Outcomes

CRSC outcomes are 10 per cent higher than the best-case scenario national average. We know this because measuring and reporting our outcomes is central to our philosophy at CRSC.

We want to inform our patients and be transparent in doing so, but it’s also a vital guide to how we review and improve our practice.

Measuring outcomes objectively is more complicated than it might at first seem. What is a good outcome? What does success look like?

These questions can have very different answers depending on who’s asking them. One person’s perfect outcome might be to live a cancer-free life no matter what additional cost. For someone else, it might be the ability to live without any restriction on their quality of life, or perhaps to return to work as quickly as possible.

In practice, however, it’s not always possible to ensure all of these.

So what do we mean by good outcomes? At CRSC, we mean safe surgery, that minimises the trauma of surgery and allows for a quick recovery.

A useful way of measuring these outcomes is to use a composite of several care plan aims – often referred to as a ‘textbook outcome’. If any one of these is not achieved, the outcome would be logged as a ‘failure’.

Figure 1: Textbook outcomes for cancer patients at CRSC

We achieve a textbook outcome for almost 9 out of every 10 cancer patients we see (see Figure 1). For non-cancer patients requiring major operations the number is 8 out of 10, and for hernia patients the figure rises to more than 90 per cent.

For our cancer patients who require major surgery (bowel resection), the factors we record are:

1. Conversion to open surgery (where keyhole and/or robotic surgery was planned, but could not be completed)
2. Severe complications (one that required return to theatre and/or unplanned admission to the intensive care unit)
3. Length of stay more than 10 days (our average length of stay is between 4 and 5 days, but exceedingly long stays are often related to less severe complications)
4. Readmission to hospital within 30 days
5. Mortality within 90 days
6. Positive resection margin R1 (R1 describes viable tumour very close or at the level of the dissection, suggesting that some cancer cells may have been left behind)

Figure 2a: Cancer Patient Outcomes

Figure 2b: Major surgery patient (non-cancer) outcomes

For the outcomes of non-cancer patients who require major surgery (Figure 3a), we only record points 1-5 above. This is because R1 margins are a cancer-specific outcome.

Figure 2c: Hernia patient outcomes

Our hernia patient outcomes (Figure 2c), are recorded similarly to our non-cancer patient outcomes. The difference is that a stay of more than one day is recorded as a failure.

Figure 3: CRSC patient outcomes by factor

Of course, outcomes aren’t just determined by surgical intervention. Perioperative care, including the decision-making process and the general health of patients before they undergo surgery are also a factor.

Direct comparisons can be difficult as data is collected in slightly different ways. The most complete data sets available are for cancer surgery, which typically report textbook outcomes between 50 and 77 per cent worldwide.

The NHS provides exact figures through the National Bowel Cancer Audit. The figures from 2021-2022 are:

1. Conversion: 8% (varying between 3% and 13% in different regions of England)
2. Severe complications: 7.6% (return to theatre)
3. Length of stay >10 days: 20%
4. Readmission to hospital within 30 days: 11.3%
5. Mortality within 30 days: 1.6%
6. Positive resection margin (R1 rate): 7.4%

Bearing in mind that multiple factors could be present in the same patient, (and therefore not reported as a composite outcome), textbook outcomes in the NHS would be expected to be somewhere between a worst-case scenario of 44.1 per cent and a best-case scenario of 78.4%.

That means CRSC outcomes are 10% higher than the best-case scenario national average.