publication report upper gi cancer quality performance ... · upper gi cancer qpi data for patients...

An Official Statistics Publication for Scotland

Information Services Division

Publication Report

Upper GI Cancer Quality Performance Indicators

Patients diagnosed during 2013

Publication date – 17th February 2015

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Contents

Contents............................................................................................................................ 2

Introduction ....................................................................................................................... 3

Foreword from Upper GI Cancer Clinical Leads ............................................................... 5

Results and Commentary.................................................................................................. 7

Case Ascertainment ...................................................................................................... 7

Overall Performance Summary ..................................................................................... 8

Quality Performance Indicators ................................................................................... 10

Clinical Trials ............................................................................................................... 49

List of abbreviations ........................................................................................................ 51

List of Tables ................................................................................................................... 52

Contact ........................................................................................................................... 53

Further Information ......................................................................................................... 53

Rate this publication ........................................................................................................ 53

A1 – Background Information ...................................................................................... 54

A2 – Upper GI Cancer QPIs ........................................................................................ 54

A3 – Upper GI Clinical Trials ....................................................................................... 56

A4 – Publication Metadata (including revisions details) ............................................... 57

A5 – Early Access details (including Pre-Release Access) ......................................... 59

A6 – ISD and Official Statistics .................................................................................... 60

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Introduction The Better Cancer Care plan, published in 2008, included a commitment to 'develop a work programme which will define how we will take forward… quality indicators for cancer services'. To achieve this, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG), which includes responsibility for:

The development of small sets (approximately 10-15 indicators) of tumour specific national quality performance indicators (QPIs) as a proxy measure of quality care.

Overseeing the implementation of the national governance framework that underpins the reporting of performance against these national QPIs.

The QPIs have been developed collaboratively with the three Regional Cancer Networks: North of Scotland Cancer Network (NOSCAN), South East Scotland Cancer Network (SCAN), West of Scotland Cancer Network (WoSCAN), Information Services Division (ISD), and Healthcare Improvement Scotland. The QPIs are published on the Healthcare Improvement Scotland website. These indicators, used to drive quality improvement in cancer care across NHSScotland are kept under regular review; NHS Boards will be required to report against QPIs as part of a mandatory national cancer quality programme. ISD support NHS Boards in improving the quality of local data collection and reporting through the production of data validation specifications, and measurability criteria for QPIs. The current data sets are outlined on the Cancer Audit website. A rolling programme of reporting is planned across many tumour sites. National reports will include comparative reporting of performance against QPIs at NHS Board level across NHS Scotland, trend analysis and survival analysis (where applicable). This approach will help overcome existing issues relating to the reporting of small volumes in any one year. This report assesses performance against 11 Upper GI Cancer QPIs using clinical audit and SMR01 data relating to patients diagnosed with Upper GI cancer for the period from January to December 2013. This was the first year of QPI data collection; therefore, this report provides the first opportunity to review performance against these new measures and to review the effectiveness of the measures themselves. Therefore, this report contains only one year, rather than three years of data, as will be the norm in future publications. As a result of this, the information in this report may be impacted by the effect of small numbers. Future reporting of Upper GI QPIs may include changes or refinements to indicator definitions and measurability criteria based on a review of this first publication– refer to the Healthcare Improvement Scotland website for the latest version of these QPIs.

http://www.scotland.gov.uk/Topics/Health/health/cancer

http://www.noscan.scot.nhs.uk/

http://www.scan.scot.nhs.uk/

http://www.woscan.scot.nhs.uk/

http://www.isdscotland.org/

http://www.healthcareimprovementscotland.org/programmes/cancer_care_improvement/cancer_resources/cancer_qpis.aspx


http://www.sehd.scot.nhs.uk/mels/CEL2012_06.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=d23bf48a-d2f9-43b4-be57-465f6ff101d2&version=-1


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Data collection and analysis

Upper GI cancer QPI data for patients diagnosed in 2013 were collected by NHS Boards, supported by the regional cancer networks, then analysed against the Upper GI cancer measurability document. Aggregated analysed data were then submitted to ISD via a data collection template for collation to allow comparisons at NHS Board level for both Gastric and Oesophageal cancers.

Data quality and completeness

Small numbers: Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). However, any commentary provided by NHS Boards relating to the impacted indicators will be included as a record of continuous improvement.

Quality Assurance:

A quality assurance assessment of the Upper GI Cancer QPI dataset was conducted on a sample of records throughout mainland Scotland. 282 records were assessed, which represents approximately 19% of Upper GI cancer patients in the QPI cohort who completed their treatment in 2013 and for which records were submitted to ISD. The accuracy of recording of all data items in the Upper GI Cancer QPI data set for this sample was very high, ranging from 96% to almost 100%.

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Upper_GI_Cancer_QPI_Measurability_V1.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Upper_GI_Cancer_QPI_Measurability_V1.pdf

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Foreword from Upper GI Cancer Clinical Leads The three Regional Cancer Networks (North of Scotland Cancer Network (NOSCAN), South East Scotland Cancer Network (SCAN), and West of Scotland Cancer Network (WOSCAN)) aim to promote the highest standards of cancer care and equity of access to cancer services across Scotland. The development and introduction of national Quality Performance Indicators (QPI) represents a major step forward for patients with Upper GI Cancer. Only by collecting accurate and relevant audit data can we identify areas of future development to improve the service. This first report is an impressive piece of work based on data for 1,512 patients diagnosed with Oesophago-Gastric Cancer in 2013 in Scotland of which 374 were treated in NOSCAN, 413 in SCAN and 725 in WOSCAN. This data was formally presented at the National Oesophago-Gastric Cancer Audit Meeting held in Glasgow on 24th October 2014. The QPIs have been developed by clinical staff across the three Regional Cancer Networks in collaboration with Information Services Division, Healthcare improvement Scotland, Scottish Cancer Coalition and the Scottish Government. The measures have been developed with a clear focus on patient outcomes to allow us to identify action points where QPIs have not been achieved, identify areas of high quality care that should continue and be shared across NHS Boards, and to reflect on whether the QPIs are robust and achieving what they set out to achieve. Key Recommendations / Key Points to Note Overall performance against the 11 Upper GI Cancer QPIs was generally good across all NHS Boards; however no individual NHS Board met all 11 QPI targets. This suggests that the target levels for the QPIs are challenging and that there are areas for improvement. QPI 1 – Diagnosis at initial endoscopy The Networks have agreed to undertake targeted audit to study patients who were not diagnosed at the time of initial endoscopy to identify whether appropriate biopsy protocols were used and evaluate any delays in diagnosis. QPI 4 – Nutritional assessment This QPI was not met by any of the three Networks. It is not clear whether this is because patients did not require dietary assessment at the time of diagnosis, whether the recording is adequate, or whether patients requiring assessment have been unable to have this due to dietetic resources. There was overwhelming agreement that all patients diagnosed with Oesophago-Gastric cancer should have an early nutritional assessment. The Networks have agreed to undertake targeted audit to evaluate whether all patients require a formal dietetic assessment or whether a nutritional screening tool could help to identify those requiring formal dietetic assessment.

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QPI 6 - 30 and 90 Day Mortality Following Surgery Overall the postoperative mortality rates following Upper GI cancer resection in Scotland were excellent and comfortably achieved the QPI targets. However, NOSCAN did not meet the targets for oesophageal or gastric resection. It was agreed that the past three years data should be obtained and further analysis undertaken. QPI 10 – Curative treatment rates The QPI target of 35% was not met by any of the three Networks. The Networks believe this reflects the advanced stage of disease at diagnosis and other health problems of patients. The best way to achieve this target is through earlier detection of Upper GI cancer. Variation in types of curative treatment of oesophageal cancer It was noted at the National meeting that there was a variation between Networks in the type of curative treatment used for oesophageal cancer. This had been noticed in previous years and was primarily related to a higher proportion of patients receiving chemoradiotherapy in NOSCAN, rather than surgery (with or without neo-adjuvant therapy) as in the other two Networks. The Networks have agreed to undertake targeted audit to be presented at the next national meeting to identify the reasons for this variance and any differences in outcome in order to ensure there is equity of care across Scotland. A significant amount of data has been collated and analysed for this report and the information and audit teams across NHS Scotland are to be congratulated. We would like to thank the Network audit facilitators for their hard work in collecting the audit data for this report. Mr Peter Lamb Mr Matthew Forshaw Mr Sami Shimi Chair, SCAN Upper GI Clinical Lead Chair, NOSCAN Upper GI WOSCAN Upper GI MCN

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Results and Commentary

Case Ascertainment

Case ascertainment is a measure of data quality and is calculated by comparing the number of new patients captured by the cancer audit with a five year average of the numbers recorded on the cancer registry. A five year average is used for registry data as the information is not available until sometime after the year under examination. This is due to data collection and verification processes. As the number of cases will vary each year, it is possible for case ascertainment to be over or under 100%. Therefore, the figures presented should be seen as an indication only.

Average case ascertainment across the NHS Boards in 2013 was 98% Seven NHS Boards had a case ascertainment figure over 100%

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Estimated Case Ascertainment (%) - 2013

No. of Audit Records

Diagnosed in 2013

Average No. of Cancer

Registrations (2008-12)

Estimated Case

Ascertainment %

NOSCAN 374 392 95.5

Grampian 157 153 102.3

Orkney 3 4 68.2

Shetland 10 5 185.2

Highland (incl. Argyll) 58 82 70.7

Tayside 133 137 97.1

Western Isles 13 9 138.3

SCAN 413 381 108.3

Lothian 226 208 108.8

Fife 102 99 103.4

Borders 39 33 118.2

Dumfries & Galloway 46 42 109.5

WoSCAN 725 767 94.5

Ayrshire & Arran 96 116 82.8

Lanarkshire 152 156 97.4

Forth Valley 87 88 99.1

Greater Glasgow & Clyde 390 407 95.7

Scotland 1512 1540 98.2

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Overall Performance Summary

The tables below summarise the overall performance across the country for each QPI. QPI Summary table – Oesophageal Cancer by Health Board

QPI Gram

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Isle

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Greater

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QPI 1 * - Endoscopy > 90% 81% - 63% 92% 79% 100% 82% 79% 91% 88% 91% 84% 86% 88% 90% 82% 85% 84%

QPI 2 * - Radiological Staging> 90% 94% - 100% 92% 95% 100% 94% 95% 96% 81% 100% 95% 97% 98% 94% 81% 88% 91%

QPI 3 * - Staging and Treatment Intent> 95% 81% - 75% 83% 95% 90% 86% 85% 97% 54% 61% 82% 92% 97% 98% 64% 79% 82%

QPI 4 * - Nutritional Assessment> 85% 94% - 50% 19% 84% 20% 72% 41% 57% 50% 52% 47% 62% 70% 45% 32% 45% 53%

QPI 5 * - Appropriate Selection of

Surgical Patients> 80% 86% - - 24% 79% - 55% 83% 75% 100% 100% 86% 43% 100% 73% 82% 79% 74%

QPI 6(i)** - 30 Day Mortality Following

Surgery< 10% 25% - - 17% 0% - 11% 2% - - - 2% - 0% - 0% 0% 3%

QPI 6(ii)** - 90 Day Mortality Following

Surgery< 10% 25% - - 17% 0% - 11% 3% - - - 3% - 0% - 0% 0% 4%

QPI 8 ** - Length of Hospital Stay

Followng Surgery> 60% 71% - - 67% 59% - 63% 80% - - - 79% 88% 43% - 63% 63% 70%

QPI 9(i) ** - Resection Margins> 70% 50% - - 67% 54% - 56% 55% - - - 55% - 44% - 74% 71% 61%

QPI 10 * - Curative Treatment Rates> 35% 30% - 0% 35% 22% 20% 26% 30% 29% 27% 33% 30% 20% 17% 27% 23% 22% 25%

QPI 11(i) * - 30/90 Day Mortality

Following Oncological Treatment

(Curative)Chemoradiotherapy - 30 day 4% - - 14% 0% - 6% - - - - 0% - - - 0% 0% 3%

Chemoradiotherapy - 90 day 4% - - 14% 20% - 8% - - - - 0% - - - 6% 4% 6%

Adjuvant Chemotherapy - 30 day - - - - - - - - - - - - - - - 0% 0% 0%


Neoadjuvant chemotherapy - 30 day 0% - - 0% 0% - 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1%

Neoadjuvant chemotherapy - 90 day 29% - - 8% 0% - 12% 4% 0% 0% 0% 2% 0% 0% 0% 0% 0% 4%

Adjuvant radiotherapy - 30 day - - - - - - - - - - - - - - - - - -


QPI 11(ii) * - 30/90 Day Mortality


(Palliative)Chemotherapy

6% - - 25% 0% - 11% 11% 0% - 17% 9% 7% 14% 17% 7% 10% 10%

Radiotherapy15% - - 0% 14% - 11% 8% 0% - - 4% 0% - 14% 13% 11% 10%

Target

< 10%

< 20%

‘-‘ excluded due to small numbers * data shown by board of diagnosis ** data shown by board of surgery

Met or exceeded target

Target not met

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QPI Summary table – Gastric Cancer by Health Board

QPI Gram

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Taysid

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Weste

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Ayrsh

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Greate

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QPI 1 * - Endoscopy > 90% 69% - - 100% 76% - 74% 75% 94% 77% 67% 79% 79% 93% 80% 73% 79% 78%

QPI 2 * - Radiological Staging> 90% 81% - - 83% 91% - 86% 93% 94% 92% 85% 93% 84% 93% 80% 79% 83% 86%

QPI 3 * - Staging and Treatment Intent> 95% 55% - - 67% 91% - 71% 68% 88% 46% 54% 69% 81% 95% 88% 56% 72% 71%

QPI 4 * - Nutritional Assessment> 85% 95% - - 33% 63% - 75% 28% 62% 46% 23% 38% 55% 73% 24% 27% 41% 47%

QPI 5 * - Appropriate Selection of

Surgical Patients> 80% - - - - - - 100% - - - - 100% 100% 57% - 82% 80% 86%

QPI 6(i)** - 30 Day Mortality Following

Surgery< 10% 14% - - - 25% - 19% 4% - - - 3% 0% 0% - 7% 5% 7%

QPI 6(ii)** - 90 Day Mortality Following

Surgery< 10% 14% - - - 25% - 19% 4% - - - 6% 0% 0% - 8% 5% 8%

QPI 7 ** - Lymph Node Yield> 80% 43% - - - 50% - 50% 70% - - - 74% 88% 83% - 63% 67% 67%

QPI 8 ** - Length of Hospital Stay

Followng Surgery> 60% 100% - - - 60% - 82% 85% - - - 88% 90% - - 88% 87% 87%

QPI 9(i) ** - Resection Margins> 90% 86% - - - 100% - 94% 83% - 0% - 87% 100% 100% - 96% 95% 92%

QPI 10 * - Curative Treatment Rates> 35% 17% - - 0% 25% - 19% 27% 15% 15% 31% 23% 26% 15% 24% 21% 21% 21%

QPI 11(i) * - 30/90 Day Mortality


(Palliative)

Chemoradiotherapy - 30 day - - - - - - - - - - - - - - - - - -

Chemoradiotherapy - 90 day - - - - - - - - - - - - - - - - - -



Neoadjuvant chemotherapy - 30 day - - - - - - 0% - - - - 0% 0% 0% - 0% 0% 0%

Neoadjuvant chemotherapy - 90 day - - - - - - 14% - - - - 0% 0% 14% - 11% 10% 9%



QPI 11(ii) * - 30/90 Day Mortality


(Palliative)Chemotherapy 8% - - - - - 5% 10% - - - 7% 11% 7% - 10% 9% 8%

Radiotherapy - - - - - - 14% - - - - - - - - - - 18%

< 20%

Target

< 10%

Clinical Trials Summary Table – by SCRN Clinical Access to Clinical Trials SCRN - North & East SCRN - South East SCRN - West

Trials Interventional > 7.5% 1.0% 3.1% 0.7%

Translational > 15% 8.7% 0.3% 6.4% ‘-‘ excluded due to small numbers * data shown by board of diagnosis ** data shown by board of surgery Met or exceeded target

Target not met

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Quality Performance Indicators

The following section includes a detailed summary of each of the eleven Upper GI cancer QPIs (for both Oesophageal and Gastric cancers where applicable) outlining the variation at NHS Board level. Charts are colour coded by network. Where performance at either level is shown to fall below the target, commentary from the relevant NHS Board is included to provide context to the variation.

QPI 1: Endoscopy: Patients with oesophageal or gastric cancer should undergo endoscopy and biopsy to reach a diagnosis of cancer.

For diagnosis of oesophageal or gastric cancer the use of endoscopy is recommended. However, it may not always be technically possible to undertake a biopsy and patient choice may also be a factor. Numerator: Number of patients with oesophageal or gastric cancer who undergo endoscopy who have a histological diagnosis made following initial endoscopy and biopsy. Denominator: All patients with oesophageal or gastric cancer who undergo endoscopy. Exclusions: No exclusions. Target: 90% or above

Oesophageal Cancer Of the 1,033 patients with oesophageal cancer who underwent endoscopy in Scotland in 2013, 865 had a histological diagnosis made following the initial endoscopy and biopsy. This equates to a rate of 84% which is below the target rate of 90% for this indicator. At NHS Board level, the performance against this indicator ranged from 63% to 100% with only five NHS Boards exceeding the target: NHS Highland, NHS Western Isles, NHS Fife, NHS Dumfries and Galloway and NHS Forth Valley.

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QPI 1: Endoscopy - %Patients diagnosed following initial endoscopy (Oesophageal)

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% Performance Numerator Denominator

Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 80.5 91 113 - - - - -

Orkney - - - - - - - -

Shetland 62.5 5 8 - - - - -

Highland 92.2 47 51 - - - - -

Tayside 79.2 80 101 - - - - -

Western Isles 100.0 10 10 - - - - -

NOSCAN 81.8 234 286 - - - - -

Lothian 78.9 120 152 - - - - -

Fife 91.2 62 68 - - - - -

Borders 88.5 23 26 - - - - -

Dumfries and Galloway 90.6 29 32 - - - - -

SCAN 84.2 234 278 - - - - -

Ayrshire and Arran 85.9 55 64 - - - - -

Lanarkshire 88.0 81 92 - - - - -

Forth Valley 90.3 56 62 - - - - -

Greater Glasgow and Clyde 81.7 205 251 - - - - -

WoSCAN 84.6 397 469 - - - - -

Scotland 83.7 865 1033 - - - - - Source: Cancer audit - Data not shown due to small numbers or zero values

Following case note review a number of NHS Boards commented that for many patients a histological diagnosis was made following a subsequent endoscopy: NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde, NHS Lothian, NHS Fife, NHS Borders and NHS Grampian. NHS Tayside noted that patients on surveillance endoscopy were included within this measure which had impacted on their results and NHS Shetland highlighted that small numbers had resulted in large percentage shifts for this measure. Gastric Cancer Of the 450 patients with gastric cancer who underwent endoscopy in Scotland in 2013, 353 had a histological diagnosis made following the initial endoscopy and biopsy. This equates to a rate of 78% which is below the target rate of 90% for this indicator. At NHS Board level, the performance against this indicator ranged from 67% to 100% with only three NHS Boards exceeding target: NHS Highland, NHS Fife and NHS Lanarkshire.

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QPI 1: Endoscopy - %Patients diagnosed following initial endoscopy (Gastric)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 69.0 29 42 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 100.0 6 6 - - - - -

Tayside 75.9 22 29 - - - - -

Western Isles - - - - - - - -

NOSCAN 74.1 60 81 - - - - -

Lothian 75.0 51 68 - - - - -

Fife 93.9 31 33 - - - - -

Borders 76.9 10 13 - - - - -


SCAN 79.4 100 126 - - - - -


Lanarkshire 93.2 55 59 - - - - -

Forth Valley 80.0 20 25 - - - - -


WoSCAN 79.4 193 243 - - - - -


Again a number of NHS Boards commented that for many patients a histological diagnosis was made following a subsequent endoscopy, or there was no malignancy on initial endoscopy: NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde, NHS Fife, NHS Lothian and NHS Borders. NHS Forth Valley noted that small numbers had impacted on percentages and that it was not always clinically appropriate to biopsy every patient at initial endoscopy. NHS Greater Glasgow and Clyde highlighted that the figures for gastric cancer reflect advanced cases where registration at MDT only occurs and NHS Dumfries and Galloway commented that a number of patients were unable to undergo biopsy due to patient clinical conditions. Following local review of results NHS Grampian concluded that an appropriate number of patients had diagnostic endoscopies and robust criteria for unequivocal reporting of invasive disease on endoscopic biopsies had been appropriately applied. The board will audit the results and an appropriate intervention will be undertaken if required.

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NHS Shetland noted that small numbers had impacted on percentages and NHS Tayside indicated that their figures included a diverse group of patients and therefore biopsy was not always appropriate at initial endoscopy. Several Health Boards noted that it was not possible to biopsy gastric cancer patients presenting with an upper GI bleed where the priority was the arrest of haemorrhage. These patients were usually brought back for a timely second endoscopy and biopsy.

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QPI 2: Radiological Staging: Patients with oesophageal or gastric cancer should undergo CT of chest, abdomen +/- pelvis.

The primary tumour and its local extent should be defined and the presence or absence of metastatic disease assessed. However, some patients may not be fit enough to undergo investigations and/or treatment or refuse for factors of patient choice. Numerator: Number of patients with oesophageal or gastric cancer who undergo contrast enhanced CT of chest and abdomen +/- pelvis. Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions. Target: 90% or above

Oesophageal Cancer

Overall in Scotland, 91% of patients diagnosed with oesophageal cancer in 2013 received a contrast enhanced CT of the chest and abdomen (+/- pelvis) to check for the presence of any metastatic disease related to the primary tumour. Only NHS Borders and NHS Greater Glasgow and Clyde did not meet the target of 90%.

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QPI 2: Radiological Staging - %Patients receiving CT of chest and abdomen +/- pelvis (Oesophageal)

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Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 93.9 108 115 - - - - -

Orkney - - - - - - - -

Shetland 100.0 8 8 - - - - -

Highland 92.3 48 52 - - - - -

Tayside 95.0 96 101 - - - - -

Western Isles 100.0 10 10 - - - - -

NOSCAN 94.1 272 289 - - - - -

Lothian 95.4 145 152 - - - - -

Fife 95.6 65 68 - - - - -

Borders 80.8 21 26 - - - - -


SCAN 94.6 264 279 - - - - -


Lanarkshire 97.8 90 92 - - - - -

Forth Valley 93.5 58 62 - - - - -


WoSCAN 87.9 415 472 - - - - -


Following casenote review NHS Greater Glasgow and Clyde noted that the denominator for this QPI includes palliative registration cases which had impacted on percentages and also identified a local data recording issue where the use of contrast was not always documented in the CT report. NHS Borders commented that the five cases not undergoing contrast enhanced CT had incomplete imaging.

NHS Lothian, NHS Fife and NHS Highland reported appropriate reasons for patients not having a CT for example fitness/co-morbidities or an incidental finding where the patient had died shortly after diagnosis.

Gastric Cancer

For gastric cancer it was more difficult to achieve the target – at a national level 86% of the 466 patients diagnosed received the CT. This was driven by a number of Boards performing below the target – NHS Grampian, NHS Highland, NHS Dumfries and Galloway, NHS Ayrshire and Arran, NHS Forth Valley and NHS Greater Glasgow and Clyde – and is likely to be indicative of a number of patients presenting with more advanced disease who are not fit enough to undergo CT. The smaller numbers for gastric cancer compared to oesophageal cancer may also be a contributing factor in this performance.

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QPI 2: Radiological Staging - %Patients receiving CT of chest and abdomen +/- pelvis (Gastric)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 81.0 34 42 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 83.3 5 6 - - - - -

Tayside 90.6 29 32 - - - - -


NOSCAN 85.9 73 85 - - - - -

Lothian 93.2 69 74 - - - - -

Fife 94.1 32 34 - - - - -

Borders 92.3 12 13 - - - - -


SCAN 92.5 124 134 - - - - -


Lanarkshire 93.3 56 60 - - - - -

Forth Valley 80.0 20 25 - - - - -


WoSCAN 83.0 205 247 - - - - -

Scotland 86.3 402 466 - - - - -

Source: Cancer audit - Data not shown due to small numbers or zero values

Following casenote review valid clinical reasons were specified by NHS Ayrshire and Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde, NHS Lothian and NHS Fife for those patients not undergoing CT. These included emergency surgery, poor renal function and advanced disease at presentation.

NHS Fife, NHS Borders and NHS Dumfries and Galloway noted that incomplete imaging had impacted results and NHS Highland flagged that small numbers had resulted in large percentage shifts.

It should be emphasised that this QPI specifically states the use of a contrast enhanced CT is required to meet the criteria and that this was not always clinically possible and may not have been easily recorded.

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QPI 3: Staging and treatment intent: Patients with oesophageal or gastric cancer should be staged using the TNM staging system and have statement of treatment intent recorded prior to treatment commencing.

Patients with gastric or oesophageal cancer should undergo careful staging to assess the extent of disease and inform treatment decision making. This may involve multiple investigations. However, some patients may not be fit enough to undergo investigations and/or treatment - in these cases an attempt at TNM staging should be undertaken based on the information available. Numerator: Number of patients with oesophageal or gastric cancer who have TNM stage and treatment intent (radical or palliative) recorded at MDT prior to treatment. Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions Target: 95% or above

Oesophageal Cancer It was particularly challenging for the Boards in Scotland to achieve this target. At a Scotland level, only 82% of the 1,040 patients diagnosed with oesophageal cancer in 2013 had TNM stage and treatment intent discussed and recorded at the MDT prior to treatment. Only NHS Tayside, NHS Fife, NHS Lanarkshire and NHS Forth Valley achieved target for this QPI for oesophageal cancer patients.

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30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

% P

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QPI 3: Staging and treatment intent - %Patients with stage and treatment intent recorded prior to MDT (Oesophageal)

18



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 80.9 93 115 - - - - -

Orkney - - - 1 33.3 - - -

Shetland 75.0 6 8 - - - - -

Highland 82.7 43 52 - - - - -

Tayside 95.0 96 101 - - - - -

Western Isles 90.0 9 10 - - - - 1

NOSCAN 86.2 249 289 1 0.3 - - 1

Lothian 84.9 129 152 7 4.6 - - -

Fife 97.1 66 68 - - - - -

Borders 53.8 14 26 - - - - -


SCAN 82.1 229 279 7 2.5 - - -


Lanarkshire 96.7 89 92 - - - - -

Forth Valley 98.4 61 62 - - - - -


WoSCAN 79.0 373 472 - - - - -

Scotland 81.8 851 1040 8 0.8 - - 1 Source: Cancer audit - Data not shown due to small numbers or zero values

NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde, NHS Lothian, NHS Fife, NHS Dumfries and Galloway, NHS Shetland and NHS Grampian commented that many patients did not meet the QPI because they died before MDT, refused all treatment or were not discussed at MDT. In addition, NHS Greater Glasgow and Clyde noted that the current MDT system was being updated to include drop down boxes for TNM and it was anticipated that this would improve data recording. Following further review of data, NHS Grampian highlighted that there were appropriate clinical situations where, following full review of a case, uncertainty remains at the MDT on a patient’s medical fitness for radical treatment. Therefore in order to ensure appropriate specialist consideration of patients for radical treatment the decision on treatment intent is deferred until personal review by a specialised member of the upper GI cancer clinical team. Small numbers were noted in NHS Shetland and NHS Western Isles and reasons were provided for those patients who did not have TNM and treatment intent recorded. It has been agreed at QPI Baseline Review that for subsequent years analysis this indicator will also be reported separately for TNM stage and treatment intent (for both oesophageal and gastric cancer), in addition to TNM stage and treatment combined, to allow for easy identification of key quality issues. Gastric Cancer For gastric cancer, the target of 95% was only achieved by NHS Lanarkshire and NHS Western Isles (although small numbers of patients) meaning that at a national level the target was not met at 71%. This means that 127 gastric cancer patients (excluding 8 cases where staging was not recorded) in Scotland did not benefit from having their staging and treatment discussed and recorded at MDT prior to treatment.

19


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

% P

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QPI 3: Staging and treatment intent - %Patients with stage and treatment intent recorded prior to MDT (Gastric)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 54.8 23 42 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 66.7 4 6 - - - - -

Tayside 90.6 29 32 - - - - -


NOSCAN 70.6 60 85 - - - - -

Lothian 67.6 50 74 8 10.8 - - -

Fife 88.2 30 34 - - - - -

Borders 46.2 6 13 - - - - -


SCAN 69.4 93 134 8 6.0 - - -


Lanarkshire 95.0 57 60 - - - - -

Forth Valley 88.0 22 25 - - - - -


WoSCAN 72.1 178 247 - - - - -

Scotland 71.0 331 466 8 1.7 - - - Source: Cancer audit - Data not shown due to small numbers or zero values

Following casenote review NHS Ayrshire and Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde, NHS Fife and NHS Grampian noted the following reasons for patients not having staging and treatment intent recorded – patients had emergency surgery, refused all investigations, were not fit to have a CT scan or died before MDT discussion. NHS Lothian and NHS Dumfries and Galloway noted that patients listed as ‘not recorded’ were not discussed at MDT and NHS Greater Glasgow and Clyde highlighted that updates to the MDT system during 2014 should result in improved data recording going forward. NHS Tayside and NHS Shetland commented that small numbers had influenced percentages. Following further review of data, NHS Grampian highlighted that there were appropriate clinical situations where, following full review of a case, uncertainty remains at the MDT on a patient’s medical fitness for radical treatment. Therefore in order to ensure appropriate specialist consideration of patients for radical treatment the decision on treatment intent is deferred until personal review by a specialised member of the upper GI cancer clinical team.

20


QPI 4: Nutritional Assessment: Patients with oesophageal or gastric cancer should be referred for dietetic assessment where there are concerns about their nutritional status prior to commencing treatment.

All patients with oesophageal or gastric cancer should be screened using a validated nutritional screening tool to assess nutritional risk. Those at risk of nutritional problems should have access to a state registered dietician to provide appropriate advice. Poor nutritional status is a risk factor for poor tolerance of treatment whether curative or palliative and can impact greatly on quality of life. Numerator: Number of patients with oesophageal or gastric cancer referred to a dietitian within 4 weeks of diagnosis. Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions. Target: 85% or above

Oesophageal Cancer There is wide variation in performance across the country for this measure. For patients diagnosed with oesophageal cancer in 2013 in Scotland almost half (47%) were not referred to a dietitian within four weeks of diagnosis. Only NHS Grampian were able to exceed the target by implementing a process where dietitian referral is initiated at the point of MDT referral. Therefore patients are often assessed via telephone assessment before they are diagnosed.

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QPI 4: Nutritional Assessment - %Patients referred to dietitian within 4 weeks of diagnosis (Oesophageal)

21



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 93.9 108 115 - - - - -

Orkney - - - 2 66.7 - - -

Shetland 50.0 4 8 1 12.5 - - -

Highland 19.2 10 52 42 80.8 - - -

Tayside 84.2 85 101 - - - - -

Western Isles 20.0 2 10 - - - - 8

NOSCAN 72.3 209 289 45 15.6 - - 8

Lothian 41.4 63 152 - - - - -

Fife 57.4 39 68 16 23.5 - - -

Borders 50.0 13 26 - - - - -


SCAN 47.3 132 279 16 5.7 - - -


Lanarkshire 70.3 64 91 - - - - -

Forth Valley 45.2 28 62 - - - - -


WoSCAN 45.0 212 471 - - - - -


A number of NHS Boards commented that it was not always appropriate to refer all patients to a dietitian and that a number of patients had been referred after four weeks: NHS Ayrshire and Arran, NHS Lothian, NHS Fife, NHS Borders, NHS Dumfries and Galloway. Data capture issues were highlighted in NHS Borders, NHS Dumfries and Galloway, NHS Highland, NHS Shetland, NHS Western Isles and NHS Tayside and as a result Tayside, Shetland and Western Isles have implemented changes to improve data recording and ensure all patients are seen. NHS Lanarkshire has introduced new processes for improved correspondence with dietitians and a dietitian now regularly attends the MDT. Similarly NHS Forth Valley will continue to work closely with the local dietitian however noted that the service has limited capacity. NHS Greater Glasgow and Clyde highlighted that increased dietetic involvement and staffing would be required to meet the target for this QPI. Gastric Cancer For gastric cancer, it was a similar picture – only NHS Grampian and NHS Shetland (although based on small numbers) managed to achieve target. Overall in Scotland, 47% (217 patients) received a nutritional assessment within 4 weeks of diagnosis.

22


0.0

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% P

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QPI 4: Nutritional Assessment - %Patients referred to dietitian within 4 weeks of diagnosis (Gastric)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 95.2 40 42 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 33.3 2 6 4 66.7 - - -

Tayside 62.5 20 32 3 9.4 - - -

Western Isles - - - - - - - 3

NOSCAN 75.3 64 85 7 8.2 - - 3

Lothian 28.4 21 74 - - - - -

Fife 61.8 21 34 6 17.6 - - -

Borders 46.2 6 13 - - - - -


SCAN 38.1 51 134 6 4.5 - - -


Lanarkshire 73.3 44 60 2 3.3 - - -

Forth Valley 24.0 6 25 - - - - -


WoSCAN 41.3 102 247 2 0.8 - - -


Similar comments for gastric cancer were returned by boards in relation to timescales, data recording and capacity issues at an NHS Board level. Additionally it was noted that some gastric cancer patients may have specific nutritional requirements following a gastrectomy and would therefore not be referred within the four week time period specified within the QPI.

23


QPI 5: Appropriate Selection of Surgical Patients: Patients with oesophageal or gastric cancer whose treatment plan is neoadjuvant chemotherapy followed by surgery should progress to surgery following completion of chemotherapy portion of treatment plan.

Patients with oesophageal or gastric cancer who are suitable for surgical resection should be offered neoadjuvant chemotherapy treatment. It is optimal management that patients who undergo neoadjuvant chemotherapy proceed to resectional (curative) surgery; various reasons may affect this including initial under-staging of disease. Numerator: Number of patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy who then undergo surgical resection. Denominator: All patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy. Exclusions: No exclusions Target: 80% or above

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Oesophageal Cancer For oesophageal cancer, of the 145 patients in Scotland who received neo-adjuvant chemotherapy only 108 received surgical resection. At 75%, this falls short of the target of 80% for this measure. At a regional level, this was impacted by the performance in NOSCAN where almost half (45%) of patients meeting the criteria did not receive surgery post chemotherapy. WoSCAN achieved a performance of 79%, just missing the target of 80% and SCAN managed to surpass the target with a performance of 86.4%.

24


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QPI 5: Appropriate selection of surgical patients - %Patients receiving surgical resection post neo-adjuvant chemotherapy (Oesophageal)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 85.7 6 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 23.5 4 17 - - - - -

Tayside 78.6 11 14 - - - - -


NOSCAN 55.0 22 40 - - - - -

Lothian 83.3 20 24 - - - - -

Fife 75.0 6 8 - - - - -

Borders 100.0 6 6 - - - - -


SCAN 86.4 38 44 - - - - -


Lanarkshire 100.0 10 10 - - - - -

Forth Valley 72.7 8 11 - - - - -


WoSCAN 78.7 48 61 - - - - -


Valid clinical reasons for patients not proceeding to surgery were provided by NHS Ayrshire and Arran, NHS Forth Valley, NHS Lothian and NHS Fife including patient fitness, inoperable tumour, lack of response to chemotherapy, evidence of peritoneal disease at surgery or disease progression on imaging. NHS Tayside highlighted that small numbers had impacted on percentages for this QPI. Gastric Cancer The majority of NHS Boards in Scotland had fewer than 10 gastric cancer patients who received neo-adjuvant chemotherapy. At a national level, the target was exceeded with 38 (86%) out of a total of 44 patients receiving surgical resection post chemotherapy.

25


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% P

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QPI 5: Appropriate selection of surgical patients - %Patients receiving surgical resection post neo-adjuvant chemotherapy (Gastric)


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian - - - - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside - - - - - - - -


NOSCAN 100.0 8 8 - - - - -

Lothian - - - - - - - -

Fife - - - - - - - -

Borders - - - - - - - -

Dumfries and Galloway - - - - - - - -

SCAN 100.0 6 6 - - - - -


Lanarkshire 57.1 4 7 - - - - -

Forth Valley - - - - - - - -


WoSCAN 80.0 24 30 - - - - -

Scotland 86.4 38 44 - - - - - NHS Lanarkshire noted that a case review is underway and there are ongoing efforts to concentrate much of the oesophago-gastric cancer workload into a single specialist unit within Lanarkshire and it is anticipated that this will help to improve performance.

26


QPI 6: 30/90 Day Mortality Following Surgery: 30 and 90 day mortality following surgical resection for oesophageal or gastric cancer

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Numerator: Number of patients with oesophageal or gastric cancer who undergo surgical resection who die within 30/90 days of treatment. Denominator: All patients with oesophageal or gastric cancer who undergo surgical resection. Exclusions: No exclusions Target: Less than 10%

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Information at hospital level (by hospital of diagnosis and hospital of surgery) is also available in the data tables. Oesophageal Cancer For oesophageal cancer patients diagnosed in the NOSCAN Health Boards, the 30 day mortality rate following surgical resection was 11% overall which is just above the target of < 10%. For patients diagnosed within the SCAN or WoSCAN regions the mortality rate was comfortably below the threshold. Overall, in Scotland the mortality rate 30 days after surgery for oesophageal patients is low at 3%. The pattern is repeated when looking at the mortality rates after 90 days. At a Scotland level, for oesophageal cancer, the mortality rate is 4% after 90 days. The NOSCAN rate is unchanged at 11%.

http://www.isdscotland.org/Health-Topics/Quality-Indicators/Publications/2015-02-17/2015-02-17-UpperGI-QPI-Data.xls

27


0.0

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30.0%

Pe

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ceQPI 6: 30/90 Day Mortality following surgery (By Location of Surgery) - Oesophageal

30 Day Mortality 90 Day Mortality Target

30 Day Mortality following surgery (By Location of Surgery) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 25.0 2 8 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 16.7 1 6 - - - - -

Tayside - - 13 - - - - -


NOSCAN 11.1 3 27 - - - - -

Lothian 1.7 1 60 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 1.7 1 60 - - - - -

Ayrshire and Arran - - - - - - - -

Lanarkshire - - 10 - - - - -

Forth Valley - - - - - - - -

Greater Glasgow and Clyde - - 37 - - - - -

WoSCAN - - 51 - - - - -

Scotland 2.9 4 138 - - - - - 90 Day Mortality following surgery (By Location of Surgery) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 25.0 2 8 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 16.7 1 6 - - - - -

Tayside - - 13 - - - - -


NOSCAN 11.1 3 27 - - - - -

Lothian 3.3 2 60 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 3.3 2 60 - - - - -


Lanarkshire - - 8 - - - - -

Forth Valley - - - - - - - -


WoSCAN - - 45 - - - - -

Scotland 3.8 5 132 - - - - - Source: Cancer audit - Data not shown due to small numbers or zero values Note – the number of cases in the denominator for 30 day and 90 day may not match as 90 days had not elapsed at time of analysis

28


NHS Grampian commented that the results had been reviewed within the context of the four year period from 2010-2013 and practice will be carefully reviewed as part of the QPI annual reporting process. SCAN noted that all morbidity and mortality will continue to be reviewed in formal Mortality and Morbidity meetings within boards. Gastric Cancer It was a similar pattern for gastric cancer patients where again the NOSCAN Health Boards collectively did not meet the target. However, this is likely to be influenced by the relatively small sample size. For Scotland overall, the 30 day mortality rate following surgery for gastric cancer patients is under 7%. Similarly, 8% of all gastric cancer patients in Scotland who received surgical resection treatment died within 90 days of surgery. SCAN highlighted that a single death within NHS Fife had resulted in higher percentages because of low numbers and the results will be reviewed within the context of results over a number of years. As with oesophageal cancer, NHS Grampian commented that the results had been reviewed for gastric cancer within the context of the four year period from 2010-2013 and practice will be carefully reviewed as part of the QPI annual reporting process.

29


0.0

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10.0

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30.0%

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ceQPI 6: 30/90 Day Mortality following surgery (By Location of Surgery) - Gastric


30 Day Mortality following surgery (By Location of Surgery) - Gastric


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 14.3 1 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside 25.0 2 8 - - - - -


NOSCAN 18.8 3 16 - - - - -

Lothian 4.3 1 23 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 3.2 1 31 - - - - -

Ayrshire and Arran - - 7 - - - - -


Forth Valley - - - - - - - -


WoSCAN 4.8 2 42 - - - - -

Scotland 6.7 6 89 - - - - - 90 Day Mortality following surgery (By Location of Surgery) - Gastric


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 14.3 1 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside 25.0 2 8 - - - - -


NOSCAN 18.8 3 16 - - - - -

Lothian 4.3 1 23 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 6.5 2 31 - - - - -



Forth Valley - - - - - - - -


WoSCAN 5.0 2 40 - - - - -


30


QPI 7: Lymph Node Yield: For patients with gastric cancer undergoing curative resection the number of lymph nodes examined should be maximised.

Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making. Evidence recommends that at least 15 lymph nodes are resected and examined by a pathologist. Numerator: Number of patients with gastric cancer who undergo curative surgical resection where >15 lymph nodes are resected and pathologically examined. Denominator: All patients with gastric cancer who undergo curative surgical resection. Exclusions: No exclusions Target: 80% or above

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Information is presented here by Health Board of where the treatment took place. Further information at hospital level (by hospital of diagnosis and hospital of surgery) is also available in the data tables. Gastric Cancer Of the 90 gastric cancer patients receiving curative surgical resection in 2013, 60 patients had a minimum of 15 lymph nodes resected and examined. This equates to a performance of 67% but falls short of the target of >80%. None of the regional networks achieved the target.

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QPI 7: Lymph node yield - %Patients receiving curative surgical resection where > 15 lymph nodes are resected and examined (Gastric)


31



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 42.9 3 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside 50.0 4 8 - - - - -


NOSCAN 50.0 8 16 - - - - -

Lothian 69.6 16 23 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 74.2 23 31 - - - - -


Lanarkshire 83.3 5 6 - - - - -

Forth Valley - - - - - - - -


WoSCAN 67.4 29 43 - - - - -


NHS Forth Valley questioned the inclusion of palliative procedures within this measure and the potential impact this could have on performance of this QPI. The definition of the denominator in the QPI measurability document is purely based on operation code rather than treatment intent. Therefore, palliative procedures will be included even though the QPI states it should be curative only. This could have a significant effect on the performance of this QPI, particularly where there are small numbers involved as is the case for NHS Forth Valley. It was felt that the measurability for this QPI should be reviewed. This was a view shared by NHS Dumfries and Galloway and NHS Lothian.

A review of audit data was conducted by NHS Grampian comparing the 2013 data with the previous 3 years. It was concluded that the 2013 result was in contrast to previous years and they intend to undertake a surgical and pathology review to determine reasons for the lower lymph node yields i.e. was it operator dependent or related to specimen handling.

Following local review of the data, NHS Greater Glasgow and Clyde stated that discussions have taken place with pathology to determine actions to improve performance.

Following QPI Baseline Review this QPI has been updated to include reference to the fact that patients undergoing palliative resection are included within the measurement for clarity.

32


QPI 8 - Length of Hospital Stay Following Surgery: Length of hospital stay following surgery for oesophageal or gastric cancer should be as short as possible.

Length of hospital stay acts as a surrogate measure for the quality of surgery and post-operative care for patients undergoing surgical resection for oesophagogastric cancer. Numerator: Number of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 21 days of surgical procedure. Denominator: All patients undergoing surgical resection for oesophageal or gastric cancer. Exclusions: No exclusions. Target: 60% or above

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Information is presented here by Health Board of where the treatment took place. Further information at hospital level (by hospital of diagnosis and hospital of surgery) is also available in the data tables. Oesophageal Cancer For oesophageal cancer, all 3 regional networks achieved the target for this QPI although there was still some variation in performance: both WoSCAN and NOSCAN achieved a rate of 63% whereas in SCAN the figure was closer to 80%. At NHS Board level, the variation was more marked but this is largely due to the small numbers involved. At a national level, 70% of oesophageal cancer patients were able to be discharged within 21 days of receiving surgery.

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QPI 8: Length of stay - %Patients discharged within 21 days of surgery (Oesophageal)

Source: SMR01 Data - Data not shown due to small numbers or zero values


33


NHS Lanarkshire commented that due to the low numbers of patients, definitive conclusions about length of hospital stay (LOS) should be read with caution. Despite this limitation the cases have been reviewed and it is possible that the increased LOS reflects the following reasons. Standard practice within the unit is to allow patients home ‘on pass’ to return to either the ward or the hospital day surgery unit for assessment. It has been noted on dictating discharges that the recorded point of discharge is often at the later assessment which can be between 3 and 7 days from the point of hospital discharge. The other potential reason for the increased LOS is the difficult cases that have been selected for resection. Additional reasons include patients unexpectedly having preoperative stenting or having salvage oesophagectomy post chemoradiotherapy. A case review conducted by NHS Forth Valley highlighted a potential data completeness issue that may have affected performance of this QPI. Comparison of local records for patients receiving a partial gastrectomy carried out in Forth Valley Royal Hospital (emergency cases) and discharged within 21 days showed a mismatch in the number of patients compared to the SMR01 data source used for this QPI. NHS Tayside commented on the appropriateness of the target for this QPI highlighting that achieving target for a large geographical catchment area with high levels of deprivation would be challenging. Gastric Cancer A higher percentage of gastric cancer patients were discharged within 21 days: 87% of the 76 patients receiving surgical resection in Scotland in 2013 were discharged within that threshold. All 3 networks (and indeed all NHS Boards) were able to meet or exceed the target.

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QPI 8: Length of stay - %Patients discharged within 21 days of surgery (Gastric)

Source: SMR01 Data - Data not shown due to small numbers or zero values

34


QPI 9(i) - Resection Margins: Oesophageal cancers which are surgically resected should be adequately excised.

Tumour involvement of surgical resection margins is a negative prognostic factor; therefore surgery should aim to ensure resection margins are clear of tumour as this affects prognosis and long term patient outcome. Numerator: Number of patients with oesophageal cancer who undergo surgical resection in which circumferential and longitudinal surgical margin is clear of tumour. Denominator: All patients with oesophageal cancer who undergo surgical resection. Exclusions: No exclusions Target: 70% or above

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Information is presented here by Health Board of where the treatment took place. Further information at hospital level (by hospital of diagnosis and hospital of surgery) is also available in the data tables. Of the three regional networks only WoSCAN achieved the target – resection margins in 71% of WoSCAN oesophageal cancer patients receiving the surgery were found to be clear of tumour. This contrasts with SCAN and NOSCAN where the surgical margin was clear of tumour in only 55% of cases. The overall Scotland figure, therefore, was impacted by this performance at 61%.

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QPI 9(i): Resection Margins - %Patients receiving surgical resection where surgical margins are clear of tumour

(Oesophageal)


35



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 50.0 4 8 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 66.7 4 6 - - - - -

Tayside 53.8 7 13 - - - - -


NOSCAN 55.6 15 27 - - - - -

Lothian 55.0 33 60 1 1.7 - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 55.0 33 60 1 1.7 - - -


Lanarkshire 44.4 4 9 - - - - -

Forth Valley - - - - - - - -


WoSCAN 71.2 37 52 - - - - -


A case review in NHS Lanarkshire revealed that all positive margins were circumferential - there were no positive longitudinal margins. On reviewing the relevant cases it was found that a small number of patients had preoperative oesophageal stenting. It is now well documented that this results in an increased likelihood of positive circumferential resection margins. The use of oesophageal stenting had been by units not routinely involved in the management of these complicated patients. The message has now been disseminated that oesophageal stenting is not the preferred endoscopic option and that passing a feeding tube in patients who present with increasing dysphagia prior to planned resection is preferred. NHS Grampian highlighted that this single year of data is not typical of past performance. A review of data for the four year period 2010 to 2013 indicates clear surgical margins in 77% of oesophageal resections compared to 50% in 2013 only. To meet the criteria for this QPI, cases must have both circumferential and longitudinal margins clear of tumour. Both NHS Highland and NHS Lothian commented on cases where only either margin was clear thus not meeting the full criteria.

Following discussion at QPI Baseline Review it has been agreed that for subsequent year’s analysis results will be presented separately by circumferential and longitudinal resection margins, this will allow for identification of key quality issues. The target of 70% will however remain for both circumferential and longitudinal margins being clear of tumour.

36


QPI 9(ii) - Resection Margins: Gastric cancers which are surgically resected should be adequately excised.

Tumour involvement of surgical resection margins is a negative prognostic factor; therefore surgery should aim to ensure resection margins are clear of tumour as this affects prognosis and long term patient outcome. Numerator: Number of patients with gastric cancer who undergo surgical resection in which longitudinal surgical margin is clear of tumour. Denominator: All patients with gastric cancer who undergo surgical resection. Exclusions: No exclusions Target: 90% or above

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Information is presented here by Health Board of where the treatment took place. Further information at hospital level (by hospital of diagnosis and hospital of surgery) is also available in the data tables. In 2013, the majority (92%) of gastric cancer patients in Scotland who underwent surgical resection had their resection margins clear of tumour post surgery. Of the 3 regions only SCAN was below target but only marginally at 87% - this is largely influenced by NHS Lothian as the majority of surgical resections for this region are conducted within this Board (specifically at the Royal Infirmary of Edinburgh) where 82% of cases were clear of tumour.

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

% P

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ance

QPI 9(ii): Resection Margins - %Patients receiving surgical resection where surgical margins are clear of tumour

(Gastric)


37



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 85.7 6 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside 100.0 8 8 - - - - -


NOSCAN 93.8 15 16 - - - - -

Lothian 82.6 19 23 - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN 87.1 27 31 - - - - -


Lanarkshire 100.0 6 6 - - - - -

Forth Valley - - - - - - - -


WoSCAN 95.3 41 43 - - - - -


Both NHS Forth Valley and NHS Grampian commented on the small numbers impacting performance. To mitigate for this, NHS Grampian reviewed audit data for a four year period (2010 – 2013) and noted that 89% of gastric resections had clear margins. Following a case review in NHS Lothian, it was noted that the patients not meeting this target underwent either a palliative subtotal gastrectomy or a total gastrectomy for linitis plastica.

38


QPI 10 - Curative Treatment Rates: Patients with oesophageal or gastric cancer should undergo curative treatment whenever possible.

Curative treatment should be offered to as many patients as possible, as this is proven to have a survival benefit. However, patient choice, fitness and co-morbidities may preclude curative treatment. Numerator: Number of patients with oesophageal or gastric cancer who undergo curative treatment. Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions. Target: 35% or above

Oesophageal Cancer This QPI was particularly challenging to achieve as no Board managed to meet the target. There was wide variation across the country in the number of oesophageal cancer patients receiving curative treatment, ranging from 0% (likely influenced by small numbers) to 35%. Across Scotland, 25% of patients received curative treatment indicating there is considerable opportunity for improvement in this measure.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

% P

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orm

ance

QPI 10: Curative Treatment Rates - %Patients receiving curative treatment (Oesophageal)

39



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 29.6 34 115 - - - - -

Orkney - - - - - - - -

Shetland - - 8 - - - - -

Highland 34.6 18 52 - - - - -

Tayside 21.8 22 101 - - - - -

Western Isles 20.0 2 10 - - - - -

NOSCAN 26.3 76 289 - - - - -

Lothian 29.6 45 152 - - - - -

Fife 29.4 20 68 - - - - -

Borders 26.9 7 26 - - - - -


SCAN 29.7 83 279 - - - - -


Lanarkshire 17.4 16 92 - - - - -

Forth Valley 27.4 17 62 - - - - -


WoSCAN 22.2 105 472 - - - - -


Gastric Cancer For gastric cancer patients in Scotland it was a similar picture: only 21% of patients received curative treatment. No Boards in Scotland were able to achieve the target of 35%.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

% P

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ance

QPI 10: Curative Treatment Rates - %Patients receiving curative treatment (Gastric)

40



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 16.7 7 42 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside 25.0 8 32 - - - - -


NOSCAN 18.8 16 85 - - - - -

Lothian 27.0 20 74 - - - - -

Fife 14.7 5 34 - - - - -

Borders 15.4 2 13 - - - - -


SCAN 23.1 31 134 - - - - -


Lanarkshire 15.0 9 60 - - - - -

Forth Valley 24.0 6 25 - - - - -


WoSCAN 20.6 51 247 - - - - -

Scotland 21.0 98 466 - - - - -

Several NHS Boards (NHS Ayrshire and Arran, NHS Lanarkshire, NHS Forth Valley, NHS Greater Glasgow and Clyde, NHS Grampian and NHS Shetland) commented that the figures reflect patients’ late stage of disease at initial presentation and that improvement in this measure would need earlier diagnosis. In Glasgow and Lanarkshire, patient fitness was also cited as a contributing factor.

NHS Lanarkshire added that a detailed review of patients not receiving curative treatment was undertaken. Reasons included: stage of disease, patient refusing treatment (or died before treatment), fitness and no curative options. To ensure that there is not an inappropriate refusal of curative treatment based on fitness there is currently a planned change to fitness assessment. This new assessment will include dietitian, anaesthetist and surgeon input looking at a combination of nutrition, nutritional biochemistry, cardiopulmonary exercise testing, cardiac biomarkers and risk scoring. A case review in NHS Grampian for the 2 year period 2012-2013 indicated that 27.1% of patients had curative treatment as defined. It is believed that given current therapeutic modalities available and case mix and stage at presentation that a target of 35% of patients remains very challenging. NHS Tayside had a similar view that the target was too high for a deprived area.

41


QPI 11(i) - 30/90 Day Mortality Following Oncological Treatment: 30 and 90 day mortality following curative oncological treatment for oesophageal or gastric cancer

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Numerator: Number of patients with oesophageal or gastric cancer who receive curative oncological treatment who die within 30/90 days of treatment. Denominator: All patients with oesophageal or gastric cancer who receive curative oncological treatment Exclusions: No exclusions. Target: <10%

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. Where patients have received multiple treatment types (including surgery) it is possible that deaths may be ‘double counted’ across the various treatment categories described below. Therefore, it is not appropriate to aggregate numbers of deaths across each category (including those from QPI 6) as this will potentially inflate the total number of deaths. The presentation of the data for QPI 11 was discussed as part of the Baseline Review process and, for subsequent years’ analysis, results will be presented in a more meaningful format, specifically by: chemoradiotherapy with curative intent, peri-operative chemotherapy with curative intent and palliative chemotherapy. Targets will however remain unchanged. A). Chemoradiotherapy At national and regional level the target was met comfortably with fewer than 3% of oesophageal cancer patients in Scotland dying within 30 days of receiving chemoradiotherapy treatment. This figure increases to just under 6% when looking at the 90 day mortality rate.

42


0.0

5.0

10.0

15.0

20.0

25.0

30.0%

Pe

rfo

rman

ceQPI 11: 30/90 Day Mortality following Chemoradiotherapy with Curative Intent - Oesophageal


30 Day Mortality following oncological treatment (Chemoradiotherapy) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 4.3 1 23 - - - - 1

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 14.3 1 7 - - - - -

Tayside - - 5 - - - - -


NOSCAN 5.6 2 36 - - - - 1

Lothian - - - - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN - - 7 - - - - -


Lanarkshire - - - - - - - -

Forth Valley - - - - - - - -


WoSCAN - - 29 - - - - -

Scotland 2.8 2 72 - - - - 1 90 Day Mortality following oncological treatment (Chemoradiotherapy) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 4.3 1 23 - - - - 1

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 14.3 1 7 - - - - -

Tayside 20.0 1 5 - - - - -


NOSCAN 8.3 3 36 - - - - 1

Lothian - - - - - - - -

Fife - - - - - - - -

Borders - - - - - - - -


SCAN - - 7 - - - - -



Forth Valley - - - - - - - -


WoSCAN 3.7 1 27 - - - - -

Scotland 5.7 4 70 - - - - 1 Source: Cancer audit - Data not shown due to small numbers or zero values Note – the number of cases in the denominator for 30 day and 90 day may not match as 90 days had not elapsed at time of analysis

43


B). Adjuvant chemotherapy Even at a national level the number of oesophageal and gastric cancer patients receiving adjuvant chemotherapy treatment was very low so direct comparisons at Board and Regional level are not advised. A total of 40 patients across both cancers received the treatment and all were alive at 30 days post treatment. Only one patient died within 90 days of treatment. C). Neoadjuvant chemotherapy Of the 139 oesophageal cancer patients receiving Neoadjuvant chemotherapy in Scotland as a curative treatment only 1 patient died within 30 days of treatment. This increased to 5 at the 90 day threshold. At regional level, only NOSCAN exceeded the target with almost 12% of patients dying within 90 days of the treatment. However, this is based on a relatively small sample size.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

% P

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QPI 11: 30/90 Day Mortality following Neoadjuvant Chemotherapy with Curative Intent - Oesophageal


30 Day Mortality following oncological treatment (Neo-adjuvant chemotherapy) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian - - 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - 12 - - - - -

Tayside - - 14 - - - - -


NOSCAN 2.9 1 34 - - - - -

Lothian - - 24 - - - - -

Fife - - 8 - - - - -

Borders - - 6 - - - - -

Dumfries and Galloway - - 6 - - - - -

SCAN - - 44 - - - - -


Lanarkshire - - 10 - - - - -

Forth Valley - - 11 - - - - -


WoSCAN - - 61 - - - - -

Scotland 0.7 1 139 - - - - -

44


90 Day Mortality following oncological treatment (Neo-adjuvant chemotherapy) - Oesophageal


Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 28.6 2 7 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 8.3 1 12 - - - - -

Tayside - - 14 - - - - -


NOSCAN 11.8 4 34 - - - - -

Lothian 4.2 1 24 - - - - -

Fife - - 8 - - - - -

Borders - - 6 - - - - -

Dumfries and Galloway - - 6 - - - - -

SCAN 2.3 1 44 - - - - -


Lanarkshire - - 10 - - - - -

Forth Valley - - 11 - - - - -


WoSCAN - - 60 - - - - -


For gastric cancer, the pattern was similar with 9% of patients dying within 90 days when all patients were alive at the 30 day threshold. D). Adjuvant radiotherapy Fewer than 5 patients received this treatment across the country so comparison of mortality rates is not possible.

45


QPI 11(ii) - 30 Day Mortality Following Oncological Treatment: 30 day mortality following palliative oncological treatment for oesophageal or gastric cancer

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Numerator: Number of patients with oesophageal or gastric cancer who receive palliative oncological treatment who die within 30/90 days of treatment. Denominator: All patients with oesophageal or gastric cancer who receive palliative oncological treatment Exclusions: No exclusions. Target: <20%

Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Therefore, discussion of variation will be focussed at Network and National level. E). Chemotherapy Oesophageal Cancer In 2013, there were 207 patients with oesophageal cancer who received palliative chemotherapy treatment. Of these, 21 died within 30 days of receiving the treatment. This represents a mortality rate of 10% for patients receiving chemotherapy which is below the target of 20% for this QPI. Any Board which did not meet the target was impacted by the effect of small numbers.

0.0

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30.0

% P

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QPI 11(E): 30 Day Mortality following Palliative Chemotherapy - Oesophageal

46



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 6.3 2 32 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland 25.0 2 8 - - - - -

Tayside - - 16 1 6.3 - - -


NOSCAN 11.1 7 63 1 1.6 - - -

Lothian 11.1 2 18 - - - - -

Fife - - 8 - - - - -

Borders - - - - - - - -


SCAN 8.8 3 34 - - - - -


Lanarkshire 14.3 4 28 - - - - -

Forth Valley 16.7 2 12 - - - - -


WoSCAN 10.0 11 110 - - - - -


Gastric Cancer For gastric cancer patients, the mortality rate at the 30 day threshold was lower at 8% for Scotland as a whole. All Boards met target for this QPI.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

% P

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QPI 11(E): 30 Day Mortality following Palliative Chemotherapy - Gastric

47



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 7.7 1 13 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - - - - - - -

Tayside - - - - - - - -


NOSCAN 5.0 1 20 - - - - -

Lothian 10.0 1 10 - - - - -

Fife - - 3 - - - - -

Borders - - - - - - - -


SCAN 7.1 1 14 - - - - -


Lanarkshire 6.7 1 15 - - - - -

Forth Valley - - - - - - - -


WoSCAN 9.1 5 55 - - - - -


F). Radiotherapy Oesophageal Cancer 10% of patients in Scotland in 2013 with oesophageal cancer receiving palliative radiotherapy treatment died within 30 days of the treatment. The mortality rates for most Boards were lower than the threshold of 20% for this QPI, and any exceptions are due to the effect of small numbers.

0.0

5.0

10.0

15.0

20.0

25.0

% P

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ance

QPI 11(F): 30 Day Mortality following Palliative Radiotherapy - Oesophageal

48



Not Recorded

for Numerator

%Not Recorded

for Numerator

Not Recorded

for Exclusion

%Not Recorded

for Exclusion

Not Recorded for

Denominator

Grampian 15.4 4 26 - - - - -

Orkney - - - - - - - -

Shetland - - - - - - - -

Highland - - 10 - - - - -

Tayside 13.6 3 22 1 4.5 - - -


NOSCAN 11.3 7 62 1 1.6 - - -

Lothian 7.7 1 13 - - - - -

Fife - - 6 - - - - -

Borders - - - - - - - -


SCAN 4.3 1 23 - - - - -



Forth Valley 14.3 1 7 - - - - -


WoSCAN 10.5 4 38 - - - - -


Gastric Cancer For gastric cancer, there were so few patients (11 across all Scotland) who received radiotherapy; therefore comparison of mortality rates is not meaningful. The following comments relate to both parts of QPI 11. In NHS Grampian, the cases of those patients dying within 90 days of receiving neo-adjuvant chemotherapy were reviewed in detail. It was concluded that the deaths were not chemotherapy related deaths. Specifically the deaths were concluded to be as a result of operative complications or chemo resistant disease. In this case, after successive cycles of neo-adjuvant chemotherapy, palliative radiotherapy was provided instead. NHS Lothian commented that the figures include post operative death and are, therefore, not chemotherapy related. A case review within NHS Western Isles is conducted by the MDT (nurse, doctor and pharmacist) for all deaths that occur within 30 days of chemotherapy administration. This audit data could be provided if requested.

49


Clinical Trials

Access to Clinical Trials is a common issue for all cancer types; therefore, a generic QPI was developed to measure performance across the country. Further details on the development and definition of this QPI can be found here. Specifically for Upper GI, the QPI is defined as follows and Appendix A3 contains a list of Upper GI trials into which patients have been recruited in Scotland during 2013. Information is shown by each Scottish Cancer Research Network (SCRN).

Clinical Trials Access: Proportion of patients with oesophageal or gastric cancer who are enrolled in an interventional clinical trial or translational research.

All patients should be considered for participation in available clinical trials, wherever eligible. Numerator: Number of patients with oesophageal or gastric cancer enrolled in an interventional clinical trial or translational research. Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions. Target: Interventional clinical trials – 7.5% Translational research – 15%

The aspiration is to enrol a minimum of 7.5% of patients into Interventional Clinical Trials and 15% into Translational research. Clearly, there is still significant improvement to be made in this measure to ensure more patients benefit from these trials.

0

2

4

6

8

10

12

14

16

SCRN - West SCRN - North & East SCRN - South East

%

% of Upper GI Cancer Patients Enrolled in Clinical Trials

Interventional

Translational

Interventional Target

Translational Target

http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=a68a9325-5a7d-4612-903c-a13669f8c721&version=-1

50


No. of patients enrolled in

Interventional Trials

No. of patients enrolled in

Translational Research

Average no. of Cancer

Registrations

SCRN - West

No of patients 5 49 767

% enrolled 0.7% 6.4%

SCRN - North & East



SCRN - South East



The inability of the North & East to meet the Clinical Trials QPI targets for Upper GI is a reflection of the small numbers of patients who are eligible to enter the clinical trials currently available. We believe that it is right that the target set for this QPI is ambitious so that clinicians and networks are encouraged to consider all suitable patients for enrolment in clinical trials.

51


List of abbreviations QPI - Quality Performance Indicator

QIS - Quality Improvement Scotland

ISD - Information Services Division

HIS - Healthcare Improvement Scotland

NOSCAN - North of Scotland cancer network

WoSCAN - West of Scotland cancer network

SCAN - South East Scotland cancer network

MDT - Multidisciplinary team

NR - Not recorded

SCRN - Scottish Cancer Research Network

TNM - Tumour, Node & Metastases (a cancer staging classification)

52


List of Tables

Table No. Name Time period File & size

Data Tables

Upper GI Cancer QPI Data Tables 2013 Excel [115kb]

http://www.isdscotland.org/Health-Topics/Quality-Indicators/Publications/2015-02-17/2015-02-17-UpperGI-QPI-Data.xlsx

http://www.isdscotland.org/Health-Topics/Quality-Indicators/Publications/2015-02-17/2015-02-17-UpperGI-QPI-Data.xlsx

53


Contact John Connor Principal Information Analyst [email protected] 0141 282 2231 Aimee Taylor Information Analyst [email protected] 0141 282 2112

Further Information Further information on Cancer Quality Performance Indicators can be found on the Cancer QPI section of the ISD website.

Rate this publication Click here to provide feedback and rate this publication.

mailto:[email protected]



http://www.isdscotland.org/Health-Topics/Quality-Indicators/Cancer-QPI/

http://www.isdscotland.org/Health-Topics/Quality-Indicators/Cancer-QPI/

http://www.isdscotland.org/Health-Topics/Quality-Indicators/Publications/rate-this-publication.asp?ID=1361

54


Appendix

A1 – Background Information

The purpose of the cancer quality work programme and the roles and responsibilities of each organisation are outlined in Chief Executives Letter (CEL 06). This document also provides details of the data collection, quality assurance and governance processes that are critical to the reporting of QPIs.

A2 – Upper GI Cancer QPIs

The table below shows the list of Upper GI Cancer QPIs applicable to this publication. Please note that revisions to these QPIs may have been made since the initial data collection – refer to the Healthcare Improvement Scotland website for the latest version of these QPIs.

QPI Numerator Denominator Exclusions Target

QPI 1 - Endoscopy

Number of patients with oesophageal or gastric cancer who undergo endoscopy who have a histological diagnosis made following initial endoscopy and biopsy

All patients with oesophageal or gastric cancer who undergo endoscopy.

No exclusions. 90%

QPI 2 - Radiological Staging

Number of patients with oesophageal or gastric cancer who undergo contrast enhanced CT of chest and abdomen +/- pelvis.

All patients with oesophageal or gastric cancer.

No exclusions. 90%

QPI 3 - Staging and Treatment Intent

Number of patients with oesophageal or gastric cancer who have TNM stage and treatment intent (radical or palliative) recorded at MDT meeting prior to treatment.


No exclusions. 95%

QPI 4 - Nutritional Assessment

Number of patients with oesophageal or gastric cancer referred to a dietician within 4 weeks of diagnosis.


Patients receiving supportive care.

85%

QPI 5 - Appropriate Selection of Surgical Patients

Number of patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy who then undergo surgical resection.

All patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy.

No exclusions. 80%

QPI 6 - 30/90 Day Mortality Following Surgery

Number of patients with oesophageal or gastric cancer who undergo surgical resection who die within 30/90 days of treatment.

All patients with oesophageal or gastric cancer who undergo surgical resection.

No exclusions. <10%

http://www.sehd.scot.nhs.uk/mels/CEL2012_06.pdf

http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=d23bf48a-d2f9-43b4-be57-465f6ff101d2&version=-1


55


QPI 7 - Lymph Node Yield

Number of patients with gastric cancer who undergo curative surgical resection where 15 lymph nodes are resected and pathologically examined.

All patients with gastric cancer who undergo curative surgical resection.

No exclusions. 80%

QPI 8 - Length of Hospital Stay Following Surgery

Number of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 21 days of surgical procedure.

All patients undergoing surgical resection for oesophageal or gastric cancer.

No exclusions. 60%

QPI 9(i) - Resection Margins

Number of patients with oesophageal cancer who undergo surgical resection in which circumferential and longitudinal surgical margin is clear of tumour.

All patients with oesophageal cancer who undergo surgical resection.

No exclusions. 70%

QPI 9(ii) - Resection Margins

Number of patients with gastric cancer who undergo surgical resection in which longitudinal surgical margin is clear of tumour.

All patients with gastric cancer who undergo surgical resection.

No exclusions. 90%

QPI 10 - Curative Treatment Rates

Number of patients with oesophageal or gastric cancer who undergo curative treatment.


No exclusions. 35%

QPI 11(i) - 30/90 Day Mortality Following Oncological Treatment (Curative)

Number of patients with oesophageal or gastric cancer who receive curative oncological treatment who die within 30/90 days of treatment.

All patients with oesophageal or gastric cancer who receive curative oncological treatment

No exclusions. <10%

QPI 11(ii) - 30/90 Day Mortality Following Oncological Treatment (Palliative)

Number of patients with oesophageal or gastric cancer who receive palliative oncological treatment who die within 30/90 days of treatment.

All patients with oesophageal or gastric cancer who receive curative oncological treatment

No exclusions. <20%

56


A3 – Upper GI Clinical Trials

The list of clinical trials in use for Upper GI patients in Scotland across the Scottish Cancer Research Networks is shown below. Further details on these clinical trials are available from the relevant SCRN.

Study Type Study Title SCRN - West SCRN - South East SCRN - North & East

BILCAP

CAP002

ESPAC-4

FACING

FACING Main (Part 2)

IPSEN

NCRN267 - SHINE

NCRN280

NCRN366

NCRN369

ROCS

ST03

TACE-2

BRIDE

OCCAMS

RTL Advanced Study

RTL Peri-operative Study

ST03 (Translational element)

ST03 FS

UGI Tumour Bank

Translational

Interventional

57


A4 – Publication Metadata (including revisions details)

Metadata Indicator Description

Publication title Upper GI Cancer Quality Performance Indicators - 2013

Description This report shows the performance of NHS Boards against twelve Upper GI Cancer QPIs for the year 2013. Relevant commentary from NHS Boards is also included to provide local context to the data.

Theme Health and Social Care

Topic Cancer services

Format PDF Document

Data source(s) Cancer audit, Cancer registry, SMR01

Date that data are acquired August 2014

Release date February 17th 2015

Frequency Every 3 years

Timeframe of data and timeliness

Data covering patients diagnosed in 2013

Continuity of data First release of QPI data

Revisions statement This is the first release of Upper GI QPI data. It is expected that QPI definitions and measurability documents will evolve and therefore future publications may contain revisions to previously published information.

Revisions relevant to this publication

Not applicable

Concepts and definitions QPI definitions and measurability criteria are available from the Cancer Audit section of the ISD website.

Relevance and key uses of the statistics

The reporting of performance against these national QPIs is underpinned by a national governance framework that aims to use these data to improve cancer services in Scotland.

Accuracy Information on the accuracy of some of the national datasets used within this publication is available on the ISD website. ISD only receives aggregate data from each NHS Board to populate these indicators (with the exception of SMR based indicators and case ascertainment). Derivation of the figures and data accuracy are matters for individual NHS Boards.

Completeness For the reporting period, information based on the SMR01 data completeness can be found here. 100% of QPI aggregate data was returned.

Comparability The national dataset and data definitions in conjunction with the final quality performance indicators and the accompanying measurability document were agreed in public engagement to ensure data collection is comparable across the country.

Accessibility It is the policy of ISD Scotland to make its web sites and products accessible according to published guidelines.

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

http://www.isdscotland.org/Products-and-Services/Hospital-Records-Data-Monitoring

http://www.isdscotland.org/Products-and-Services/Hospital-Records-Data-Monitoring

http://www.isdscotland.org/Products-and-Services/Hospital-Records-Data-Monitoring/SMR-Completeness/

http://www.isdscotland.org/About-ISD/Accessibility/

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Coherence and clarity Statistics for each QPI are presented consistently in chart and table format at NHS Board level level, with national figures and performance targets included for comparison and clarity.

Value type and unit of measurement

The units of measure include numbers and percentages.

Disclosure The ISD protocol on Statistical Disclosure Protocol is followed.

Official Statistics designation Official Statistics

UK Statistics Authority Assessment

Not currently put forward for assessment

Last published First release

Next published February 2018

Date of first publication 17th February 2015

Help email [email protected]

Date form completed 9th January 2015

http://www.isdscotland.org/Products-and-Services/Data-Protection-and-Confidentiality/


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A5 – Early Access details (including Pre-Release Access)

Pre-Release Access Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", ISD are obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access. Standard Pre-Release Access:

Scottish Government Health Department NHS Board Chief Executives NHS Board Communication leads

Early Access for Management Information These statistics will also have been made available to those who needed access to ‘management information’, i.e. as part of the delivery of health and care: Members of the National Cancer Quality Operational Group Members of the National Cancer Quality Steering Group Early Access for Quality Assurance These statistics will also have been made available to those who needed access to help quality assure the publication: Members of the National Cancer Quality Operational Group Members of the National Cancer Quality Steering Group Upper GI Cancer Clinical Leads

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A6 – ISD and Official Statistics

About ISD Scotland has some of the best health service data in the world combining high quality, consistency, national coverage and the ability to link data to allow patient based analysis and follow up. Information Services Division (ISD) is a business operating unit of NHS National Services Scotland and has been in existence for over 40 years. We are an essential support service to NHSScotland and the Scottish Government and others, responsive to the needs of NHSScotland as the delivery of health and social care evolves. Purpose: To deliver effective national and specialist intelligence services to improve the health and wellbeing of people in Scotland. Mission: Better Information, Better Decisions, Better Health Vision: To be a valued partner in improving health and wellbeing in Scotland by providing a world class intelligence service. Official Statistics Information Services Division (ISD) is the principal and authoritative source of statistics on health and care services in Scotland. ISD is designated by legislation as a producer of ‘Official Statistics’. Our official statistics publications are produced to a high professional standard and comply with the Code of Practice for Official Statistics. The Code of Practice is produced and monitored by the UK Statistics Authority which is independent of Government. Under the Code of Practice, the format, content and timing of statistics publications are the responsibility of professional staff working within ISD. ISD’s statistical publications are currently classified as one of the following:

National Statistics (i.e. assessed by the UK Statistics Authority as complying with the Code of Practice)

National Statistics (i.e. legacy, still to be assessed by the UK Statistics Authority)

Official Statistics (i.e. still to be assessed by the UK Statistics Authority)

other (not Official Statistics)

Further information on ISD’s statistics, including compliance with the Code of Practice for Official Statistics, and on the UK Statistics Authority, is available on the ISD website.

http://www.isdscotland.org/About-ISD/About-Our-Statistics/

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