Data Item Queries

Which procedures are included as a major resection?

• Right hemicolectomy
  • Extended right hemicolectomy
  • Transverse colectomy
  • Left hemicolectomy
  • Sigmoid colectomy
  • Anterior resection
  • APER
  • Pelvic exenteration
  • Hartmann’s procedure
  • Total colectomy and ileorectal anastomosis
  • Total excision of colon and rectum
  • Total excision of colon and rectum + anastomosis of ileum to anus + create pouch

Why does the audit use the pre-2004 NCEPOD classification?

The audit uses the pre-2004 National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) classification of surgical urgency, despite there being an update to this.

The arguments to maintain the pre-2004 NCEPOD definition are that the classification based on this definition correlates strongly with:

• known risk factors for emergency treatment (age, socio-economic deprivation, and presence
  of co-morbidity)
  • the mode of admission coded in HES
  • the observed 90-day mortality.

Introducing a new classification system for a key characteristic of the surgical procedure would make it impossible to compare outcomes in different audit periods which would in turn make it impossible to monitor trends in outcome over time, which is one of the key functions of the audit.

Should we be distinguishing between sigmoid and rectal tumours?

Yes. From about 30,000 cases, using ‘rectosigmoid’ as the site of cancer generated a subset of 400 cases which could not be usefully analysed. Therefore we would encourage hospitals/trusts/MDTs to ensure that they are assigning either ‘sigmoid’ or ‘rectum’ accordingly to cases.

How will COVID-19 impact NBOCA reporting?

The patient cohort included in the 2020 annual report pre-dates the pandemic and so the results within the 2020 annual report are unaffected. However, due to pressures on providers during the initial phase of the pandemic we were unable to do our usual data checking process, and this is why there is more incomplete data for this reporting period than we would usually expect.

The 2021 report includes patients diagnosed primarily between 01 April 2019 and 31 March 2020. Major resections up to 31 March 2020 are included in order to avoid the impact of the pandemic. Patients diagnosed before 31 March 2020 and undergoing major resection after this date are included in the 2022 report. The pandemic will have started to have an impact during the period in the 2021 report.

The 2022 report includes patients diagnosed between 01 April 2020 and 31 March 2021, and patients diagnosed between 01 April 2019 and 31 March 2020 who underwent a major resection after 31 March 2020. All of these patients were diagnosed and/or treated during the COVID-19 pandemic and their outcomes are not outlier-reported. The only outcome that is outlier-reported in the 2022 report is 2-year all-cause mortality after major resection because it includes patients having surgery before the pandemic.

How should ASA Grade be recorded for patients undergoing major resection?

The ACPGBI/NBOCA recommend that ASA grade of each patient must be determined by the anaesthetist alone before resection of the cancer. The anaesthetist commonly gives this judgement as part of the “Time Out” – before the surgical procedure starts. The Colorectal Surgeon should record the ASA grade given by the anaesthetist in the operation note and this will be the grade submitted to NBOCA.

ASA grade is a central component of NBOCA risk-adjustment. Feedback from some MDTs has indicated that the diagnosis of colorectal cancer alone has been used routinely to justify ASA II – despite the fact that the large majority of colorectal cancer patients have localised disease at the time of resection and not systemic disease.

How is data completeness defined?

Definition of the data completeness measure used by NBOCA in its reporting and in Trust Results

Data completeness is defined as the proportion of patients with complete data for the variables age, sex, ASA grade, pathological TNM stage (tumour, node, metastasis staging) and site of cancer. This is because these seven variables are used for risk-adjustment. Mode of admission and number of co-morbidities are also used in the risk-adjustment model but are collected from HES/PEDW data and so are not included in the assessment of data completeness. Data completeness is only assessed in patients who underwent major resection because only in these patients could all seven data items be expected to be complete.