 for PCTs and 0.0 to 2175.2 for practices. Admissions were strongly associated with population deprivation at both levels. In a practice-level multivariate Poisson regression, registered and undiagnosed COPD prevalence, smoking prevalence and deprivation were risk factors for admission (p<0.001), while healthcare factors- influenza immunisation, patient-reported access to consultations within two days, and primary care staffing, were protective (p<0.05).Conclusion Associations of COPD admission rates with deprivation, primary healthcare access and supply highlight the need for adequate services in deprived areas. An association between admission rates and undiagnosed COPD prevalence suggests that case-finding strategies should be evaluated. Of the COPD clinical quality indicators, only influenza immunisation was associated with reduced admission rates. Patients' experience of access to primary care may also be clinically important.

  • Journal article
    Burns EM, Bottle A, Aylin P, Clark SK, Tekkis PP, Darzi A, Nicholls RJ, Faiz Oet al., 2011,

    Volume analysis of outcome following restorative proctocolectomy

    , The British journal of surgery, Vol: 98, Pages: 408-417, ISSN: 1365-2168

    BACKGROUND: This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome. METHODS: All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval. RESULTS: Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0.5 per cent and the 1-year overall mortality rate 1.5 per cent. Some 30.5 per cent of trusts performed fewer than two procedures per year, and 91.4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6.4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0.001) and a lower proportion with ulcerative colitis (P < 0.001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure. CONCLUSION: Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high- and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.

  • Journal article
    Bottle A, Jarman B, Aylin P, 2011,

    Strengths and weaknesses of hospital standardised mortality ratios.

    , BMJ: British Medical Journal, Vol: 342
  • Journal article
    Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, Faiz ODet al., 2011,

    Systematic review of discharge coding accuracy

    , ISSN: 1741-3850

    Introduction Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable analysis. This study aims to assess the published accuracy of routinely collected data sets in Great Britain. METHODS: Systematic searches of the EMBASE, PUBMED, OVID and Cochrane databases were performed from 1989 to present using defined search terms. Included studies were those that compared routinely collected data sets with case or operative note review and those that compared routinely collected data with clinical registries. RESULTS: Thirty-two studies were included. Twenty-five studies compared routinely collected data with case or operation notes. Seven studies compared routinely collected data with clinical registries. The overall median accuracy (routinely collected data sets versus case notes) was 83.2% (IQR: 67.3-92.1%). The median diagnostic accuracy was 80.3% (IQR: 63.3-94.1%) with a median procedure accuracy of 84.2% (IQR: 68.7-88.7%). There was considerable variation in accuracy rates between studies (50.5-97.8%). Since the 2002 introduction of Payment by Results, accuracy has improved in some respects, for example primary diagnoses accuracy has improved from 73.8% (IQR: 59.3-92.1%) to 96.0% (IQR: 89.3-96.3), P= 0.020. CONCLUSION: Accuracy rates are improving. Current levels of reported accuracy suggest that routinely collected data are sufficiently robust to support their use for research and managerial decision-making.

  • Journal article
    Burns EM, Bottle A, Aylin P, Darzi A, Nicholls RJ, Faiz Oet al., 2011,

    Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics

    , Vol: 343, ISSN: 1468-5833

    OBJECTIVE: To describe national reoperation rates after elective and emergency colorectal resection and to assess the feasibility of using reoperation as a quality indicator derived from routinely collected data in England. DESIGN: Retrospective observational study of Hospital Episode Statistics (HES) data. SETTING: HES dataset, an administrative dataset covering the entire English National Health Service. PARTICIPANTS: All patients undergoing a primary colorectal resection in England between 2000 and 2008. MAIN OUTCOME MEASURES: Reoperation after colorectal resection, defined as any reoperation for an intra-abdominal procedure or wound complication within 28 days of surgery on the index or subsequent admission to hospital. RESULTS: The national reoperation rate was 6.5% (15,986/246,469). A large degree of variation was identified among institutions and surgeons. Even among institutions and surgical teams with high caseloads, threefold and fivefold differences in reoperation rates were observed between the highest and lowest performing trusts and surgeons. Of the NHS trusts studied, 14.1% (22/156) had adjusted reoperation rates above the upper 99.8% control limit. Factors independently associated with higher risk of reoperation were diagnosis of inflammatory bowel disease (odds ratio 1.33 (95% CI 1.24 to 1.42), P<0.001), presence of multiple comorbidity (odds ratio 1.34 (1.29 to 1.39), P<0.001), social deprivation (1.14 (1.08 to 1.20) for most deprived, P<0.001), male sex (1.33 (1.29 to 1.38), P<0.001), rectal resection (1.63 (1.56 to 1.71), P<0.001), laparoscopic surgery (1.11 (1.03 to 1.20), P = 0.006), and emergency admission (1.21 (1.17 to 1.26), P<0.001). CONCLUSIONS: There is large variation in reoperation after colorectal surgery between hospitals and surgeons in England. If data accuracy can be assured, reoperation may allow performance to be checked against national standards from current routinely collected data, alongside other indicator

  • Journal article
    Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, Faiz Oet al., 2011,

    Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection

    , The British journal of surgery, Vol: 98, Pages: 1775-1783, ISSN: 1365-2168

    BACKGROUND: Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure-to-rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England. METHODS: The Hospital Episode Statistics (HES) database was used to identify patients undergoing primary resection for colorectal cancer between 2000 and 2008 in English National Health Service (NHS) trusts. Units were ranked into quintiles according to overall risk-adjusted mortality. Highest and lowest mortality quintiles were compared with respect to reoperation rates and FTR-surgical (FTR-S) rates. FTR-S was defined as the proportion of patients with an unplanned reoperation who died within the same admission. RESULTS: Some 144 542 patients undergoing resection for colorectal cancer in 150 English NHS trusts were included. On ranking according to risk-adjusted mortality, rates varied significantly between lowest and highest mortality quintiles (5.4 and 9.3 per cent respectively; P = 0.029). Lowest and highest mortality quintiles had equivalent adjusted reoperation rates (both 4.8 per cent; P = 0.211). FTR-S rates were significantly higher at units within the worst mortality quintile (16.8 versus 11.1 per cent; P = 0.002). CONCLUSION: FTR-S rates differed significantly between English colorectal units, highlighting variability in ability to prevent death in this high-risk group. This variability may represent differences in serious surgical complication management. FTR-S represents a readily collectable marker of surgical complication management that is likely to be applicable to other surgical specialties. Copyright (c) 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

  • Journal article
    Mamidanna R, Burns EM, Bottle A, Aylin P, Stonell C, Hanna GB, Faiz Oet al., 2011,

    Reduced Risk of Medical Morbidity and Mortality in Patients Selected for Laparoscopic Colorectal Resection in England: A Population-Based Study

    , ISSN: 1538-3644

    OBJECTIVES: To quantify the occurrence of significant medical complications following elective colorectal resection and investigate potential differences in medical morbidity following open and minimal access colorectal surgery. DESIGN: Retrospective analysis of Hospital Episode Statistics, which is a prospectively maintained national database. SETTING: All patients undergoing colorectal resection in National Health Service trusts in England. PATIENTS: Adult patients undergoing elective or planned surgery between April 2001 and March 2008. INTERVENTION: Colorectal resection for benign and malignant diagnoses. MAIN OUTCOME MEASURES: Mortality and morbidity at 30 days and 1 year following elective colorectal resection. RESULTS: One hundred thirty-eight thousand seven hundred thirty-five elective colorectal resections were identified between the study dates. Thirty-day in-hospital mortality was 3.4% and 1.7% following conventional and laparoscopic surgery, respectively (P < .001). Overall, the 30-day postoperative medical morbidity rate was 14.6%. Use of the minimal access approach demonstrated a significant reduction in total morbidity risk at 30 days (odds ratio, 0.79; P < .001) and 365 days (odds ratio, 0.81; P < .001) following case-mix adjustment. Multiple regression analyses demonstrated that cardiorespiratory complications and venous thromboembolism occurred less frequently during the index admission and up to 1 year following minimal access surgery when compared with the conventional approach (P < .049). CONCLUSIONS: In this population-based study, patients selected for laparoscopic colorectal resection were associated with lower risk of mortality as well as reduced cardiorespiratory and venous thromboembolic risk than those undergoing open surgery.

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