Assessing the Effect of Clinical Guidelines on Cancer Services for Colorectal Cancer

1. 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 lou.gonsalves@wmciu.nhs.uk tel: 0121 414 7711 fax: 0121 414 7712

2. Acknowledgements WMCIU Registration and Data Quality teams Henry Gowen Lillian Somervaille - WMPHO Richard Wilson - South Birmingham PCT Gavin Rudge - University of Birmingham

3. 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

4. Improving Outcomes in Colorectal Cancer • cancer service guidance published by DH/NICE • initially published in 1997 • updated June 2004 • recommendations on appropriate treatment and care of people with colorectal cancer • evidence-based

5. 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

6. Key Questions Has clinical practice changed in the West Midlands since the introduction of the clinical guidelines? Have outcomes improved between 1998 and 2002?

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. Diagnosis and surgery • recording of NHS numbers in HES data has improved • not all interventions are expected to match • day surgery on out-patient basis, private hospitals

14. 1998 2002 elective emergency not known Admission method(matched cases)

15. 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.”

16. Histopathology reporting(matched cases)

17. Excision margins(matched cases, resections only) IOG: • Measure: “Proportion of “curative” resections...with involved surgical margins.”

18. 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.”

19. 1998 2002 <5 5-9 10-19 >20 Surgical caseload(matched cases, resections only)

20. 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

21. Any questions?